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Effective Date:
Your coverage and that of your dependents becomes effective on the first day of the month following receipt of your enrollment form and the first premium payment. If, on that day, you or a covered dependent are confined in a hospital, the effective date will be the day following discharge from the hospital.
Pre-Existing Condition Limitation:
Pre-Existing Condition, as used in this limitation, means any Injury or Sickness, diagnosed or undiagnosed, for which Medical Care is received by a Covered Person:
a) within the 6 month period prior to the Covered Person's effective date of insurance; or
b) with respect to the limitation for increase in coverage, within the 6 month period prior to the effective date of the Covered Person's increase in coverage.
Limitations:
Nervous, Mental, Emotional Disorder, Alcoholism, and Drug Addiction Limits
The coverage The coverage provided under the Inpatient Benefits of the TRICARE Supplements for nervous, mental and emotional disorders is limited to:
a) 30 Inpatient treatment days for a Covered Person age 19 or older; or
b) 45 Inpatient treatment days for a Covered Person under age 19;
per Calendar Year.
This Inpatient limit is based on the number of days TRICARE normally provides each Calendar Year for such confinements.
In rare instances, TRICARE extends these daily limits.
If this occurs, we will limit the number of days that we provide for such confinement to the lesser of:
a) the number of days TRICARE pays for such Inpatient treatment during the Calendar Year; or
b) 90 Inpatient days per Calendar Year.
The coverage provided under the Outpatient Benefits of the TRICARE Supplements for:
a) nervous, mental, and emotional disorders; and
b) alcoholism and drug addiction;
is limited to $500 during any period of 12 consecutive months for all such disorders.
Non-Duplication of Coverage under Employer Health Program
If a claim payable under the Policy is also payable under an Employer Health Program with TRICARE as the secondary payor, we will limit our payment to an amount which, when added to the amounts paid by the Employer Health Program and TRICARE, will not exceed 100% of TRICARE Covered Expenses.
Terminations:
Insured Person Termination: The Insured Person's coverage under the Policy will cease on the first to occur of:
1)the date the Policy terminates, or the date the Organization ceases to be a Participating Organization of the Policyholder;
2) the date the required premium is not paid, subject to the Grace Period provision;
3) the first day of the month on or next following the date he or she ceases to be a Member;
4) the first day of the month on or next following the date he or she ceases to be eligible for the Plan under which he or she is covered;
5) the date we or the group cancel coverage for a Class of Eligible Person to which he or she belongs;
6) the date the Member attains age 65;
7) the date he or she becomes eligible for Medicare.
Termination of an Insured Person's insurance will not prejudice any claim which occurred before the effective date of termination.
Dependent Termination: The dependent's coverage under the Policy will cease on the first to occur of:
a) the date the Policy terminates, or the date the Organization ceases to be a Participating Organization of the Policyholder;
b) the date the required premium is not paid, subject to the Grace Period provision;
c) the first day of the month on or next following the date he or she ceases to be an Eligible Spouse or an Eligible Child;
d) the first day of the month on or next following the date he or she ceases to be eligible for the Plan under which he or she is covered;
e) the date we or the group cancel coverage for a Class of Eligible Person to which he or she belongs;
f) the date he or she ceases to be covered under TRICARE;
g) the date he or she becomes eligible for Medicare;
h) the date the Member ceases to be covered, subject to the Covered Dependent’s Continuation Provision; (This will not apply to the Spouse or Child of an Active Duty Member or a Service Disabled Member.)
i) if a Spouse, the date he/she attains age 65.
Termination of a Covered Dependent's insurance will not prejudice any claim which occurred before the effective date of termination.
Exclusions:
1. injury or sickness resulting from war or act of war, whether war is declared or undeclared;
2. intentionally self inflicted injury;
3. suicide or attempted suicide, whether sane or insane (In Missouri while sane);
4. the following services:
a) routine physical exams, unless required for school enrollment (but not sports physicals) by a Covered Child aged 5 through 11; and
b) immunizations; except that these services are covered when:
a) rendered to a Covered Child who is less than 6 years of age; or
b) ordered by a Uniformed Service for a Covered Spouse or Child of an Active Duty Member for such Spouse or child’s travel outside of the United States due to Member’s assignment;
5. domiciliary or custodial care;
6. eye refractions and routine eye exams except when rendered to a child up to 2 years (730 days) from his or her birth;
7. eyeglasses and contact lenses;
8. prosthesis (except that artificial limbs and eyes and devices which must be implanted by surgery are covered);
9. cosmetic procedures, except those resulting from Sickness or Injury while a Covered Person;
10. hearing aids;
11. orthopedic footwear;
12. care for the mentally incapacitated or physically handicapped if:
a) the care is required because of the mental incapacitation or physical handicap; or
b) the care is received by an Active Duty Member's child who is covered by the "Program for the Handicapped" under TRICARE;
13. drugs which do not require a prescription, except insulin;
14. dental care unless such care is covered by TRICARE, and then only to the extent that TRICARE covers such care;
15. any confinement, service, or supply that is not covered under TRICARE;
16. Hospital nursery charges for a well newborn, except as specifically provided under TRICARE;
17. any routine newborn care except Well Baby Care, as defined, for a child up to 2 years (730 days) from his or her birth;
18. expenses in excess of the TRICARE Cap;
19. expenses which are paid in full by TRICARE;
20. any expense or portion thereof applied to the TRICARE Outpatient Deductible except as specifically provided for under the Comprehensive Retiree Plan;
21. treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE;
22. any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program; and
23. any claim under more than one of the TRICARE Supplement Plans, or under more than one Inpatient Benefit or more than one Outpatient Benefit of the TRICARE Supplement Plans. If a claim is payable under more than one of the stated Plans or Benefits, payment will only be made under the one that provides the highest coverage, subject to the Pre Existing Condition Limitation.
Form SRP-1269 (1969)
Underwritten by Hartford Life and Accident Insurance Company, Simsbury, CT 06089
All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. |
