What Are the Exclusions and Limitations?
If your Pre-existing Conditions have been fully disclosed on your Application and not excluded or restricted by a Rider or any other provision of your Certificate, your Pre-existing Conditions are covered the same as any other Illness or Injury as of your effective date. Pre-existing Conditions include any Injury, Illness or Mental Health Disorder that existed at or prior to your initial effective date, including chronic or recurring conditions.
The following charges, treatments, care, services, supplies and/or conditions are excluded from coverage:
- Charges not Incurred during the Certificate period
- Services or treatment payable by another insurance or government
- Substance Abuse
- Charges which exceed Usual, Reasonable and Customary
- Investigational or experimental Surgeries or treatment
- Custodial, Educational or Rehabilitative Care
- Weight modification
- Cosmetic surgery, unless reconstructive surgery is directly related to a covered Injury or Illness
- Charges for use of Emergency Room for treatment of Illness unless the patient is directly admitted to the Hospital as Inpatient for further treatment of that Illness
- Individuals HIV+ at effective date
- Charges relating to congenital conditions
- Drugs or treatment for sexual dysfunction
- Drugs or treatment to promote or prevent conception
- Devices or procedures to correct sight or hearing
- Self-inflicted Injury or Illness
- Foot care, unless related to a covered accidental Injury
- Treatment or supplies not ordered by a Physician or not Medically Necessary, except for Wellness Benefits provided under the plan
- Organ transplants, except for Covered Transplants
- Speech, acupuncture, occupational or sleep therapy
- Acts of Terrorism, war, insurrection, riot or any variation thereof
- Dental Treatment, except emergency treatment following a covered Accident, or unless Dental Rider is purchased
The following are excluded from the Optional Dental Rider:
- Sealants, bleaching and oral hygiene expenses
This is a summary of exclusions contained in the Certificate of Insurance. See the Certificate of Insurance for a complete list of exclusions.
Special Illness Exclusion:
The following conditions which manifest themselves within the first 180 days of coverage are excluded: Any condition of the breast, prostate, the reproductive system, tonsils, adenoids, hemorrhoids, hernia, gallstones, kidney stones, glaucoma, cataracts, disk disease, varicose veins, all types of cysts, arthritis, and repetitive motion disorders, and any disorder or disease of the skin.
After 12 months of continuous coverage, you may be eligible for Wellness benefits that are not subject to the Deductible. If you are at least 30 years of age, you will be entitled to the following Wellness benefit: $250 per Certificate Period for a Routine Physical Exam, including OB/GYN visits for females. Additionally, females who are at least 40 years of age will be entitled to the following benefit: $100 per Certificate Period for a screening mammogram. If you are under the age of 19, you will be entitled to the following Wellness benefit: $50 per visit (including immunizations) with a maximum of three visits per Certificate Period.
Emergency Medical Evacuation:
Both plans provide coverage for Emergency Medical Evacuation to the nearest medical facility qualified to treat you rlife-threatening condition or potential loss of limb. All Emergency Medical Evacuations must be approved in advance and coordinated by HCC Medical Insurance Services. Emergency Medical Evacuations provide you with access to care when you need it most. HCC Medical Insurance Services is available 24 hours a day, 7 days a week to approve and coordinate Emergency Medical Evacuations.
In the event of a covered Emergency Evacuation, the platinum plan will provide the following benefits: the cost of an economy round trip air or ground transportation ticket for one of your relatives (parent, spouse, sibling or child age 18 years or above) for transportation to the area where you are hospitalized following Emergency Evacuation, and reasonable expenses for lodging and meals for your relative for a period not to exceed 15 days.
Other services provided by HCC Medical Insurance Services:
- Medical referrals
- Up-to-the-minute travel medical advisories
- Assistance with prescription drug replacement
- Dispatch of a doctor or specialist
- Emergency travel arrangements for family members
- Lost passport or travel documents assistance
- Embassy and consulate referrals
- Legal and accounting referrals
- Bail bond assistance
- Translation and interpretation assistance
Patient Advocacy Services:
If you are faced with a complex or severe medical condition, you will be assigned to one of HCCMIS's Patient Advocates. Your Patient Advocate is your personal assistant at HCC Medical Insurance Services on all matters relating to your treatment and claim, with the goal of securing the best possible care for you in a convenient and cost effective setting.
General Customer Service:
You've lost your ID card or your Certificate. Or, you have a question about your insurance. Or, you have filed a claim and you want to know the status of payment. These and many more questions may arise from time to time. HCC Medical Insurance Services. Customer Service Team is ready to respond. If you do not speak English, your Customer Service Representative will arrange for a telephone translator to monitor your call and assist in providing the answers you need.
CitizenSecureSM plans require pre-certiification which simply means that you must contact HCC Medical Insurance Services. as soon as possible before a planned hospitalization or surgical procedure, or within 48 hours of an emergency hospital admission, or within the first 90 days of pregnancy. Pre-certiification allows us to establish contact and make payment arrangements with your providers, negotiate discounts which will benefit both you and us, pre-arrange future care, and plan for your claim. Pre-certiification helps us help you.
Pre-existing conditions: Any Injury, Illness or Mental Health Disorder which existed at the initial Certificate Effective Date and/or any chronic or recurring Illness and/or chronic or recurring Mental Health Disorder which existed at or prior to the initial Certificate Effective Date. Pre-existing Condition also includes any complications or consequences associated with these conditions.