SAG-AFTRA Health SPD

General Exclusions

General Exclusions

The following exclusions apply to all of the Plan benefits:

  • Hospitalization, treatment, services, prescription drugs or supplies provided while you are not covered by the Plan.
  • Charges for any injury or sickness resulting from or occurring during the commission of, or attempt to commit a felony.
  • Charges for completing Claim forms, reports or copying of medical records.
  • Charges for Experimental or Investigative Procedures.
  • Charges for military-related injury or illness. However, the Veterans’ Administration or a governmental military Hospital or other governmental agency has the right to be reimbursed in accordance with the provisions of the Plan for any charges for services rendered to a covered person for services or supplies which are not related to military service. For individuals with Senior Performers coverage who are eligible for Medicare, the Hospital and medical benefits paid
    by the Plan will depend on the amount you would have received if the service had been performed in a non-governmental facility, with Medicare as the primary payor.
  • Charges for services provided or paid for by the U.S. government or any other government, except as otherwise provided herein. In addition, benefits will be payable if there is a legal obligation to pay for charges without regard to
    the existence of any insurance or employee benefit plan.
  • Charges for on-the-job injuries or illnesses. These charges are excluded whether or not your employer obtained a Workers’ Compensation policy. Occupational injuries or illnesses are normally covered by Workers’ Compensation
    Insurance. If you work through a loan-out company, you should make sure that your employer covers you under its Workers’ Compensation policy. The Plan will consider charges for injuries or illnesses that are specifically excluded from Workers’ Compensation laws.
  • Charges for services or supplies not recommended by a Physician.
  • Charges for services or supplies that are provided by any Government or governmental political subdivision in conjunction with the operation of their correctional or mental health programs.
  • Charges for services rendered by providers who are not licensed by the appropriate state or federal authority.
  • Charges for service rendered by a Provider that are not within the Provider’s licensure.
  • Charges for services rendered to you by yourself or by a Provider who is an “immediate relative” or by any person who normally lives in the covered person’s home. An “immediate relative” includes husband and wife, biological or adoptive
    parent, child and sibling, stepparent, stepchild, stepbrother and stepsister, father-in-law, mother-in-law, sister-in-law, brother-in-law, son-in-law and daughter-in-law, grandparent and grandchild, spouse of grandparent and grandchild. This exclusion does not apply to benefits provided under the Express Scripts prescription drug program.
  • Charges for state-mandated benefits not otherwise covered by the Plan. The Plan is self-funded and therefore is not subject to state-mandated insurance laws because of an exemption provided under ERISA.
  • Charges for telephone, email or internet consultations.
  • Charges in excess of the Contract Rate. In-network Providers cannot bill you for covered charges in excess of the Contract Rate.
  • Charges in excess of the Plan’s Allowance.
  • Charges in excess of the reasonable charge.
  • Charges incurred for a service or supply that is not Medically Necessary. This exclusion also applies to any hospitalization (or any part of a Hospital stay) that is related to a procedure that is not Medically Necessary or that is not recommended or approved by a Provider.
  • Charges incurred on account of declared or undeclared war, and illness or injuries resulting from war, whether declared or undeclared, or any act of war.
  • Charges submitted for which you are not financially responsible.
  • Charges submitted more than 15 months after the date services are incurred (18 months for Hospital charges).
  • Charges that are not considered appropriate for the treatment of an illness or accident.
  • Charges incurred as a result of an injury or illness that is caused by the act or omission of another person (except as provided under the subrogation and reimbursement provision).