General Exclusions include expenses for. a. services received prior to your Effective Date or after the date your coverage terminates; b. services not within the service categories described in Part VIII. COVERED BENEFITS AND SERVICES and any amendments attached hereto, unless such services are specifically required to be covered by applicable law; c. services provided by a Physician or other Health Care Provider related to you by blood or marriage; d. services beyond the scope of practice authorized for a Health Professional under applicable state law; e. services which are not Medically Necessary as defined in this Contract and as determined by AvMed. The ordering of a service by a Health Care Provider does not in itself make such service Medically Necessary or a Covered Service; f. services rendered at no charge; g. services to diagnose or treat any Condition which initially occurred or resulted from you being under the influence of alcoholic beverages, any chemical substance set forth in Section 877.111, Florida Statutes, or any substance controlled under Chapter 893, Florida Statutes (or, with respect to such statutory provisions, any successor statutory provisions). Notwithstanding, this Exclusion shall not apply to the use of any Prescription Medication by you if such medication is taken on the specific advice of a Physician in a manner consistent with such advice; h. services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group; i. services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in connection with: i. medical care connected with Armed Forces service (for both sickness and injury); services received at military or government facilities; services received to treat an injury arising out of your service in the Armed Forces, Reserves or National Guard; or ii. your participation in, or commission of, any act punishable by law as a misdemeanor or felony whether or not you are charged or convicted, or which constitutes riot or rebellion; or your engaging in an illegal occupation. Coverage will be available if a Member demonstrates that an injury resulted from an act of domestic violence or a Condition, whether or not the Condition was diagnosed before the occurrence of the injury. j. any expenses for Claims denied because we did not receive information requested from you about whether or not you have other coverage (including personal injury motor vehicle insurance (PIP) or supplemental insurance plans) and the details of such coverage; k. treatment, services or supplies received for injury or illness arising out of, or in the course of, employment for wage or profit, provided the Member is covered under or could be covered under any Worker’s Compensation Act, Occupational Disease Act, or similar act or law, unless the Member is self-employed.
Appears in 1 contract
General Exclusions include expenses for. a. services received prior to your Effective Date or after the date your coverage terminates;
b. services not within the service categories described in Part VIIIIX. COVERED BENEFITS AND SERVICES SERVICE CATEGORIES and any amendments amendment(s) attached hereto, unless such services are specifically required to be covered by applicable law;
c. services provided by a Physician or other Health Care Provider related to you by blood or marriage;
d. services beyond the scope of practice authorized for a Health Professional under applicable state law;
e. services which are not Medically Necessary as defined in this Contract and as determined by AvMed. The ordering of a service by a Health Care Provider does not in itself make such service Medically Necessary or a Covered Service;
f. services rendered at no charge;
g. services to diagnose or treat any Condition which initially occurred or resulted from you being under the influence of alcoholic beverages, any chemical substance set forth in Section 877.111, Florida Statutes, or any substance controlled under Chapter 893, Florida Statutes (or, with respect to such statutory provisions, any successor statutory provisions; or if outside Florida, applicable state law). Notwithstanding, this Exclusion shall not apply to the use of any Prescription Medication by you if such medication is taken on the specific advice of a Physician in a manner consistent with such advice;
h. services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group;
i. services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in connection with:
i. medical care connected with Armed Forces service (for both sickness and injury); services received at military or government facilities; services received to treat an injury arising out of your service in the Armed Forces, Reserves or National Guard; or
ii. your participation in, or commission of, any act punishable by law as a misdemeanor or felony whether or not you are charged or convicted, or which constitutes riot or rebellion; or your engaging in an illegal occupation. Coverage will be available if a Member demonstrates that an injury resulted from an act of domestic violence violence, or a medical Condition, whether or not the Condition was diagnosed before the occurrence of the injury.
j. any expenses for Claims denied because we did not receive information requested from you about whether or not you have other coverage (including personal injury protection motor vehicle insurance (PIP) or supplemental insurance plans) and the details of such coverage;
k. treatment, services or supplies received for injury or illness arising out of, or in the course of, employment for wage or profit, provided the Member is covered under or could be covered under any Worker’s Compensation Act, Occupational Disease Act, or similar act or law, unless the Member is self-employed.
