Arizona Health Insurance > Celtic Insurance Company > Exclusions & Limitations

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HEALTH PLAN EXCLUSIONS

Benefits are not paid under any plan for a sickness or bodily injury resulting from:

• any act of war, declared or undeclared, or service in the military forces of any country, including non-military units supporting such forces;
• participation in a riot, felony, or other illegal act or being under the influence of alcohol, drugs or narcotics unless taken as prescribed by a physician;
• suicide or attempted suicide, or self-inflicted bodily injury while sane or insane;
• free of charge in lieu of this insurance;
• by a government-operated hospital unless the insured person is required to pay;
• for treatment received outside the United States except for a medical emergency while traveling for up to a maximum of 90 consecutive days;
• sickness or bodily injury that arises out of, or as a result of, any work if the insured person is required to be covered under Worker’s Compensation or similar legislation.

Other exclusions include:

• normal pregnancy and delivery, elective or repeat cesarean section;
• routine physical examinations and “well-baby” care of a dependent child unless CeltiCare II Plus option is chosen. “Well-baby” care is defined as charges not related to a sickness or bodily injury;
• treatment or surgical procedure relating to fertility, including diagnosis or treatment of infertility;
• birth control (except where state mandated);
• tubal ligations and vasectomies performed while hospital confined are not covered. The reversal of a tubal ligation or vasectomy is not covered at any time;
• treatment or surgery for exogenous, endogenous, or morbid obesity;
• gender reassignment (sex change or reassignment);
• eye refractions, vision therapy, glasses or fitting of glasses, contact lenses, surgical or non-surgical treatment to correct refractive eye disorders, or any treatment or procedure to correct vision loss;
• hearing aids, exams or fittings, or surgical or non-surgical treatment or procedure to correct hearing loss;
• treatment or medication that is experimental or investigational;
• custodial care;
• treatment of drug addiction or chemical dependency;
• myringotomy or dilation and curettage and surgical treatment of tonsils, adenoids or hernia within first 6 months of coverage;
• outpatient prescription drugs, unless purchased at a participating pharmacy.

IMPORTANT PLAN INFORMATION

Eligibility Requirements – To qualify for coverage, a primary applicant must be six months or over and under 641/2 years of age and must not be covered under any other health insurance plan. Applicant must be a United States citizen or a foreign resident who has been living in the United States for at least two years under a permanent visa. Dependents must be 6 weeks or older.

Pre-existing Conditions – A pre-existing condition is a sickness or bodily injury for which an insured person received a diagnosis, medical advice, consultation, or treatment during the 12 months prior to the effective date, or for which an insured person had symptoms 12 months before the effective date which would cause an ordinarily prudent person to seek medical care or treatment.

Celtic will provide full coverage of pre-existing medical conditions if certain specific guidelines are met. The applicant must fully disclose all pre-existing medical conditions on the application. Then, if they pass our underwriting guidelines, on a standard basis, we’ll provide full coverage. Benefits are not paid for an insured person’s undisclosed pre-existing condition until coverage has been in force 12 months from the effective date provided coverage was issued on a standard basis.

Term Life Insurance Option - If available in your state, you may elect the Term Life Insurance option, which pays a benefit to the beneficiary if the primary insured person dies. The maximum benefit amount is $25,000 for individuals ages 18-64 years and $10,000 for individuals ages 6 months through 17 years.

When Coverage Begins and Ends – Your effective date will appear on the schedule page of your Certificate Booklet or Policy, provided that you mail in your premium payment with your application and are accepted for coverage. Coverage ends when:

• you fail to make the required premium payments;
• you cease to be an eligible dependent;
• you begin living outside the United States;

* This is not intended to provide full details of Celtic plans and may change at the discretion of Celtic Insurance Company. Complete terms of coverage are outlined in the individual Certificate Booklets and set forth in the applicable insurance policy. In applying for coverage, the primary insured agrees to be bound by the Certificate or Policy. The benefits described here and any accompanying literature are the standard benefits offered by Celtic. Policy provisions vary in some states.