SLPC 28071 1/17 (exp. 1/19)
What are the exclusions?*
We will not pay benefits for the covered employee or dependent relating to or resulting, directly or indirectly, from any of the following: services or treatment for which the covered employee or dependent is not charged, unless there is no charge because the facility is a United States government facility; services or treatment not included in the Schedule; services or treatment provided by a family member; services or treatment rendered or hospital confinement outside the United States; any cancer diagnosed solely outside the United States; services or treatment provided primarily for cosmetic purposes; services or treatment for premalignant conditions; services or treatment for conditions with malignant potential; services or treatment for non-cancer illnesses; service in the armed forces or related auxiliaries such as the National Guard or Army Reserve of any country, combination of countries, or international organization at war, whether declared or not; war or any act of war, whether declared or not; taking part in a riot or insurrection, or an act of riot or insurrection; committing or attempting to commit an assault or felony; incarceration in a penal institution of any kind; treatment of mental illness; intoxication (intoxication means the covered employee’s or dependent’s blood alcohol level exceeds the legal limit for operating a motor vehicle in the jurisdiction in which the injury occurs); intentionally self-inflicted injury, while sane or insane; or suicide or attempted suicide, while sane or insane.
What are the limitations?*
All benefits are subject to a pre-existing conditions limitation. A pre-existing condition means a sickness, symptom or physical finding, or any related sickness, symptom or physical finding, for which the covered employee or dependent consulted with or received advice from a licensed medical or dental practitioner; or received medical or dental care, treatment or services, including taking drugs, medicine, insulin or similar substances during the 12 months that end on the day before the covered employee or dependent became insured under the policy. We will not pay benefits for claims resulting, directly or indirectly, from a pre-existing condition unless the covered employee or dependent is diagnosed with cancer after 12 consecutive months during which the covered employee or dependent is continuously insured under this plan.
*Subject to state law variations.