Benefit Policy Exclusions
Click the links below to see the details for each benefit exclusion.
Basic Life
With respect to the Life Insurance Benefit, in the event an Insured, while sane or insane (in Missouri while sane), dies from intentionally self-inflicted injuries or any attempts thereat, within two years from the effective date of coverage, Companion Life's liability shall be only to return premiums paid under this Policy as to such Insured.
Voluntary Life
With respect to the Life Insurance Benefit, in the event an Insured, while sane or insane (in Missouri while sane), dies from intentionally self-inflicted injuries or any attempts thereat, within two years from the effective date of coverage, Companion Life's liability shall be only to return premiums paid under this Policy as to such Insured.
Voluntary AD&D
This Policy does not provide benefits for any loss caused by or resulting from:
- Declared or undeclared war or any act of war;
- Service in the armed forces of any country or international authority;
- Suicide or intentionally self-inflicted injury whether the Insured was sane or insane (in Missouri while sane) at the time of the suicide or injury;
- Flying in an aircraft owned, operated, leased or chartered by the Policyholder;
- Participation in, or in consequence of having participated in, the commission of any felony;
- Sickness or disease, ptomaine or bacterial infection (except infections occurring through an accidental cut or wound);
- Intentionally taking a narcotic, drug, barbiturate, hallucinogenic drug, alcohol or any combination of these when not part of a professional medical treatment plan.
The Policy will not pay benefits for any disability which:
- is not being continuously treated by a physician, unless it is determined by Us that continued care is of no benefit to You;
- is the result of Injury or Sickness that, in either case, arises out of work for wage or profit;
- is the result of an intentionally self-inflicted injury or a suicide attempt;
- is the result of declared or undeclared war, or any act of war, or armed aggression, or which results from service in the armed forces of any country or international authority;
- is the result of participation in a riot or insurrection, or commission of, or attempt to commit an assault or felony, or while engaged in an illegal occupation.
Firms Ineligible For Short Term Disability |
Ammunition | Metal and Coal Mining |
Ammusement Parks, Clubs, Sports, Other Recreational Services | Oil and Gas Extraction, Mining and Quarrying |
Asbestos Products | Police Protection |
Detective, Guard and Armored Car Services | Private Households |
Explosives | Small Arms, Ordnance and Accessories |
Fire Protection | Theatrical Producers, Bands, Entertainers |
Eating Places | |
I. Covered Expenses will not include and no benefits will be payable:
- for Class III Procedures in the first 12 months that the insured is covered under this plan except:
- when this plan replaces the insured's coverage under the employer's prior plan;
- the prior plan contained similar benefits for Class III Procedures as this plan;
- the prior plan had been in effect for at least 18 months; and
- takeover benefits have been approved by Companion Life.
- in the first twelve months that a person is insured if the person is a Late Entrant; except for exams, cleanings and fluoride application.
- for any treatment which is for cosmetic purposes, or to correct congenital malformations, other than medically necessary treatment of congenital cleft in the lip or palate, or both.
- to replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed bridge within five years of the date of the last placement of these items. Replacement of an existing implant supported prosthetic device is covered only once every ten (10) years from the placement date of such device and only then if it is unserviceable and cannot be made serviceable. But if a replacement is required because of an accidental bodily injury sustained while the Insured is covered under this section, it will be a Covered Expense.
- for initial placement of any prosthetic appliance, implants or fixed bridge unless such placement is needed because of the extraction of one or more natural teeth while the Insured is covered under this section. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth.
- for any procedure begun before the Insured was covered under this section.
- for any procedure begun after the Insured's insurance under this section terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the Insured's insurance under this section terminates.
- to replace lost or stolen appliances.
- for appliances, restorations, or procedures to:
- alter vertical dimension;
- restore or maintain occlusion;
- splint or replace tooth structure lost as a result of abrasion or attrition; or
- treat disturbances of the temporomandibular joint.
- for any procedure which is not shown on the List of Dental Procedures.
- for education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control.
- for the completion of claim forms.
- for orthodontia service, Class IV, when this optional coverage is not elected and the premium is not paid. In any event, orthodontia covered charges will not include charges:
- incurred by employee or spouse; or
- incurred by a dependent child age 19 or over (unless optional Adult Orthodontia Benefit is Selected); or
- for any services payable under any other provisions of the policy; or
- for any services in the first 12 months the insured person is covered under the policy.
- for sealants which are:
- not applied to a permanent molar.
- applied after attaining age 17.
- reapplied to a molar within 3-years from the date of a previous sealant application.
- subgingival curettage or root planing (procedure numbers 4220, and 4341) unless the presence of periodontal disease is confirmed by both x-rays and pocket depth summaries of each tooth involved.
- because of an injury arising out of, or in the course of, work for wage or profit.
- by an Insured because of a sickness, injury or condition for which he or she is eligible for benefits under any Worker's Compensation act or similar laws.
- for charges for which the Insured is not liable or which would not have been made had no insurance been in force.
- for services which are not recommended by a dentist or which are not required for necessary care and treatment.
- because of war or any act of war, declared or not.
- to an Insured if payment is not legal where the Insured is living when expenses are incurred.
- Any services related to: equilibration; bite registration or bite analysis.
- Crowns for the purpose of periodontal splinting.
- Charges for: precision or semi-precision attachments, and any endodontic treatment associated with it; or other customized attachments.
II.Payment For Services During the First 12 Months Shall Be Limited As Follows:
If:
- this plan replaces the insured's coverage under the employer's prior plan;
- the prior plan contained similar benefits as this plan; and
- this results in continuous coverage, then, we limit what we pay to the lesser of:
- what the prior plan would have paid; or
- what this plan would usually pay. We will deduct any benefits actually paid by the prior plan under any extension provision.
No benefits will be paid for services or materials connected with or charges arising from:
- Orthopic or vision training, sub-normal vision aids, and any associated supplemental testing;
- Aniseikonic lenses
- Medical and/or surgical treatment of the eye, eyes, or supporting structure;
- Corrrected eyewear required by an employer as a condition of employment, and safety eyewear unlessspecifically covered under plan;
- Services provided as a result of any Worker's Compensation law;
- Plano non-prescription lenses and non-prescription sunglasses (except for 20% discount);
- Services or materials provided by any other group benefit providing for vision care;
- Two pair of glasses in lieu of bifocals.