Appears in 1 contract
General Exclusions include expenses for. a. services received prior to your Effective Date or after the date your coverage terminates;
b. services not within the service categories described in Part VIIIIX. COVERED BENEFITS AND SERVICES SERVICE CATEGORIES and any amendments amendment(s) attached hereto, unless such services are specifically required to be covered by applicable law;
c. services provided by a Physician or other Health Care Provider related to you by blood or marriage;
d. services beyond the scope of practice authorized for a Health Professional under applicable state law;
e. services which are not Medically Necessary as defined in this Contract and as determined by AvMed. The ordering of a service by a Health Care Provider does not in itself make such service Medically Necessary or a Covered Service;
f. services rendered at no charge;
g. services to diagnose or treat any Condition which initially occurred or resulted from you being under the influence of alcoholic beverages, any chemical substance set forth in Section 877.111, Florida Statutes, or any substance controlled under Chapter 893, Florida Statutes (or, with respect to such statutory provisions, any successor statutory provisions). Notwithstanding, this Exclusion shall not apply to the use of any Prescription Medication by you if such medication is taken on the specific advice of a Physician in a manner consistent with such advice;
h. services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group;
i. services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in connection with:
i. medical care connected with Armed Forces service (for both sickness and injury); services received at military or government facilities; services received to treat an injury arising out of your service in the Armed Forces, Reserves or National Guard; or
ii. your participation in, or commission of, any act punishable by law as a misdemeanor or felony whether or not you are charged or convicted, or which constitutes riot or rebellion; or your engaging in an illegal occupation. Coverage will be available if a Member demonstrates that an injury resulted from an act of domestic violence violence, or a medical Condition, whether or not the Condition was diagnosed before the occurrence of the injury.
j. any expenses for Claims denied because we did not receive information requested from you about whether or not you have other coverage (including personal injury protection motor vehicle insurance (PIP) or supplemental insurance plans) and the details of such coverage;
k. treatment, services or supplies received for injury or illness arising out of, or in the course of, employment for wage or profit, provided the Member is covered under or could be covered under any Worker’s Compensation Act, Occupational Disease Act, or similar act or law, unless the Member is self-employed.
Appears in 1 contract
General Exclusions include expenses for. a. services received prior to your Effective Date or after the date your coverage terminates;
b. services not within the service categories described in Part VIII. COVERED BENEFITS AND SERVICES and any amendments attached hereto, unless such services are specifically required to be covered by applicable law;
c. services provided by a Physician or other Health Care Provider related to you by blood or marriage;
d. services beyond the scope of practice authorized for a Health Professional under applicable state law;
e. services which are not Medically Necessary as defined in this Contract and as determined by AvMed. The ordering of a service by a Health Care Provider does not in itself make such service Medically Necessary or a Covered Service;
f. services rendered at no charge;
g. services to diagnose or treat any Condition which initially occurred or resulted from you being under the influence of alcoholic beverages, any chemical substance set forth in Section 877.111, Florida Statutes, or any substance controlled under Chapter 893, Florida Statutes (or, with respect to such statutory provisions, any successor statutory provisions; or if outside Florida, applicable state law). Notwithstanding, this Exclusion shall not apply to the use of any Prescription Medication by you if such medication is taken on the specific advice of a Physician in a manner consistent with such advice;
h. services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group;
i. services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in connection with:
i. medical care connected with Armed Forces service (for both sickness and injury); services received at military or government facilities; services received to treat an injury arising out of your service in the Armed Forces, Reserves or National Guard; or
ii. your participation in, or commission of, any act punishable by law as a misdemeanor or felony whether or not you are charged or convicted, or which constitutes riot or rebellion; or your engaging in an illegal occupation. Coverage will be available if a Member demonstrates that an injury resulted from an act of domestic violence or a Condition, whether or not the Condition was diagnosed before the occurrence of the injury.
j. any expenses for Claims denied because we did not receive information requested from you about whether or not you have other coverage (including personal injury motor vehicle insurance (PIP) or supplemental insurance plans) and the details of such coverage;
k. treatment, services or supplies received for injury or illness arising out of, or in the course of, employment for wage or profit, provided the Member is covered under or could be covered under any Worker’s Compensation Act, Occupational Disease Act, or similar act or law, unless the Member is self-employed.
