Arizona Health Insurance > Golden Rule Insurance Company > Plan Exclusions & Limitations

General Exclusions

No benefits are payable for expenses which:

• Are due to pregnancy (except for complications of pregnancy) or routine newborn care (unless optional coverage is selected, if available),
• Are for routine or preventive care unless provided for in the policy
• Are incurred while confined primarily for custodial, rehabilitative or educational care or nursing services.
• Result from or in the course of employment for wage or profit, if the covered person is insured, or is required to be insured, by workers' compensation insurance pursuant to applicable state or federal law.  If you enter into a settlement that waives a covered person's right to recover future medical benefits under a workers' compensation law or insurance plan, this exclusion will still apply.
• Are in relation to, or incurred in conjunction with, investigational treatment.
• Are for dental expenses or oral surgery, eyeglasses, contacts, eye refraction, hearing aids, or any examination or fitting related to these.
• Are for modification of the physical body, including breast reduction or augmentation.
• Are incurred for cosmetic or aesthetic reasons, such as weight modification or surgical treatment of obesity.
• Would not have been charged in the absence of insurance.
• Are for eye surgery to correct nearsightedness, farsightedness, or astigmatism.
• Result from war, intentionally self-inflicted bodily harm (whether sane or insane), or participation in a felony (whether or not charged).
• Are for treatment of temporomandibular joint disorders, except as may be provided for under covered expenses.
• Are incurred for animal-to-human organ transplants, artificial or mechanical organs, procurement or transportation of the organ or tissue, or the cost of keeping a donor alive.
• Are incurred for marriage, family, or child counseling.
• Are for recreational or vocational therapy or rehabilitation.
• Are incurred for services performed by an immediate family member.
• Are not specifically provided for in the policy or incurred while your certificate are not in force.
• Are for any drug treatment or procedure that promotes conception.
• Are for any procedure that prevents conception of childbirth.
• Result from intoxication, as defined by applicable state law in the state where the illness or injury occurred, or under the influence of illegal narcotics or controlled substances unless administered or prescribed by a doctor.
• Are for or related to surrogate parenting.
• Are for or related to treatment of hyperhidrosis (excessive sweating).
• Are for fetal reduction surgery.
• Are for alternative treatments, except as specifically identified as covered expenses under the policy/certificate, including: acupressure, acupuncture, aroma therapy, hypnotism, massage therapy, rolfing, and other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health.

Benefits will not be paid for services or supplies that are not medically necessary to the diagnosis or treatment of an illness or injury, as defined in the policy.

General Limitations

• Expenses incurred by a covered person for the treatment of tonsils, adenoids, middle ear disorders, hemorrhoids, hernia, or any disorders of the reproductive organs are not covered during the covered person's first six months of coverage under the policy.  This provision will not apply if treatment is provided on an "emergency" basis.  "Emergency" means a medical condition manifesting itself by acute signs or symptoms that could reasonably result in placing a person's life or limb in danger if medical attention is not provided within 24 hours.
• Covered expenses will not include more than what was determined to be the reasonable and customary charge for a service or supply.
• Transplants eligible for coverage under the Transplant Expense Benefit are limited to two transplants in a 10-year period.
• Charges for an assistant surgeon are limited to 20% of the primary surgeon's covered fee.
• Covered expenses for surgical treatment of TMJ, excluding tooth extractions, are limited to $10,000 per covered person.
• All diagnoses or treatments of mental disorders, as defined in the policy, including substance abuse, are limited to a lifetime maximum benefit of $3,000 (not covered in Saver Plans, subject to state variations).  Covered expenses for outpatient diagnosis or treatment of mental disorders are further limited to $50 per visit.  As with any other illness or injury, inpatient care that is primarily for educational or rehabilitative care are not covered.
• Covered outpatient expenses relating to diagnosis or treatment of any spine or back disorders are limited to a maximum of $2,000 per calendar year.  CAT scan and MRI tests are not subject to this limitation.
• Covered expenses are limited to no more than a 34-day supply for any one outpatient prescription drug order or refill.