Page 10 - Nationwide_Care Access Plan
P. 10
Exclusions
Consult the certificate of insurance for a complete list of exclusions and description of the benefits not covered.
Except as specifically provided for in the policy, the plan does not provide any benefits when a covered person receives
any of the following treatments, services or supplies:
›› A pre-existing condition, as defined ›› Surgery to correct refractive errors
›› Preventive care, including routine physical examinations and ›› Routine eye exams, glasses or contact lenses, or visual therapy
›› Routine hearing exams or hearing aids
immunizations (unless the optional Preventive Care Benefit ›› Penile implants and fertility and sterility studies
rider is shown as included on the schedule of benefits) ›› Voluntary abortion; infertility including impregnation
›› Treatment that is not medically necessary or not
recommended by a doctor, or is not due to an injury or illness techniques; or reversal of sterilization
›› Any treatment provided by a government-owned or ›› Mental illness disorders; substance abuse; tobacco-cessation
government-operated facility or by government-employed
health care providers programs and products
›› A weekend hospital confinement occurring between noon on ›› Marriage or family counseling, recreational therapy, equine
any friday and noon the following sunday for non-emergency
procedures, unless medically necessary or unless surgery is therapy, educational therapy, social therapy, sex therapy; or
scheduled for the next day sexual reassignments, dysfunctions or inadequacies
›› An illness or injury which arises out of or in the course of ›› Meridian therapy (acupuncture), or spinal manipulation
any employment for wage or profit or an illness or injury for ›› Orthotics; treatment, services or supplies related to the feet
which you or your covered dependent spouse has or had a by means of posting, strapping or range-of-motion studies; or
right to recovery under any Workers’ Compensation Law or related to paring or removal corns, calluses, bunions
Occupational Disease Law. This exclusion does not apply to or toenails
an employment related injury or illness if you or your covered ›› Obesity or weight reduction including all forms of surgery
dependent spouse is a sole proprietor, partner, or owner and complications resulting from such surgery; education or
eligible under state law to legally elect to not be covered training material
under workers’ compensation and who is not insured under, ›› Treatment for which the covered person is not required to pay;
and who does not have or had a right to recovery for such or treatment rendered by a person who ordinarily resides in
employment related injury or illness under any Workers’ your household or a member of your immediate family
Compensation Law or Occupational Disease Law. ›› Custodial care, domiciliary care or rest cures regardless of
›› Physical or psychological examinations required by any who prescribes or renders such care; inpatient personal
third party, such as by a court or for employment, licensing, convenience items
insurance, school, sports or recreational purposes ›› An injury or illness resulting from participation in hazardous
›› An injury or illness incurred while on active duty with the avocations including: mountain or rock climbing, skydiving,
military of any country or international organization, or hang gliding, motor vehicle racing, scuba diving, rodeo or
resulting from war, act of war or participation in a riot private aviation
or insurrection ›› Telephone consultations, missed appointment fees and fees
›› An injury or illness incurred during the commission or for completing claim forms
attempted commission of a crime or felony or while engaged ›› Treatment, services or supplies for complications of conditions
in an illegal act or while imprisoned that are not covered under the policy
›› An injury or illness, incurred due to, or contracted as a ›› Outpatient prescription medications
consequence of a covered person being intoxicated or under ›› Treatment, services or supplies related to the teeth gums, or
the influence of illegal narcotics or other drugs, unless the any other associated structures
drug is administered by a doctor and taken in accordance with ›› Treatment for temporomandibular joint (TMJ) dysfunction
the prescribed dosage ›› Experimental or investigational procedures, drugs or
›› An injury or illness for which treatment, services or supplies treatment methods
were received or purchased outside the United States unless ›› Intentionally self-inflicted injury or illness while sane;
the charges are incurred while traveling on business or for except a self-inflicted injury or illness that is the result of a
pleasure, for a period not to exceed 90 days, and the charges medical condition
are incurred for an emergency, provided the treatment, ›› Outpatient treatment, services and supplies except as
services or supplies used in connection with the emergency specifically provided for in the policy
are approved for use in the United States ›› Physical, speech or occupational therapy
›› Treatment, services or supplies for (a) breast augmentation; ›› Hospice or home health care
(b) the removal of breast implants unless medically necessary ›› Treatment, services or supplies to improve the appearance or
and related to surgery performed as reconstructive surgery self-perception of a covered person, which does not restore
due to an illness; and (c) breast reduction surgery unless a bodily function including, without limitation, cosmetic or
medically necessary due to an illness plastic surgery, hair loss or skin wrinkling, or the complications
of any such treatment
›› Pregnancy except complications of pregnancy
Brochure Care Access Plan L 0518 10
Consult the certificate of insurance for a complete list of exclusions and description of the benefits not covered.
