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<br />Ronda Municipal Insurance Trust
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<br />Medical Master Plan of Ben.flb
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<br />(ll) Well Child Care - the reasonable fees charged by a physician for physicals,
<br />examinations, developmental assessments, anticipatory guidance,
<br />immunizations and laboratory tests, in keeping with prevailing medical
<br />standards, which are not required for the treatment of illness or injury, for
<br />covered dependent children from the moment of birth to sixteen (16) years of
<br />age, are payable subject to the following:
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<br />(a) A lifetime maximum of eighteen visits at the following age intervals; birth,
<br />two months, four months, six months, nine months, twelve months,
<br />fifteen months, eighteen months, two years, three years, four years, five
<br />years, six years, eight years, ten years, twelve years, fourteen years and
<br />sixteen years.
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<br />(b) Benefits are limited to one visit payable to one physician for all service
<br />provided at that visit.
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<br />(c) The benefit is not subject to the calendar year deductible, but is subject
<br />to the coinsurance, if applicable.
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<br />(12) Therapeutic Treatment - by a radiologist including radium, radon, isotope, x-
<br />ray and cobalt bomb therapy when in connection with proven malignancies.
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<br />(13) Newborn Care - when rendered by a physician to a newborn dependent child
<br />of a participant, from the moment of birth, for covered injury or sickness,
<br />including necessary care or treatment of medically diagnosed congenital
<br />defects, birth abnormalities, or prematurity. A newborn infant of a
<br />dependent child is eligible and shall be covered so long as the dependent
<br />child is covered but not to exceed eighteen (18) months.
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<br />Other Medical Services - The expenses incurred for the following services will be
<br />paid as stated in the Schedule of Benefits (in excess of any deductible andj or
<br />coinsurance) for reasonable fees up to the Lifetime Maximum of this Plan or to the
<br />end of the calendar year whichever first occurs.
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<br />(1) Emergency Professional Ambulance Service - to the nearest hospital able to
<br />provide the care required for the patient. Transportation costs of a newborn
<br />to and from the nearest available facility appropriately staffed and equipped
<br />. to treat the newborn's condition, when such transportation is certified by the
<br />attending physician as necessary to protect the health and safety of- the
<br />newborn child shall be covered. The coverage of such transportation costs
<br />shall not exceed the reasonable fees, and in no event shaJ.1 exceed the sum of
<br />$1,000,**
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<br />(2) Prosthetic and Other Devices - initial (under this Plan) appliances, crutches,
<br />braces, cardiac pacemakers, standard model wheelchair, or other mechanical
<br />appliances medically necessary for the correction of conditions arising out of
<br />injuries or sickness, provided the equipment is prescribed by a physician,
<br />and the equipment does not, in whole or in part, serve as a comfort or
<br />convenience item. Written approval must be obtained by the Trust for
<br />prosthetics and other devices which exceeds $500 in cost. The Trust shall
<br />have the right to buy or rent such appliances as they may elect.
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<br />(3) Splints, Casts, Trusses.
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<br />(4) Other Durp.ble Medical Equipment Rental- required for temporary therapeutic,
<br />provided the equipment is prescribed by a physician, and the equipment does
<br />not, in whole or in part, serve as a comfort or convenience item. Written
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