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Treatment of Teeth and Surrounding Tissue and Structure; Acts of War; When There Is Government Coverage Available; and Experimental Drugs

This article is a breakdown of specific exclusions from coverage found in a typical individual health insurance policy.

(Typical wording*):

Limitations, Exclusions and Non-Waiver (cont.)

B. Exclusions (cont.): [In addition to other general Policy exclusions from coverage, the Policy does not provide coverage for any of the following, all of which are specifically excluded]:

6. treatment of the teeth, the surrounding tissue or structure, including the gums and tooth sockets. This exclusion does not apply to treatment: (a) due to injury to natural teeth; or (b) for malignant tumors;
7. Injury or Sickness due to any act of war (whether declared or undeclared);
8. services provided by any state or Federal government agency, including the Veterans Administration unless, by law, an Insured must pay for such services;
9. charges that are payable or reimbursable by either: (a) a plan or program of any governmental agency (except Medicaid); or (b) services covered by Medicare Part A, Part B and/or Part D (If the applicable Insured does not enroll in Medicare when eligible, We will estimate the charges that would have been paid if such enrollment had occurred);
10. services for Sickness or Injuries related to Your job to the extent You are covered or are required to be covered by the Workers' Compensation law. If You enter into a settlement agreement wherein You agree to give up Your right to recover future medical benefits under a Workers' Compensation law, this Policy will not pay those medical benefits that would have been payable in the absence of that settlement.
11. Inpatient administration of experimental drugs or substances not approved for general use by the Food and Drug Administration except those off-label drugs used in the treatment of cancer if such drugs are recognized for treatment of the covered condition in a standard reference compendia or in substantially accepted peer-reviewed medical literature, or drugs labeled "Caution – limited by Federal law to investigational use";

Our sample policy does not provide benefits for the expenses of routine dental care, even if that treatment involves surgery. The only exceptions to that rule are when treatment is required to repair injury to your natural teeth or treatment of teeth or surrounding tissue or structure caused by malignant tumors.

The expenses of treatment for injuries or sickness resulting from acts of war are clearly excluded. This exclusion does not apply to acts of terrorism. For example, those people injured during the 9/11 attacks would not be excluded from coverage. Military personnel injured in military action are covered by the Federal government.

If you are covered or eligible for coverage under any governmental plan, coverage under this policy would be excluded. Note that if you agree to settle a Worker's Comp claim with the thought in the back of your mind that you will also be able to collect medical benefits from your insurance policy, you will be sorely disappointed. Benefits under this sample policy will be excluded to the extent they would have been payable by the Workers' Comp insurance in the absence of the settlement.

The policy generally does not allow for coverage for the cost of experimental drugs, but does allow some leeway in this regard for experimental drugs related to cancer treatment.

*Wording may vary from contract to contract and from state to state.



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