Benefit Exclusions
Medical Benefit Exclusions These exclusions apply: • Services not medically necessary except specifically outlined preventive care. • Servicesfor complications arising from a non-coveredservice. • Services or supplies for any illness arising out of or in the course of employment if benefits are payable under a Workers' Compensation, disability or occupational disease law. • Charges which the person is not legally required to pay. • Chargesmade bya hospitalownedor operated bythe U.S.government ifthe chargesare directly related to sicknessor injuryconnectedtomilitary service. • Services or supplies payable or available through a Federal, State or Local Government Agency(other than Medicare, Medicaid, CHAMPUS,CHAMPVA and non-service-related retired VA Benefits). • Custodial services not intended primarily to treat a specific injuryor sickness,or any educationor training. • Experimentalor investigational procedures and treatments (includingdrugs and devices). • Non-prescription, non-legendor over-the-counter drugs. • Vitamins (exceptpre-natal and children's vitamins), minerals, diet foodsor supplements and other nutritional supplies unless specifically authorized as a benefit under the terms of the plan. • Cosmetic surgery and cosmetic drugs used for cosmetic purposes like Retin-A/Tretinoin and Minoxidil/Rogaine. • Reports, evaluations, examinations or hospitalizations not required for health reasons such as employment or insurance examinations. • Treatment of teeth/periodontalium except for emergency dental work to stabilize teeth due to injury to sound natural teeth. • Reversal of voluntary sterilization procedures. • Weight control or weight reduction programs unless prescribed to treat Morbid Obesity, Gastric and Intestinal Bypass, Stapling, Bubble and similar procedures. • Transsexual surgery and relatedservices. • Therapyto improve general physical condition. • Personal or comfort items suchas personal care kits, television, and telephone rental inhospitals. • Surgical treatment for correction of refractive errors, including radial keratotomy (i.e. LASIK surgery). • Routine, palliative and cosmetic foot care. • Amniocentisis,ultrasoundoranyotherprocedures requestedsolelyforsexdetermination ofafetus,unlessmedicallynecessaryto determinethe existenceofasex-linked geneticdisorder. • Over-the-counterdisposable or consumable supplies, including support garments and other non-medical substancesregardless of their intended use. • Charges in excess of the Reasonableand Customary allowance. • An injury sustained while attempting to commit or committing a felony. • Aninjury or illness resultingfrom participation in a conflictinvolving any armed forces inan act of war, whether or not declared. • Contact lenses, eye glasses, and frames, except for contact lenses after cataract surgery. • Services or supplies provided by a person who ordinarily resides in the patient's home or is related to the patient by blood, marriage or adoption. • Services or supplies provided for which no charge would be made in absence of the Plan. • Unless a Medical Care Benefit, therapeutic treatment unless conclusive scientific evidence proves it improves health outcome. • Behavioral Modification Therapy unless the therapy is for the treatment of a developmental disorder or a congenital learning disability. • Educational, scholastic and vocation testing and training. • Services or supplies (including appliances, equipment and construction) for comfort or convenience, personal hygiene or beautification, as determined by the Plan Administrator, unless
such service or supply is primarily and customarily used only for medical reasons. • Services and supplies for which benefits are recoverable under no-fault insurance. • The provision of services or supplies which would be unlawful given where the Covered Person resides. • Telephone consultations.
Dental Benefit Exclusions These exclusions apply to the MetLife Plan: • Services which are not dentally necessary , do not meet generally accepted standards of care for treating the particular dental condition or are deemed experimental in nature. • Services for which you would not be required to pay in the absence of dental insurance. • Servicesor suppliesreceivedby youor your dependentbefore dental insurancestarts for that person. • Services which are primarily cosmetic (for Texas residents, see notice page section in Certificate of Coverage). • Serviceswhich are neither performed nor prescribed by a dentist except for those services of a licensed dental hygienist (scalingand polishing of teeth or fluoride treatments) which are supervised and billed by a dentist.
• Services or appliances which restore or alter occlusion or vertical dimension. • Restoration of tooth structure damaged by attrition, abrasion or erosion. • Restorations or appliances used for the purpose of periodontal splinting. • Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.
• Personal supplies or devices including, but not limited to: water picks, tooth brushes or dental floss. • Decoration, personalization or inscription of any tooth, device, appliance crown or other dental work. • Missed appointments, prescription drugs, caries susceptibility tests or Intra and extraoral photographic images. • Services covered under Workers' Compensation, an occupational disease law or any employer liability law. • Services for which Tishman is not required to pay or those services that are covered under other coverage provided by Tishman. • Services received at a facility maintained by the employer, labor union, mutual benefit association or VA hospital. • Temporary or provisional restorations or appliances. • Servicesfor which the submitted documentation indicates a poor prognosis. • The following when charged by a dentist on a separate basis: claim form completion, infection control, local anesthesia, non-intravenous conscious sedation or analgesia (e.g. nitrous oxide) • Dentalservicesarising out ofaccidentalinjuryto the teeth and supportingstructures, except for injuriesto the teeth due to chewingor bitingfood. • Initialinstallation ofafixedandpermanent denture to replacenatural teethwhichwere missingbefore suchpersonwasinsuredfordental insurance,except forcongenitally missingnatural teeth. • Other fixed denture prosthetic services not described elsewhere in the Certificate of Coverage. • Precision attachments, except when the precision attachment is related to implant prosthetics. • Initial installation or replacement of a full or removable denture to replace natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth. • Addition of teeth to a partial removable denture to replace natural teeth which were missing before such person was insured fordental insurance,exceptforcongenitally missing natural teeth. • Adjustmentof a denture made within six months after installation by the same dentist who installed it. • Implants including, but not limited to any related repair, surgery, placement, restorations, maintenance and removal. • Fixed and removable appliances for correction of harmfulhabits. • Diagnosisand treatment oftemporomandibular joint(TMJ)disorders. This exclusiondoesnot apply to residents of Minnesota. • Repair or replacement of an orthodontic device. • Duplicate prosthetic devices or appliances. • Replacementof a lost or stolen appliance, cast restoration or denture. 15
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