the payment of benefits in connection with the Covered Service, or reduce the benefits in proportion to the amount of the copayment, deductible, and/or coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that you remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a Non-Participating Provider who has agreed to charge you or charged you at an in-network benefits level or some other benefits level not otherwise applicable to the services received. charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law. for or in connection with experimental procedures or treatment methods not approved by the American Optometric Association or the appropriate vision specialty society. 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 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. expenses for supplies, care, treatment, or surgery that are not medically necessary.
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 vision 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 the health care service was delivered.
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Coordination of Benefits This section applies if you or any one of your Dependents is covered under more than one Plan and determines how 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.
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