UniCare Sound Plans
Limitations & Exclusions
The primary limitations and exclusions for these medical insurance plans are listed below. These listings
are an overview only. A more detailed list of each plan’s limitations and exclusions can be found in the applicable certificate of coverage.
These plans do not provide benefits for:
- Any amounts in excess of maximum amounts of covered expenses stated in the certificate of coverage
- Services not specifically listed in the certificate of coverage as covered services
- Services or supplies that are not medically necessary
- Services or supplies that UniCare considers to be for experimental procedures or investigative procedures
- Services received before the effective date of coverage or during an inpatient stay that began before that effective date
- Services received after coverage ends
- Services for which you have no legal obligation to pay or for which no charge would be made if you did not have a health policy or insurance coverage
- Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or
occupational disease law, even if you do not claim those benefits
- Any intentionally self inflicted injury or illness.
- Conditions caused by: (a) an act of war; (b) the inadvertent release of nuclear
energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) an insured participating in the military service of any
country; (d) an insured participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured’s commission of, or attempt to commit a felony or as a
direct result of the insured being engaged in an illegal occupation; (f) an insured, being under the influence of illegal narcotics, alcohol or non-prescribed controlled substances unless
administered under the advice of a physician.
- Any services provided by a local, state or federal government agency, except when payment under the certificate of coverage is expressly required by federal or state law.
- If you are eligible for Medicare, any services covered by Medicare under parts A or B are excluded regardless of actual enrollment in Medicare or payment by Medicare for those services.
However, for any covered services, if there is a balance remaining after the Medicare payment, or the amount that Medicare would have paid had you enrolled in the program, UniCare will pay
the remaining balance up to the Medicare allowable amount. In no event, however, will the actual amount UniCare pay exceed the amount that UniCare would have paid if it were the sole
insurance carrier.
- Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration hospitals and military treatment facilities
will be considered for payment according to current legislation.
- Professional services received or supplies purchased from yourself, a person who lives in the insured’s home or who is related to the Insured by blood, marriage or adoption, or any of
the insured’s employers.
- Inpatient or outpatient services of a private duty nurse.
- Inpatient room and board charges in connection with a hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; custodial care or rest cures;
services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
- Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
- Treatment of drug, or other substance addiction or abuse except as specifically stated in the certificate of coverage.
- Dental services except as specifically provided in the certificate of coverage.
- Orthodontic services.
- Dental implants or associated procedures.
- Hearing aids.
- Routine hearing tests except as provided under Well Baby and Well Child Care.
- Optometric services except as specifically stated in the certificate of coverage.
- An eye surgery solely for the purpose of correcting refractive defects of the eye.
- Outpatient speech therapy.
- Any drugs, medications, or other substances dispensed or administered in any outpatient setting.
- Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical
community. This exclusion does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or for
medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy.
- Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change.
- Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies.
- All services related to the evaluation or treatment of fertility and/or infertility.
- All non-prescription contraceptive drugs, devices and/or supplies that are available over the counter or without a prescription, and non-FDA approved prescription contraceptive drugs,
devices and/or supplies. FDA approved prescription contraceptive drugs or devices available through a licensed pharmacy are covered under the prescription drug benefit of this plan.
- Cryopreservation of sperm or eggs.
- Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
- Services primarily for weight reduction or treatment of obesity.
- Routine physical exams or tests that do not directly treat an actual illness, injury or condition.
- Charges by a provider for telephone consultations.
- Items which are furnished primarily for your personal comfort or convenience.
- Educational services except for diabetes self-management training and as specifically provided or arranged by UniCare.
- Nutritional counseling or food supplements.
- Any services received on or within 12 months after the effective date of coverage if they are related to a pre-existing condition.
- Foreign Country Provider charges are excluded under this Plan except as specifically stated in the certificate of coverage.
- Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth
retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and
such treatment must be likely to result in a significant improvement of the insured's condition.
- Routine foot care.
- Charges for which we are unable to determine our liability because you failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records
and information We requested; or (b) provide Us with information We requested regarding the circumstances of the claim or other insurance coverage.
- Charges for animal to human organ transplants.
- Charges for pregnancy or maternity care, including normal delivery, elective abortions or cesarean sections.
- Claims received after 15 months from the date the service was rendered.
