all nutritional supplements and formulae except for infant formula needed for the treatment of inborn errors of metabolism. for or in connection with an Injury or Sickness arising out of, or in the course of, any employment for wage or profit. telephone, email, internet consultations and telemedicine. charges for the delivery of medical and health-related services via telecommunications technologies, including telephone and internet, unless provided as specifically described under Covered Expenses. massage therapy. abortions, unless a Physician certifies in writing that the pregnancy would endanger the life of the mother, or the expenses are incurred to treat medical complications due to abortion. General Limitations No payment will be made for expenses incurred for you or any one of your Dependents: for charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected Injury or Sickness. to the extent that you or any one of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid. to the extent that payment is unlawful where the person resides when the expenses are incurred. for charges which would not have been made if the person had no insurance. to the extent that they are more than Maximum Reimbursable Charges. to the extent of the exclusions imposed by any certification requirement shown in this plan. expenses for supplies, care, treatment, or surgery that are not Medically Necessary. charges made by any covered provider who is a member of your family or your Dependent's family. expenses incurred outside the United States other than expenses for Medically Necessary urgent or emergent care while temporarily traveling abroad.
benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. Coverage under this Plan plus another Plan will not guarantee 100% reimbursement. Definitions For the purposes of this section, the following terms have the meanings set forth below: Plan Any of the following that provides benefits or services for medical care or treatment: Group insurance and/or group-type coverage, whether insured or self-insured which neither can be purchased by the general public nor is individually underwritten including closed panel coverage. Coverage under Medicare and other governmental benefits as permitted by law, excepting Medicaid and Medicare supplement policies. Medical benefits coverage of group, group-type, and individual automobile contracts. Each Plan or part of a Plan which has the right to coordinate benefits will be considered a separate Plan. Closed Panel Plan A Plan that provides medical or dental benefits primarily in the form of services through a panel of employed or contracted providers, and which limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel. Primary Plan The Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan. Secondary Plan A Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Plan. A Secondary Plan may also recover from the Primary Plan the Reasonable Cash Value of any services it provided to you. Reasonable Cash Value An amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service if rendered under similar or comparable circumstances by other health care providers located within the immediate geographic area where
HC-EXC302
01-19
the health care service was delivered. Order of Benefit Determination Rules
Coordination of Benefits This section applies if you or any one of your Dependents is covered under more than one Plan and determines how
A Plan that does not have a coordination of benefits rule consistent with this section shall always be the Primary Plan.
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