MEDICAL EXCLUSIONS AND LIMITATIONS

Pre-existing Conditions
This plan contains a 12 month Pre-existing Condition Limitation period during which time pre-existing conditions are excluded from coverage. A pre-existing condition is any injury or sickness for which the insured received medical advice or treatment from a physician within the 6 months immediately prior to their first day of coverage, or if there is a waiting period, the first day of the waiting period. The pre-existing condition limitation does not apply to pregnancy, newborns or adopted children or children placed for adoption enrolled within 30 days of birth, adoption or placement for adoption. If an employee or dependent enrolls as a Late Enrollee, or during a Special Enrollment Period, for the purpose of reducing the pre-existing condition limitation period, any period before such late or Special Enrollment Period is not a waiting period and the pre-existing condition limitation period will not be reduced by any such period.

Full or partial credit will be given towards the satisfaction of the pre-existing condition exclusion period, for the period of time a person was covered under prior creditable coverage. In order to receive credit, a person must have had no break or gap in coverage of 63 days or more prior to the person enrolling in this plan. This applies to all employees on the date of transfer as well as to new enrollees.

Prior Creditable Coverage
Creditable coverage is prior coverage a person had under: any group health plan (including FEHBP, COBRA, Peace Corps etc.), an individual health plan, Medicare, Medicaid, CHAMPUS, a state risk pool, Indian Health Service or tribal organization coverage, or any public health plan, as defined in the regulations. The employee must enroll for coverage in this plan within 30 days of becoming eligible, subject to the satisfaction of any waiting period. Any waiting period included in this plan must be met before the employee becomes insured. Any such waiting periods run concurrently with the pre-existing condition limitation period.

Deductible Transfer Credit
Credit for the amount of deductible satisfied under the prior carrier's group plan will be given to all employees and dependents on the date of transfer. Deductible transfer only applies if the member had an HSA compatible plan prior to enrolling with The PerfectHealth Insurance Company.

Other Exclusions and Limitation
No payment will be made for the following unless otherwise noted:

• Medical care not approved by a doctor, received in a U.S. Government facility, or for which the insured without this insurance would not be legally obligated to pay.
• Cosmetic treatment, except under certain conditions.
• Dental care or treatment, but we do cover:
  • hospital services provided while hospital confined.
  • dental care or treatment up to 24 months for injury to the jaw or sound natural teeth, and
  • doctors charges for the removal of up to 4 impacted teeth.
• Hearing aids, eye refractions, surgery to correct a refractive eye disorder, eyeglasses, contact lenses or their fittings, except for the first pair of eyeglasses or contact lenses prescribed after cataract surgery.
• Any injury or sickness due to war or armed conflict.
• Medical care of an injury due to taking part in a felony.
• Any injury or sickness sustained in the course of employment or covered by Workers' Compensation or a similar law, unless the insured is not eligible for coverage under such law.
• Services furnished by a person who is the insured or insured's spouse, or a member of the insured's immediate family.
• Care provided by the insured's or dependent's employer, labor union or similar group, for which no charge would normally be made in the absence of this insurance.
• Experimental, investigative, developmental or educational medical care.
• Reversal of surgical sterilization, embryo transplant services (including but not limited to GIFT and In Vitro fertilization). Infertility services except those included under eligible expenses.
• Sex change operations.
• Orthognathic surgery to correct malalignment of the jaw due to skeletal deformity.
• Custodial care.
• Adult routine health exams or preventive care except those services included under eligible expenses.