CHAMPVA (Civilian Health and Medical Program of the Department of Veteran Affairs)

Definitions:
Skilled Nursing Facility does not mean: a) a hospital; or b) a place for rest, custodial care, or the aged; or c) a place for the treatment of mental disease, drug addicts or alcoholics.




Termination:
A Covered Person's coverage under the Policy will cease on the first to occur of: a) the date the Policy terminates, or the date the AMRA 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 date you or your widow(er) terminates membership in the Participating Organization; d) the first premium due date on or next following the date a dependent ceases to be an Eligible Spouse or an Eligible Child; e) the date we or the group cancel coverage for a class of Eligible Person to which he or she belongs; f) the first premium due date on or next following the date he or she ceases to be covered by CHAMPVA; g) the date he or she becomes eligible for Medicare; h) if a spouse, the date he or she attains age 65; i) if a child, the date he or she attains age 18, or age 23 if enrolled full-time in a school of higher learning. Termination of insurance will not prejudice any claim which occurred before the effective date of termination.




Exclusions:
This Policy does not cover: 1. treatment or confinement not ordered by a physician or necessary for medical care; 2. intentionally self-inflicted injury; 3. suicide or attempted suicide, whether sane or insane; 4. sickness or injury resulting from acts of war, whether declared or undeclared; 5. routine physical exams, eye exams, hearing exams and immunizations, except when considered Well Baby Care covered by CHAMPVA; 6. eye refractions; 7. custodial care, care received in a retirement home, rest home or halfway house, or domiciliary care; 8. rest cures; 9. hearing aids; 10. orthopedic footwear; 11. eyeglasses or contact lenses; 12. cosmetic procedures except those resulting from sickness or injury occurring while a Covered Person under the Policy; 13. drugs (other than insulin and other diabetic supplies) which do not require a prescription; 14. any confinement, service or supply not covered by CHAMPVA as contained in Regulations 38 CFR17.272; 15. expenses paid in full by CHAMPVA; 16. expenses in excess of the CHAMPVA Allowed Amount; 17. expenses in excess of the CHAMPVA Cap; 18. care for the mentally or physically incapacitated if the care is required because of the mental or physical incapacitation; 19. any part of a covered expense which the Covered Person is not legally obligated to pay; 20. care received as part of a grant, study or research program; 21. care considered experimental or investigational.

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.

Form SRP-1269 (1992) 

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.

Note: These entities are not affiliated with the TRICARE Supplement in any way.