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<br />SECDON 5-EXCLUSIONS AND LIMITATIONS <br /> <br />Our liability llndf'r this Policy will not be increased if the Plan nrovides more liberal cxclusi~ SInd <br />Hmitations provisions. . <br /> <br />In addition to the exclusions and limitations provided under the Plan, this Policy will not cover any of the <br />following (unless such exclusion or limitation is specificaDy waived by rider or endorsement): <br /> <br />1. Deductibles, co-payment amounts, or any other charges which are not payable under the terms of the <br />Plan or charges which are payable by the Plan, ~ to You :from. any other source. <br /> <br />2. Charges for Experimental or Investigative services, treatments or supplieS; or drugs which have not <br />been approved by the Food and Drog Admini!:ltration. <br /> <br />3. Any conditions for which benefits of any kind are paid or payable, by judgment or settlement, 1U1der <br />any Workers Compensation or Occupational Law, even if the Covered Person:fiills to claim his or <br />her rights to such benefits. <br /> <br />4. Claims for a Covered Person who, on the date that .coverage 1Dlder this Policy would otherwise <br />begin, is an employee who is not actively at work at his or her normaljob or is a retired employee or <br />dependent of an employee who is unable to perfmm the normal activities of a person of like age or <br />sex. <br /> <br />No benefits will be provided for any charges Incurred until the day after the date that such Covered <br />Person if an employee returns to active work on a full-time basis or if a retired employee or <br />eligible dependent of an employee is able to perform the nonn8l activities of a person oflike age <br />and sex. . <br /> <br />5. Charges resoIting :from any extra or non-contractua1 damages or legal fees and expenses for thC <br />defense thereof: or any fines or statutory penalties. <br /> <br />6. Any procedure or treatment to change pbysica1' cbamcteristics to those of the opposite sex, or any <br />otbm- treafmeJrt or studies rc1atcd to a sex ch8nge or 1:rP.atment of sexual disorders. <br /> <br />7. Any services furnished by an institution which is primarily a rest home, a place. for the aged. a <br />nursing home, a Convalescent home, a place for custodial care, or any other place of like character. <br /> <br />8. Services or expenses for charges Incurred as a result of suicide or attempted suicide, whether sane or <br />insane; or;ntentional self-inflicted injury or illness. <br /> <br />9. Injury or illness which occurs due to a Covered Person's commission of: or attempt to commit a <br />criminal act or while a Covered Person is engaged in an illegal activity. <br /> <br />10. Legal expenses of any kind or description, including legal expenses :related to or l'nctmed for the <br />confinf':l'l1P.l1t of a Covered Person or any compulsory process to adopt, abstain from, or cease to <br />continue a particolar mode oftrea1mcot. care or therapy. <br /> <br />11. Services done for cosmetic pmposes" mlless ped'OIDled to otmecI: functional disorders or congenital <br />anomalies; or due to accidental iJ:Vury occmring while that iIidividual is a Covered Person. <br /> <br />SL-2001 <br /> <br />10 <br /> <br />(6101) <br />