Limitations/Terms of Coverage Clause Samples
The Limitations/Terms of Coverage clause defines the specific boundaries and conditions under which an insurance policy or service agreement provides protection or benefits. It typically outlines what is included and excluded from coverage, such as types of losses, events, or damages that are not covered, and may set caps on the amount payable or the duration of coverage. By clearly stating these terms, the clause helps manage expectations and reduces disputes by ensuring all parties understand the extent and limits of the protection offered.
Limitations/Terms of Coverage. 1. When You are receiving inpatient care in a Facility, We will not cover additional charges for medications and supplies You take home from the Facility.
2. We will cover additional charges for special duty nurses and charges for private rooms if Medically Necessary. If You occupy a private room, and the private room is not Medically Necessary, Our coverage will be based on the Facility’s maximum semi-private room charge. You will have to pay the difference between that charge and the private room charge.
Limitations/Terms of Coverage. Ambulance services are covered only when Medically Necessary, except: o When ordered by an employer, school, fire or public safety official and the Member is not in a position to refuse; or o When a Member is required by Us to move from a Non-Network Provider to a Network Provider. • We do not cover travel or transportation expenses, unless connected to an Emergency Medical Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. • We do not cover: o Non-ambulance transportation such as ambulette, van or taxi cab; o Trips to a Physician’s office or clinic; or o Trips to a morgue or funeral home. • Ambulance trips must be made to the closest local facility that can give Covered Services appropriate for Your condition. If none of these facilities are in Your local area, You are covered for trips to the closest facility outside Your local area. Ambulance usage is not covered when another type of transportation can be used without endangering the Member’s health. Any ambulance usage for the convenience of the Member, family or Physician is not a Covered Service.