Summary Plan Description

Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

GENERAL LIMITATIONS AND EXCLUSIONS

In addition to any limitations or specific exclusions described in this Summary Plan Description, there are general imitations and exclusions, which apply to all benefits. No payments will be made for expenses incurred for you or your eligible dependents:

for services, supplies or treatments, which are not Medically Necessary, as defined herein;
for fees which are in excess of the Reason and Customary charges for such services, supplies, or treatment as defined herein;
for charges which are not received by the Fund Office, along with all required supporting information necessary to process the claim, within 12 months from the date services were rendered;
for services or supplies not listed as covered charges;
for Cosmetic Surgery;
Infertility procedures;
Artificial insemination, in-vitro fertilization, G.I.F.T. or like procedures, and any services associated with such procedures;
for expenses incurred as a result of past or present services in the armed forces of any government;
for loss caused by war or any act of war;
for an Injury or an Illness that is employment-related or that is covered under Workers' Compensation Law, occupational disease law, or similar laws;
for expenses for military service-related care in a veterans' facility or a Hospital operated by the United States, unless required by law;
for any charges which you or your dependent are not legally required to pay, including charges that would not have been assessed if no insurance coverage existed;
for services for which there is no legally enforceable charge;
for charges for Custodial Care;
for meals, meal preparation, personal comfort or convenience items, housekeeping services, Custodial Care, and protective or companion services;
for charges incurred for the completion of claim forms and mailing fees;
for charges incurred for handling fees, unless directly related to test results;
for expenses incurred as a result of failure to keep a scheduled appointment;
for interest or other penalties;
for any services rendered by a Physician or any other provider of medical services to himself or his immediate family, including parents, spouse, brothers, sisters, children, and grandchildren;
for any expenses for which you or your dependent is in any way paid or entitled to payment for those expenses by or through a public program;
for Experimental procedures, equipment, treatment or course of treatment, as defined herein;
for experimental drugs or substances not approved by the Food and Drug Administration, or for drugs labeled: "caution limited by Federal law to investigational use";
for refractive eye surgery, including keratotomy;
for services of a naturopath, homeopathic, hypnotherapy, faith-healer or other like services;
for expenses incurred for functional visual training;
for any expenses related to surrogate parenting;
for routine care of the feet out of the Hospital (except for diabetics);
for any expenses related to foot care for treatment, services, or supplies in connection with: corns; calluses; nails; weak, strained, or flat feet; any instability or imbalance of the feet; or shoes, orthotics, or any other inserts;
for travel, except as specifically covered by this Plan;
for services rendered by interns, residents, and Physicians in training;
for medical treatment of obesity and morbid obesity including but not limited to any type or variation of bariatric surgery, specialized medical weight reduction programs and medications, except that, the exclusion for bariatric surgery will not apply to claims by you or your eligible dependents (the” Bariatric Applicant”) if(i) the Bariatric Applicant has secured prior written approval (precertification) from GHI that the Bariatric Applicant satisfies the criteria stated in GHI’s most recent Clinical Policy Bulletin for medically necessary services, and (ii) the procedure is performed by a Network surgeon in a Network facility known to have an effective program for performing such surgery and follow-up program. No more that 80% of the network allowable rate will be processed. The Bariatric Applicant will be responsible for twenty 20% co-payment. No more that one bariatric surgery per lifetime will be covered for each Bariatric Applicant who qualified for coverage under this exception. Benefits will include medically necessary services and supplies that GHI determines in its latest Clinical Policy Bulletin, to be appropriate and essential to the long term success of the bariatric surgery. However, benefits will not be provided for subsequent services or procedures that become medically necessary as a result of the Bariatric Applicant’s non-compliance with prescribed, post-surgery, medical treatment.
for corrective eye surgery for near/far sightedness, including but not limited to PRK, and LASIK;
for any services or supplies for or in connection with acupuncture;
for vitamin injections;
for any expenses related to transsexual surgery, counseling or like services or treatment;
for any expenses, or portion thereof, for which mandatory automobile no-fault benefits are recovered or recoverable;
for services rendered in the treatment of TMJ;
for services beyond the scope of the license of the person performing them;
for services rendered in the study or treatment of sleeping disorders of any kind; and
for services rendered in the fitting, prescribing and purchasing of hearing aids.