Benefit Exclusions Sample Clauses
Benefit Exclusions. Marrriage or family counseling and other conditions may be specifically excluded on your certificate of coverage. It is your responsibility to call your insurance company to see what is covered and what services you are responsible for.
Benefit Exclusions. No benefits shall be provided to you under this Agreement if (a) you terminate your employment with the Company whether or not you believe you have good reason for such termination, (b) you become entitled to the benefits described in Section 5(iii) of the Change in Control Severance Agreement between you and the Company, or (c) your employment terminates as a result of your death or your Disability (as defined in the Change in Control Severance Agreement).
Benefit Exclusions. The following shall be excluded from the benefits to be provided to Subscribers and eligible Dependents.
1. Benefits or services for injuries or conditions compensable under Worker’s Compensation or Employers’ Liability laws.
2. Benefits or services available from any federal or state government agency; or from any municipality, county, or other political subdivision or community agency; or from any foundation or similar entity.
3. Charges for services or supplies for which no charge is made that the patient is legally obligated to pay or for which no charge would be made in the absence of dental coverage.
4. Benefits for services or appliances started prior to the date the patient became eligible under this Plan may be excluded.
5. Charges for services when a claim is received for payment more than twelve (12) months after services are rendered.
6. Charges for any professional services performed by a relative of the patient.
7. Charges for treatment by other than a properly licensed dentist (unless allowed by state law), except radiographic images (x−rays) ordered by a dentist, cleaning and scaling of teeth, and topical application of fluoride may be performed by a properly licensed hygienist if treatment is rendered under the supervision and guidance of the dentist, in accordance with generally accepted dental standards.
8. Charges for completion of forms or submission of documentation required by DDPOK for a benefit determination. Such charges are not billable to the patient when services are provided by a Delta Dental Participating Dentist. Such charges are denied if submitted by a Nonparticipating Dentist.
9. Charges for house calls, hospital calls, or office visits.
10. Charges for missed or cancelled appointments, hospitalization or additional fees charged for hospital treatment, or management fees.
11. Charges for bleaching of teeth.
12. Prescription drugs, premedications, andƒor relative analgesia.
13. Experimental procedures.
14. Benefits or services for orthodontic treatment, unless specifically provided herein.
15. Charges for repair of an orthodontic appliance.
16. Charges for replacement of lost or missing crowns and appliances, or for stolen appliances.
17. Benefits or services to correct congenital or developmental malformations, for example, cleft palate, etc.
18. Services for the purpose of improving appearance when form and function are satisfactory and there is insufficient pathological condition evident to warrant the treatment (cosmet...
Benefit Exclusions. Covered Expenses will not include, and no payment will be made for the following: Procedures and services not included in the list of covered dental expenses;
Benefit Exclusions. Subject to provisions to the contrary in the supplementary terms, no benefits for medical expenses and/or daily benefits are paid in the following cases: • Cost shares and benefit reductions under other insur- ance policies • Conditions existing prior to the effective date of the contract • Treatment and measures that are not effective, expe- dient or economical; the effectiveness of the treatment or measure must be scientifically proven • Interventions to remedy or improve physical defects and disfiguration, unless made necessary by an in- sured event • Treatment aimed at self-fulfilment, self-development or personality development or other purposes that do not involve the treatment of an illness • Weight reduction programmes, dietary advice, strengthening therapy, cellular therapy • Dental treatment, except in connection with compul- sory benefits under mandatory basic health insurance pursuant to the Swiss Federal Health Insurance Act (KVG/▇▇▇▇▇) • Measures ordered by a judicial or administrative au- thority (therapy instead of a prison sentence, alcohol tests, etc.) • Consequences of riots, terrorist acts, crimes or of- fences of any type and measures implemented to counteract them, unless the insured can prove that he did not actively participate on the side of the perpetra- tors or incite them to further violence • Treatment during foreign military service and/or fol- low-up treatment • Illness and accidents as a consequence of acts of war – in Switzerland – in another country, unless the illness or accident oc- curs within a period of 14 days from the first out- break of warlike activities in the country in which the insured person is staying and he was taken by sur- prise by the outbreak of warlike activities while stay- ing there – For expatriates and insured persons who are work- ing abroad for a short period (up to 12 months) on behalf of their employer, coverage also extends to accidents that are the consequence of acts of war, provided that the insured person did not actively participate in or incite these acts or intentionally travel to the war zone. Sanitas may temporarily or permanently suspend this ad- ditional coverage for specific countries subject to notice of fourteen days.
Benefit Exclusions. Unless specified in the Benefits Schedule/Table of Benefits, or in any written endorsement, or agreed by Alliance Health in writing, no claim can be made for compensation or payment for damage or expenses caused by or as a result of the following: Abuse of Alcohol or Any Other Substance Whether Controlled or Not: Treatment for alcoholism, narcotics, drug and substance abuse/dependency or any addictive condition of any kind and any injury or illness arising from the Insured Person being under the influence of alcohol, drugs or any other intoxicating substance, including medicines prescribed by a medical Doctor or Consultant. Including treatment for smoking, or to give up smoking. General treatment of any withdrawal symptoms brought on by a prior addiction. Acting Against Medical Advice: Failing to follow instructions or advice given to you by your family doctor, a general practitioner, specialist or therapist in regard of your diet, your exercise or any other factors. Allergic Conditions and Disorders: Desensitising, or neutralising treatment for any allergic condition.
Benefit Exclusions. Exclusions from Sick Leave Bank benefits include but are not limited to the following.
a. Any illness, injury, or quarantine of anyone other than the Sick Leave Bank member.
b. Any employee eligible for Worker’s Compensation is not eligible for Sick Leave Bank benefits.
c. Once an employee is eligible for disability retirement, all Sick Leave Bank benefits will cease.
d. An employee who at the time of Sick Leave Bank application is on an approved leave of absence, suspended, or terminated from SMCPS is not eligible for Sick Leave Bank benefits.
e. Normal pregnancies and childbirth are not considered eligible reasons for Sick Leave Bank benefits.
f. Members with available leave are not eligible for Sick Leave Bank benefits. Members must use all accumulated annual, personal, and sick leave before being eligible for leave from the bank. Members eligible for direct sick leave transfer from other employees must exhaust those options first. (Refer to appropriate negotiated agreements – CEAMC Article 8.3, d, 1, 5th bullet – EASMC Article VIII, C, 1, a, 5 – SMASA Article VIII, C, 1 and Article VIII, C, 1, a, 5.)
g. Donated sick leave granted in one school year cannot be carried over and used in a subsequent school year. Unused Sick Leave Bank days will be returned to the bank.
h. A member who is receiving benefits from the Sick Leave Bank may not work secondary employment. To do so will result in immediate termination of Sick Leave Bank benefits and revocation of any previously granted days.
Benefit Exclusions. No benefits shall be provided to you under this Agreement if (a) you terminate your employment with the Company whether or not you believe you have good reason for such termination, (b) your employment terminates as a result of your death or your Total and Permanent Disability (as defined in the ESRIP), or (c) you become entitled to the Change in Control Severance Benefit (as defined in the ESRIP).