Reso 98-109 - Laserfiche WebLink

Home Browse Search

Ronda Municipal Insurance Trust Medical Master Plan of Benefits amount of savings and your request for payment. SECTION VIII - EXCLUSIONS AND LIMITATIONS Unless otherwise expressly covered in Section VI of the Plan, coverage under this Plan for participants is subject to the following exclusions ,and limitations for which no benefits shall be paid: (1) Services or supplies for beautifying or cosmetic purposes unless: (a) necessitated by an accidental injury while covered under this Plan and performed within six (6) months following the date of the accident, and (b) required to restore a normal bodily function, (2) Services or supplies provided by any custodial institution, rest home, nursing home, sanitarium, health spa, health resort, place of rest, institution or home for the aged, drug addicts, or alcoholics, or a place for the treatment of pulmonary tuberculosis or mental or nervous disorders. (3) Fees for routine physical examinations or periodic check-ups, except as otherwise specifically stated in this Plan. (4) Any service or supplies to a participant hospitalized for primarily rest, restj cure or primarily for observation. (5) Services or supplies for injury or sickness resulting from drug or alcohol abuse, or resulting from intoxication or consumption of drugs or alcohol. (6) Eye refractions, keratotomies, eye glasses, hearing aids and examinations or the prescription or fitting thereof, eye exercise, visual training or orthoptics. (7) Travel expenses, whether or not travel is recommended by a physician. (8) Hospital service or supplies for a participant who shall remain in a hospital after the attending physician advises that further hospital service is unnecessary . . (9) Dentist, physician or hospital expenses for dental care and treatment including treatment or removal of teeth and immediately adjacent structures (ie. gingival) and any services for orthodontia, prosthodontia, periodontia and preparation for dentures unless, as a result of an accident, natural teeth have been damaged or a fracture or dislocated jaw requires setting, and then only if such dental treatment is rendered within ninety (90) days from the date of the accident. (10) Massage unless the massage is prescribed by a physician, which prescription specifies the number of treatments and is performed under the direct supervision of a physician or by a massage therapist, and is approved in advance by the Trust. (11) Services or supplies for the primary purpose of providing rehabilitation to a participant including, but not limited to, rehabilitative services related to alcohol and drug abuse or accident or sickness arising therefrom, occupational therapy, speech therapy, and pain management training and educational programs. (12) Services or supplies for surgery for sexual reassignment or reconstruction, or