Common use of Note to carriers Clause in Contracts

Note to carriers. This exclusion for abortion is only to be included in a policy issued to a religious employer granted such an exclusion. A “religious employer” means an organization that is organized and operates as a nonprofit entity and is referred to in section 6033(a)(3)(A)(i) or (iii) of the Internal 10 Revenue Code of 1986 (26 U.S.C. s.6033), as amended.] Care or treatment by means of acupuncture except when used as a substitute for other forms of anesthesia. The amount of any charge which is greater than an Allowed Charge. Services for ambulance for transportation from a Hospital or other health care Facility, unless [Member] is being transferred to another Inpatient health care Facility. [Broken Appointments.] Blood or blood plasma which is replaced by or for a[Member]. Care and/or treatment by a Christian Science Practitioner. Completion of claim forms. [Preventive contraceptive services and supplies that are rated “A” or “B” by the United States Preventive Services Task Force shall be excluded from this Policy if the Policyholder is a Religious Employer or and Eligible Organization as defined under 45 C.F.R. 147.131, as amended] Services or supplies related to Cosmetic Surgery, except as otherwise stated in this Contract; complications of Cosmetic Surgery; drugs prescribed for cosmetic purposes Services related to Custodial or domiciliary care. Dental care or treatment, including appliances and dental implants, except as otherwise stated in this Contract. Care or treatment by means of dose intensive chemotherapy, except as otherwise stated in this Contract. Services or supplies, the primary purpose of which is educational providing the [Member] with any of the following: training in the activities of daily living; instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities except as otherwise stated in this Contract. Experimental or Investigational treatments, procedures, hospitalizations, drugs, biological products or medical devices, except as otherwise stated in this Contract. Extraction of teeth, except for bony impacted teeth or as otherwise covered under this Contract. Services or supplies for or in connection with:

Note to carriers. This exclusion for abortion is only to be included in a policy issued to a religious employer granted such an exclusion. A “religious employer” means an organization that is organized and operates as a nonprofit entity and is referred to in section 6033(a)(3)(A)(i) or (iii) of the Internal 10 Revenue Code of 1986 (26 U.S.C. s.6033), as amended.] Care or treatment by means of acupuncture except when used as a substitute for other forms of anesthesia. The amount of any charge which is greater than an Allowed Charge. Services for ambulance for transportation from a Hospital or other health care Facility, unless [Member] is being transferred to another Inpatient health care Facility. [Broken Appointments.] Blood or blood plasma which is replaced by or for a[Member]. Care and/or treatment by a Christian Science Practitioner. Completion of claim forms. [Preventive contraceptive services and supplies that are rated “A” or “B” by the United States Preventive Services Task Force shall be excluded from this Policy if the Policyholder is a Religious Employer or and Eligible Organization as defined under 45 C.F.R. 147.131, as amended] Services or supplies related to Cosmetic Surgery, except as otherwise stated in this Contract; complications of Cosmetic Surgery; drugs prescribed for cosmetic purposes Services related to Custodial or domiciliary care. Dental care or treatment, including appliances and dental implants, except as otherwise stated in this Contract. Care or treatment by means of dose intensive chemotherapy, except as otherwise stated in this Contract. Services or supplies, the primary purpose of which is educational providing the [Member] with any of the following: training in the activities of daily living; instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities except as otherwise stated in this Contract. Experimental or Investigational treatments, procedures, hospitalizations, drugs, biological products or medical devices, except as otherwise stated in this Contract. Extraction of teeth, except for bony impacted teeth or as otherwise covered under this Contract. Services or supplies for or in connection with:: except as otherwise stated in this Contract, exams to determine the need for (or changes of) eyeglasses or lenses of any type; eyeglasses or lenses of any type except initial replacements for loss of the natural lens or as otherwise covered under this Contract; or eye surgery such as radial keratotomy or Lasik surgery, when the primary purpose is to correct myopia (nearsightedness), hyperopia (farsightedness) or astigmatism (blurring). Services or supplies provided by one of the following members of the Employee's family: spouse, child, parent, in-law, brother, sister or grandparent. Services or supplies furnished in connection with any procedures to enhance fertility which involve harvesting, storage and / or manipulation of eggs and sperm. This includes, but is not limited to the following: a) procedures: in vitro fertilization; embryo transfer; embryo freezing; and Gamete intra-fallopian Transfer (GIFT) and Zygote Intrafallopian Transfer (ZIFT), donor sperm, surrogate motherhood; and b) Prescription Drugs not eligible under the Prescription Drugs section of the Contract; and c) ovulation predictor kits. See also the separate Exclusion addressing sterilization reversal. Except as otherwise stated in the Hearing Aids and Newborn Hearing Screening provisions, services or supplies related to hearing aids and hearing examinations to determine the need for hearing aids or the need to adjust them. Services or supplies related to herbal medicine. Services or supplies related to hypnotism. Services or supplies necessary because the [Member] engaged, or tried to engage, in an illegal occupation or committed or tried to commit an indictable offense in the jurisdiction in which it is committed, or a felony. Exception: As required by 29 CFR 2590.702(b)(2)(iii) this exclusion does not apply to injuries that result from an act of domestic violence or to injuries that result from a medical condition. Except as stated below, Illness or Injury, including a condition which is the result of disease or bodily infirmity, which occurred on the job and which is covered or could have been covered for benefits provided under workers' compensation, employer's liability, occupational disease or similar law;