Limitations

GENERAL LIMITATIONS
No benefits shall be payable under the Plan with respect to:

1 Services or expenses incurred prior to the effective date or after the termination date of coverage under the Plan.

2. Any services, supplies, charges or expenses which are not specifically included and listed as covered expenses under a portion of the Plan for which the Covered Person is eligible, including any charge or portion of a charge which is in excess of the usual, reasonable and customary charges as defined by the Plan.

3. Unless otherwise directed pursuant to an External Appeal, those for or in connection with services or supplies that are, as determined by the Plan, to be experimental or investigational. A drug, a device, a procedure, or treatment will be determined to be experimental or investigational if:

there are insufficient outcomes data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved;

or if required by the FDA, approval has not been granted for marketing;

or a recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational, or for research purposes;

or the written protocol or protocols used by the treating facility, or the protocol or protocols of any other facility studying substantially the same drug, device, procedure, or treatment, or the written informed
consent used by the treating facility or by another facility studying the same drug, device, procedure, or treatment states that it is experimental, investigational, or for research purposes. However, this exclusion will not apply with respect to services or supplies (other than drugs) received in connection with a disease; if Aetna determines that:

the disease can be expected to cause death within one year, in the absence of effective treatment;

and the care or treatment is effective for that disease or shows promise of being effective for that disease as demonstrated by scientific data. In making this determination Aetna will take into account the results of a review by a panel of independent medical professionals. They will be selected by Aetna. This panel
will include professionals who treat the type of disease involved. Also, this exclusion will not apply with respect to drugs that have been granted treatment investigational new drug (IND) or Group c/treatment IND status;

or are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute;

if Aetna determines that available scientific evidence demonstrates that the drug is effective or shows promise of being effective for the disease.

4. Unless specifically listed as covered under the Plan, any services not necessary, as determined by the Plan, for diagnosis, care or treatment of an illness or injury; except that circumcisions, abortions, vasectomies and tubal ligations shall be covered as if related to an illness.

5. Unless specifically listed as covered under the Plan, vaccinations, inoculations, preventive shots, and routine physical examinations.

6. Any treatment or service not prescribed or recommended by a Physician or other provider of services defined as eligible for payment by the Plan.

7. Unless specifically listed as covered under the Plan, any charges for hearing aids or their repairs, eye glasses, eye examinations, correction (including surgical) of vision, unless medically necessary.

8. Any services/treatments for which benefits are provided under any state or federal workers' compensation, employers' liability or occupational disease law.

9. Charges for any care or treatment of teeth, gums or alveolar process unless such charges are for:

a. reduction of fractures of the jaw or facial bones;

b. surgical correction of cleft lip, cleft palate, or protruding mandible;

c. removal of stones from salivary ducts;

d. bony cysts of the jaw, torus palatinus, leukoplakia or malignant tissues;

e. freeing of muscle attachments; or

f. charges for dental care or treatment except for such care or treatment due to accidental injury to sound natural teeth within 12 months of the accident and except for dental care or treatment necessary due to congenital disease or anomaly.

10. Those for cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect.

11. Expenses incurred for the treatment of corns, calluses or toenails, unless the charges are for the removal of nail roots or in conjunction with the treatment of a metabolic or peripheral-vascular disease.

12. Expenses incurred for Custodial Care Services.

13. Expenses incurred for orthopedic shoes, orthotics and other supportive appliances for the feet.

14. Any illness, accident, treatment or medical condition arising out of war or act of war (whether declared or undeclared), participation in a felony, riot or insurrection or service in the Armed Forces or units auxiliary thereto.

15. Any charges for care or treatment provided or furnished by the United States Government or the government of any country, except to the extent that federal or state law requires the Plan to provide benefits for such care or treatment.

16. Any services for which a charge would not have been made in the absence of coverage, except to the extent that federal law requires the Plan to provide benefits for such services.

17. Any expenses or charges that the member or patent is not legally responsible to pay for.

18. Except as specifically covered under Hospice Care, services or expenses that cannot reasonably be expected to lessen the patients disability and to enable him to live outside of an institution.

19. Charges for services/treatment for which an adequate claim is not filed with the Claims Administrator within 15 months from the date of service.

20. Expenses for prescription drugs or medicines prescribed for use on an out-patient basis, except to the extent specifically listed as covered expenses under the Plan's Prescription Drug Expense Benefits.

21. Any charges for services/treatment related to weight reduction, unless medically necessary or for the treatment of morbid obesity.

22. Any charges. for services/treatment related to an accident, to the extent that benefits for such services/treatment are paid/payable or recovered/recoverable through/from mandatory automobile no-fault insurance coverage.

23. Any charges for services provided by a member of the patient’s immediate family.

24. Those for education or special education or job training whether or not given in a facility that also provides medical or psychiatric treatment.

25. Charges/ expenses for acupuncture therapy except acupuncture when it is performed by a physician as a form of anesthesia in connection with surgery that is covered by the Plan.

26. Services to the extent for which an employee, retired employee or dependent:

A. Is entitled to benefits under either Part A or Part B of Medicare, or,

B. Would have been entitled to benefits under Part A or Part 8 of Medicare, except that, although being eligible, failed to enroll for the benefits, or

C. Would have been entitled to benefits under Part B of Medicare, but having enrolled, failed to continue to make payment of the premiums thereof.

PRE-EXISTING CONDITIONS
Pre-existing Condition Exclusion - There is an 11-month waiting period (for new employees and their families only) for any condition, injury or disease for which medical treatment or advice was received within a six month period prior to the effective date of coverage.