Appears in 1 contract
General Exclusions include expenses for. a. services received prior to before your Effective Date coverage under this Contract is effective or after the date your coverage terminates;
b. services not within the service categories described in Part VIIIIX. COVERED BENEFITS AND MEDICAL SERVICES and any amendments attached hereto, unless such services are specifically required to be covered by applicable law;
c. services which are not Medically Necessary, as defined in this Contract, and as determined by AvMed;
d. services provided by a Physician or other Health Care Provider related to you by blood or marriage;
d. e. services beyond the scope of practice authorized for a Health Professional Care Provider under applicable state law;
e. services which are not Medically Necessary as defined in this Contract and as determined by AvMed. The ordering of a service by a Health Care Provider does not in itself make such service Medically Necessary or a Covered Service;
f. services rendered at no charge;
g. services to diagnose or treat any Condition which initially occurred while you were (or which directly or indirectly resulted from from, or is connection with you being being) under the influence of alcoholic beverages, any chemical substance set forth in Section 877.111, Florida Statutes, or any substance controlled under Chapter 893, Florida Statutes (or, with respect to such statutory provisions, any successor statutory provisions). Notwithstanding, this Exclusion shall will not apply to the use of any Prescription Medication by you if such medication is taken on the specific advice of a Physician in a manner consistent with such advice;
h. services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group;
i. services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in connection with:
i. medical care connected with Armed Forces service (for both sickness and injury); services received at military or government facilities; services received to treat an injury arising out of your service in the Armed Forces, Reserves or National Guard; or
ii. your participation in, or commission of, any act punishable by law as a misdemeanor or felony whether or not you are charged or convicted, ; or which constitutes riot or rebellion; or your engaging in an illegal occupation. Coverage will be available if a Member demonstrates that an injury resulted from an act of domestic violence or a Condition, whether or not the Condition was diagnosed before the occurrence of the injury.
j. any expenses for Claims denied because we did not receive information requested from you about whether or not you have other coverage (including personal injury protection motor vehicle insurance (PIP) or supplemental insurance plans) and the details of such coverage;
k. treatment, services or supplies received for injury or illness arising out of, or in the course of, employment for wage or profit, provided the Member is covered under or could be covered under any Worker’s Compensation Act, Occupational Disease Act, or similar act or law, unless the Member is self-employed.
Appears in 1 contract
General Exclusions include expenses for. a. services received prior to before your Effective Date coverage under this Contract is effective or after the date your coverage terminates;
b. services not within the service categories described in Part VIIIIX. COVERED BENEFITS AND MEDICAL SERVICES and any amendments attached hereto, unless such services are specifically required to be covered by applicable law;
c. services which are not Medically Necessary, as defined in this Contract, and as determined by AvMed;
d. services provided by a Physician or other Health Care Provider related to you by blood or marriage;
d. e. services beyond the scope of practice authorized for a Health Professional Care Provider under applicable state law;
e. services which are not Medically Necessary as defined in this Contract and as determined by AvMed. The ordering of a service by a Health Care Provider does not in itself make such service Medically Necessary or a Covered Service;
f. services rendered at no charge;
g. services to diagnose or treat any Condition which initially occurred while you were (or which directly or indirectly resulted from from, or is connection with you being being) under the influence of alcoholic beverages, any chemical substance set forth in Section 877.111, Florida Statutes, or any substance controlled under Chapter 893, Florida Statutes (or, with respect to such statutory provisions, any successor statutory provisions). Notwithstanding, this Exclusion shall will not apply to the use of any Prescription Medication by you if such medication is taken on the specific advice of a Physician in a manner consistent with such advice;
h. services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group;
i. services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in connection with:
i. medical care connected with Armed Forces service (for both sickness and injury); services received at military or government facilities; services received to treat an injury arising out of your service in the Armed Forces, Reserves or National Guard; or
ii. your participation in, or commission of, any act punishable by law as a misdemeanor or felony whether or not you are charged or convicted, ; or which constitutes riot or rebellion; or your engaging in an illegal occupation. Coverage will be available if a Member demonstrates that an injury resulted from an act of domestic violence or a Condition, whether or not the Condition was diagnosed before the occurrence of the injury.
j. any expenses for Claims denied because we did not receive information requested from you about whether or not you have other coverage (including personal injury protection motor vehicle insurance (PIP) or supplemental insurance plans) and the details of such coverage;
k. treatment, services or supplies received for injury or illness arising out of, or in the course of, employment for wage or profit, provided the Member is covered under or could be covered under any Worker’s Compensation Act, Occupational Disease Act, or similar act or law, unless the Member is self-employed.. A dditional Exclusions
Appears in 1 contract