Except as specifically provided for in the policy, the plan does not provide any benefits when a covered person receives
any of the following treatments, services or supplies:
›› A pre-existing condition, as defined ›› Surgery to correct refractive errors
›› Preventive care, including routine physical examinations and ›› Routine eye exams, glasses or contact lenses, or visual therapy
›› Routine hearing exams or hearing aids
immunizations (unless the optional Preventive Care Benefit ›› Penile implants and fertility and sterility studies
rider is shown as included on the schedule of benefits) ›› Voluntary abortion; infertility including impregnation
›› Treatment that is not medically necessary or not
recommended by a doctor, or is not due to an injury or illness techniques; or reversal of sterilization
›› Any treatment provided by a government-owned or ›› Mental illness disorders; substance abuse; tobacco-cessation
government-operated facility or by government-employed
health care providers programs and products
›› A weekend hospital confinement occurring between noon on ›› Marriage or family counseling, recreational therapy, equine
any friday and noon the following sunday for non-emergency
procedures, unless medically necessary or unless surgery is therapy, educational therapy, social therapy, sex therapy; or
scheduled for the next day sexual reassignments, dysfunctions or inadequacies
›› An illness or injury which arises out of or in the course of ›› Meridian therapy (acupuncture), or spinal manipulation
any employment for wage or profit or an illness or injury for ›› Orthotics; treatment, services or supplies related to the feet
which you or your covered dependent spouse has or had a by means of posting, strapping or range-of-motion studies; or
right to recovery under any Workers’ Compensation Law or related to paring or removal corns, calluses, bunions
Occupational Disease Law. This exclusion does not apply to or toenails
an employment related injury or illness if you or your covered ›› Obesity or weight reduction including all forms of surgery
dependent spouse is a sole proprietor, partner, or owner and complications resulting from such surgery; education or
eligible under state law to legally elect to not be covered training material
under workers’ compensation and who is not insured under, ›› Treatment for which the covered person is not required to pay;
and who does not have or had a right to recovery for such or treatment rendered by a person who ordinarily resides in
employment related injury or illness under any Workers’ your household or a member of your immediate family
Compensation Law or Occupational Disease Law. ›› Custodial care, domiciliary care or rest cures regardless of
›› Physical or psychological examinations required by any who prescribes or renders such care; inpatient personal
third party, such as by a court or for employment, licensing, convenience items
insurance, school, sports or recreational purposes ›› An injury or illness resulting from participation in hazardous
›› An injury or illness incurred while on active duty with the avocations including: mountain or rock climbing, skydiving,
military of any country or international organization, or hang gliding, motor vehicle racing, scuba diving, rodeo or
resulting from war, act of war or participation in a riot private aviation
or insurrection ›› Telephone consultations, missed appointment fees and fees
›› An injury or illness incurred during the commission or for completing claim forms
attempted commission of a crime or felony or while engaged ›› Treatment, services or supplies for complications of conditions
in an illegal act or while imprisoned that are not covered under the policy
›› An injury or illness, incurred due to, or contracted as a ›› Outpatient prescription medications
consequence of a covered person being intoxicated or under ›› Treatment, services or supplies related to the teeth gums, or
the influence of illegal narcotics or other drugs, unless the any other associated structures
drug is administered by a doctor and taken in accordance with ›› Treatment for temporomandibular joint (TMJ) dysfunction
the prescribed dosage ›› Experimental or investigational procedures, drugs or
›› An injury or illness for which treatment, services or supplies treatment methods
were received or purchased outside the United States unless ›› Intentionally self-inflicted injury or illness while sane;
the charges are incurred while traveling on business or for except a self-inflicted injury or illness that is the result of a
pleasure, for a period not to exceed 90 days, and the charges medical condition
are incurred for an emergency, provided the treatment, ›› Outpatient treatment, services and supplies except as
services or supplies used in connection with the emergency specifically provided for in the policy
are approved for use in the United States ›› Physical, speech or occupational therapy
›› Treatment, services or supplies for (a) breast augmentation; ›› Hospice or home health care
(b) the removal of breast implants unless medically necessary ›› Treatment, services or supplies to improve the appearance or
and related to surgery performed as reconstructive surgery self-perception of a covered person, which does not restore
due to an illness; and (c) breast reduction surgery unless a bodily function including, without limitation, cosmetic or
medically necessary due to an illness plastic surgery, hair loss or skin wrinkling, or the complications
of any such treatment
›› Pregnancy except complications of pregnancy
Brochure Care Access Plan L 0518 10