The exclusionary period shall be reduced by the length of time that the individual was covered under a prior health plan. Any coverage under a prior health plan which was followed by a gap in coverage of more than ninety (90) days shall not be considered.
A prior health plan may include any of the following:

• A group health plan;

• Health insurance coverage;

• Part A or B of Title XVIII of the Social Security Act;

• Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928; Chapter 55 of title 10, United States Code;

• A medical care program of the Indian Health Service or of a tribal organization;

• A state health benefits risk pool;

• A health plan offered under chapter 89 of title 5, United State Code;

• A public health plan;

• A health benefit plan under section 5(e) of the Peace Corps Act;

• Title XXI of the Social Security Act (State Childrens’ Health Insurance Program); or

• Any other arrangement sponsored by a state, the membership composition of which is specified by the state and which is established and maintained primarily to provide health coverage for individuals who are residents of such state and who, by reason of the existence or history of a medical condition-

Are unable to acquire medical care coverage for such condition through insurance or from an HMO, or
Are able to acquire such coverage only at a rate which is substantially in excess of the rate for such coverage through the membership organization.

An individual enrolling for the Consortium's Plan for the first time shall be considered a "new" employee by the Claims Administrator, unless waived, in accordance with the above guidelines, by the Office of Risk Management. Failure to obtain a waiver from the Office of Risk Management may cause the new enrollee to be faced with an 11-month pre-existing condition exclusion period.

SUBROGATION / DUTY TO COOPERATE
Subrogation is a legal term that means the substitution of one person in place of another with respect to a claim. Under certain circumstances, if you have a right to sue another person or entity, the health plan may be subrogated, or substituted, to your right to sue.

For example, suppose you are injured when you fall while climbing a flight of stairs in a building when a rotted stair gives way and the Plan pays the medical expenses you incur as a result of this injury. If you have the right to sue the owner of the building or anyone else to recover for your injuries, this subrogation provision would allow us to sue those persons in your place, even if you chose not to personally file any lawsuit.
Therefore, in the event that you suffer an injury or illness for which another party may be responsible and we pay benefits as a result of the injury or illness, we will be subrogated and succeed to your right of recovery against the party responsible for your illness or injury to the extent of benefits we have paid. This means that we have we have the right to proceed against any party responsible for your injury or illness to recover the benefits we have paid. We may sue any responsible party, independently of you, with or without your consent and regardless of whether you choose to pursue any claim.

You must obtain the Plan Administrator’s consent before entering into any settlement or other agreement with respect to your injury or illness with any third party. This includes any settlement or agreement with respect to your injury or illness, even if it is determined, initially or later, that the third party may not be liable for your injury or illness.

You must not take any action that could prejudice or interfere with the rights of the Plan or the Plan Administrator reserved under this Section.

You must promptly inform the Plan Administrator of the occurrence of any event that may result, or has resulted, in payment under this Plan for which another person or entity may be responsible.

Reimbursement for Expenses We Have Paid. Under certain circumstances, we are entitled to be reimbursed for the benefits we have paid to you or on your behalf from amounts you received in a settlement with, or judgment against, a party responsible for your illness or injury. This shall be limited to the extent that such amounts are specifically identified for, or allocated to, expenses for which we have paid. You will not be obligated to reimburse us for any legal expenses associated with a legal action instituted on our initiative.

Duty to Cooperate with Us. By participating in this Plan, you agree to cooperate with us fully in any action or proceeding we may undertake against any party responsible for your illness or injury to recover the benefits we have paid to you or on your behalf. If you fail or refuse to cooperate with us in the enforcement of our rights under this Plan, you will have violated the provisions of this Plan and will be required to repay us for the
amount of benefits we have paid to you. Failure to pay may result in coverage termination. We agree to invoke this requirement only when your illness or injury caused by a third party results in our expenditure on your behalf of an amount exceeding $500 under this coverage.

An illustrative example: Suppose that you are injured in a fall from a flight of stairs, as described in the previous example, and we choose to pursue a lawsuit or other action against the owner of the building in which the stairs were located or against some other party who is legally responsible for your injuries. If you refuse to assist in our lawsuit or other action when requested, such as by refusing to provide us with requested information about your injuries and the incident, you will be required to repay us for all amounts we have paid to you with respect to your injuries, provided that we have paid to you or on your behalf benefits in the amount of at least $500 with respect to your injuries.

Responsibility for Legal Expenses. We agree to pay all expenses associated with any legal action instituted on our initiative. You shall remain solely responsible for all legal fees and other expenses associated with actions you initiate, except that the amount we recover shall be reduced pro rata to the extent of such legal fees and expenses that you incur.

Obtaining Our Consent. When our prior consent is required, we agree not to unreasonably withhold it, and we agree to waive all penalties under these provisions if we fail to respond within 30 days from the date we receive your written request for prior consent.

Examples Used in This Section. The examples used in this section, above, are included solely for the purposes of illustration and are not intended to enlarge, reduce or otherwise alter or amend the effect of any of the substantive provisions of this section.

RECOVERY OF OVERPAYMENT
If a benefit payment is made by the Plan, to or on behalf of any person, which exceeds the benefit amount such person is entitled to receive in accordance with the terms of the group contract, this Plan has the right:

• to require the return of the overpayment on request; or

• to reduce by the amount of the overpayment, any future benefit payment made to or on behalf of that person or another person in his or her family.

Such right does not affect any other right of recovery this Plan may have with respect to such overpayment.