LIMITATIONS AND EXCLUSIONS:
In order to be eligible for coverage: Employees must be legally working: (a) in the United States or (b) outside the United States, for a US based employer, in a country or region approved by Guardian. An applicant must enroll within 31 days of the coverage effective date. An open enrollment will occur each year during a 30 day time period specified by the policyholder. If an applicant does not enroll during their initial enrollment period, he/she may not enroll until the next open enrollment period. This Plan will not pay benefits for: • Treatment relating to a covered person: taking part in any war or act of war (including service in the armed forces), commission of or attempt to commit a felony, an act of terrorism, or participating in an illegal occupation, riot or insurrection. .• Suicide or any intentionally self-inflicted injury Elective surgery; Surgery to correct vision or hearing, unless medically necessary surgery for glaucoma, cataracts or other sickness or injury; Dental care, dental xrays, or dental treatment; Gastric or intestinal bypass services including lap banding, gastric stapling, and other similar procedures to facilitate weight loss; the reversal, or revision of such procedures; or services required for the treatment of complications from such procedures. This exclusion does not apply to completion of a weight reduction
program that may be payable under the Health Screening benefit ; Rest cures or custodial care, or treatment of sleep disorders;
Services, treatment or supplies rendered outside the United States or Canada; Cosmetic surgery. This Exclusion does not apply to reconstructive surgery: (a) on an injured part of the body following infection or disease of the involved part; (b) of a congenital disease or anomaly of a covered dependent newborn or adopted infant; or (c ) on a nondiseased breast to restore and achieve symmetry between two breasts following a covered Mastectomy; Treatment or removal of warts, moles, boils, skin blemishes or birthmarks, bunions, acne, corns, calluses, the cutting and trimming of toenails, care for flat feet, fallen arches or chronic foot strain; Service, treatment or loss related to alcoholism or drug addiction, except for drugs prescribed by the Covered Person’s Doctor and taken as prescribed; Care or treatment for mental or nervous disorders; Services, treatment or loss rendered in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay; Services or treatment Provided by a Doctor, Nurse or any other person who is employed or retained by a Covered Person or who is a Covered Person’s Spouse, parent, brother, sister, child, Domestic Partner or partner in a civil union. Surgery and treatment, procedures, products or services that are experimental or investigative. Treatment of a Covered Dependent Child’s Children; Sickness or Injury sustained while on active duty in the armed forces of any country. This does not include Reserve or National Guard duty for training. GP-1-HI-15 This documentis asummaryof themajorfeatures of thereferencedinsurancecoverage. Itis intendedforillustrativepurposes onlyanddoes notconstituteacontract. Theinsurance plan documents, including the policy and certificate, comprise the contract for coverage. The full plan description, including the benefits and all terms, limitations and exclusions that apply will be contained in your insurance certificate. The plan documents are the final arbiter of coverage. Coverage terms may vary by state and actual sold plan. The premium amounts reflected in this summary are an approximation; if there is a discrepancy between this amount and the premium actually billed, the latter prevails.
All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, New York, NY
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