Starbridge Choices>Why Starbridge Choices>Limitations & exclusions

Dependent eligibility

Your Dependent is:

Your spouse

Your unmarried children under 19 years old, or

Your unmarried children who are 19 years old through 25 years old if the child is attending an accredited school full time and is dependent on you for support.

Pre-existing Condition Limitation (Medical) 1.

Benefits are not paid for a Pre-Existing condition. A Pre-existing Condition is one in which you have been diagnosed, treated or sought advice from a physician during the 6 months before becoming insured.

A condition will no longer be pre-existing:

at the end of 6 months of continuous coverage during which there is no medical diagnosis, treatment, advice or expense, or

after 12 months of continuous coverage.

Pre-existing coverage does not apply to a pregnancy or to newborn or adopted children. The pre-existing limitation can be reduced by the amount of time you were previously insured if you became insured under this policy within 63 days after termination of prior coverage.

When Coverage Ends

You or your dependent’s coverage will end:

when you no longer pay your premium

when you or your dependent enters the armed forces,

the day you or your dependent is no longer eligible for insurance, or

when the policy is terminated by your employer or us.

Benefit Limitations 1.

Coverage is not provided for services, supplies or equipment when a charge is not usually made in the absence of insurance.

No coverage is provided for loss caused by or resulting from:

Injury or sickness arising out of or in the course of employment;

Act of war;

Expenses which are not ordered by a Physician;

Cosmetic surgery. This does not apply to reconstructive surgery due to:

trauma, infection, or other disease; or

congenital disease or anomaly of a covered dependent newborn or adopted infant; or

surgery on a non-diseased breast to restore and achieve symmetry between two breasts following a mastectomy.

Hearing examinations or hearing aids;

Vision services and supplies other than for a disease process, radial keratotomy, keratomileusis or excimer laser photo refractive keratectomy or similar type procedures or services;

Charges made by a health care provider who is a member of your family or who is living with you;

Custodial Care confinement in a Hospital or Skilled Nursing Facility;

Home Health Care Services, unless provided in place of a Hospital confinement.

Commission of a felony;

Manipulations of the musculoskeletal system;

Treatment of mental or nervous disorders, alcoholism, or any form of substance abuse;

Intentionally self-inflicted injury or suicide attempt;

Dental care and treatment, except that required by injury and rendered within 6 months of the injury;

Treatment which is experimental or investigational.

Any expense incurred after the date the policy terminates.

Life Insurance

If you die while insured, we will pay the amount of life insurance in force at the time of your death. The payment will be made in one sum to your designated beneficiary after we receive proof of your death.

If your have no surviving beneficiary, payment will be made to your estate. At our option, payment may be made to one or more of the following: spouse, parent, child, or sibling.

No coverage is provided for:

death from air travel,

death while you reside outside of the continental US or Canada,

or death within 2 years from your effective date as a result of suicide.

No coverage is provided by death caused by:

War,

Suicide within 2 years of your effective date,

Medical or surgical treatment of sickness of disease, or

Flight except as a passenger in a commercial airline

Short Term Disability

Short Term Disability requires:

You be under the regular care of a physician,

Not under the elimination period,

The maximum benefit is reached or you cease to be totally disabled,

The weekly benefit be made up of 7 consecutive days, and

A period of less than a full week be calculated on a daily basis.

If you are totally disabled at different times while the policy is in force, from the same or related conditions, each time will be treated as a continuous period of total disability, unless there is a lapse of 6 months between disabilities.

No coverage is provided from disability resulting from:

Injury or sickness during the course of employment,

Act of war,

Your commission of a felony,

A period of disability during which you are not under the care of a doctor,

Mental or nervous disorders, alcoholism, or any form of substance abuse, or

Intentionally self inflicted injury or suicide attempt.

For any pre-existing condition.

We will waive the premium payment if you become totally disabled and receive benefits under the plan.

In-Hospital Indeminity Plan

This benefit is in addition to any other benefits under the policy. If you are confined to a hospital, we will pay benefits as specified in the plan documents.

Benefits will not be paid for any pre-existing conditions. A pre-existing condition is any condition for which you have been diagnosed, treated, sought advice from, or consulted with a physician during the 6 months before you became insured.

The pre-existing exclusion will cease to apply to a condition after either:

the end of a continuous 6 months of coverage during which

no expense is incurred,

no diagnosis or treatment is received, and

a physician is not consulted, or

12 months of continuous coverage.

The pre-existing limitation does not apply to a pregnancy, or newborn or adopted children. The pre-existing limitation can be reduced by the period of time you were previously insured for the condition causing the claims, provided you were insured with this other plan within 63 days of termination of your prior coverage.

The In-Hospital Indemnity excludes the following from coverage:

Hospital confinement which is not necessary treatment is not covered;

Any period of confinement for which a charge is not customarily made in the absence of insurance;

Loss caused by or resulting from:

Injury or sickness in the course of employment;

Act of war;

Your commission of a felony.;

Hospital confinement which is not ordered by a Physician;

Cosmetic surgery. This does not apply to reconstructive surgery:

Following surgery resulting from trauma, infection, or other diseases of the involved part; or

Because of a congenital disease or anomaly of a covered Dependent newborn or adopted infant; or

On a non-diseased breast to restore and achieve symmetry between two breasts following a mastectomy.

Any period of custodial care confinement;

Treatment of mental or nervous disorders, alcoholism, or any form of substance abuse;

Intentionally self-inflicted injury or suicide attempt.

Any expense incurred after the date the policy terminates.

Additional In-Hospital Medical Expense

This benefit is in addition to any other benefits under the policy. If you are confined to a hospital, we will pay benefits as specified in the plan documents.

Benefits will not be paid for any pre-existing conditions. A pre-existing condition is any condition for which you have been diagnosed, treated, sought advice from, or consulted with a physician during the 6 months before you became insured.

Additional Accident Benefit

This benefit supplements the basic medical coverage. It will be paid only after the basic medical coverage is exhausted. We will pay usual and customary expenses for necessary treatment incurred:
Benefits will be subject to applicable maximums, cash deductibles, participation rates and maximum occurrences.

FOOTNOTES

1. This provision or limitation varies by state.

2. For groups sitused in New York, this plan is underwritten by AMLICO in Hicksville, NY. Plan design and rates may vary.

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