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s. dental Treatment of the teeth, gums, or structures directly supporting the teeth, including dental
X-rays, examinations, repairs, orthodontics, periodontics, casts, splints, and services for dental
malocclusion for any condition are not covered, except if provided for or in connection with an
injury to sound natural teeth and a continuous course of dental Treatment is started within six (6)
months of the injury. Sound natural teeth are defined as natural teeth that are free of active
clinical decay, have at least fifty percent (50%) bony support, and are functional in the arch; or

t. cosmetic care, except when the Hospital Confinement is due to medically-necessary
reconstructive plastic surgery. Medically-necessary reconstructive surgery is defined as:
1. surgery as the result an injury; or
2. surgery to restore a normal bodily function; or
3. surgery to improve functional impairment by anatomic alteration made necessary as a result
of a congenital birth defect; or
4. breast reconstruction following mastectomy.

Also, no benefits will be payable under the Rider for:
a. loss that begins prior to the Rider Effective Date;
b. Treatment for which no charges are made by the provider of same;
c. services which are primarily for rest care, convalescent care, or for rehabilitation; or
d. any injury or Sickness paid for under any state or federal Workers’ Compensation, Employers’

Liability Law, or similar law.

PRE-EXISTING CONDITION(S) The benefits of the Rider will not be payable during the first twelve
(12) months that coverage is in force with respect to an Insured Person for any loss caused by Pre-
Existing Condition(s). This twelve (12) month period is measured from the Rider Effective Date for each
Insured Person.

We will pay the Intensive Care Unit Indemnity Benefit Amount shown on the Policy Schedule Page
for each Day that an Insured Person is confined to the Intensive Care Unit of a Hospital as an
Inpatient. For benefits to be payable, the Intensive Care Unit Confinement must:
a. be due to an injury, Sickness, or Complication of Pregnancy;
b. begin while the Rider is in force for an Insured Person;
c. be for at least twenty-four (24) hours; and
d. be at the direction of and under the supervision of a Physician.

Benefits will not be payable beyond a Maximum Benefit Period of thirty (30) Days, as shown on the
Policy Schedule Page, for any one (1) Period of Confinement.

Upon attainment of Age sixty-five (65), coverage for each Insured Person will be reduced by fifty
percent (50%) as shown on the Policy Schedule Page.

LY-LSH-OC-B-FL 8 10/13
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