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Secure> STM
Exclusions and
Limitations
Secure STM health insurance allows you and your family to
purchase quality, affordable major medical
health insurance coverage on a temporary basis.
Coverage is
provided for physician services, surgery,
outpatient and inpatient care
and prescription drugs.
Is
there a pre-existing condition limitation?
Pre-existing conditions are not covered. This includes any
condition or complication that was treated or produced
symptoms five years prior to your Secure STM effective date.
The pre-existing condition limitation may vary by state.
What are the plan exclusions and limitations?
The following is a partial list of
services or charges not covered by Secure STM:
- Any services that are
not medically necessary
- Eye exams, eyeglasses,
hearing aids and surgery
- Dental or orthodontic
services
- Treatment of foot
conditions
- Conditions resulting
from an act of war
- Maternity and newborn
treatment prior to discharge, any infertility treatments
or sterilization treatments
- Spinal manipulation or
adjustment
- Services performed by
family members or for which a charge would otherwise not
be incurred
- Medical care received
outside of the United States
- Services payable by
Medicare or Worker's Compensation coverage
- Cosmetic surgery,
treatment for acne, hair loss or varicose veins
- Transplant services to
the transplant donor
- Routine physical exams
and tests, preventive care and immunizations
- Experimental or
investigational services
- Learning disorders,
attention deficit disorder, hyperactivity or autism
- Mental or nervous
disorders, depression or suicide attempt
- Alcohol or drug
dependency and disorders
- Obesity treatments
- Sleep disorders
- Over-the
counter-medications and prescription drugs
- Participation in
school or organized competitive sports or any high risk
sport
- Certain surgeries
during the first six months
The limitations and
exclusions may vary by state. Please see the
Policy/Certificate of Insurance for detailed information
about these and other plan limitations and exclusions.
Can I continue coverage?
If your need for temporary health insurance continues, you
may apply for another Secure STM plan. Your application is
subject to eligibility, underwriting requirements and state
availability of the coverage. The next coverage period is
not continuous and any condition incurred during the last
coverage period will be excluded as a pre-existing
condition.
What is a usual, reasonable
and customary charge?
A "usual, reasonable and customary charge" is the charge
typically made by physicians or suppliers of medical
services, medicines and supplies within a specific
geographic area as determined by us.Usual, Reasonable and
Customary means with respect to fees or charges, fees for
medical services or supplies which are usually charged by
the provider for the service or supply given and the average
charge for the service or supply in the locality in which
the service or supply is received; whichever is less, or
with respect to treatment or medical services, treatment
which is reasonable in relationship to the service or supply
given and the severity of the condition. In reaching a
determination as to what amount should be considered as
Usual, Reasonable and Customary for services and supplies;
we may use and subscribe to a standard industry reference
source that collects data and makes it available to its
member companies.
When does coverage terminate?
Coverage ends when the premium is not paid when due; you
enter full-time active duty in the Armed Forces; you become
eligible for Medicare; the elected coverage period expires;
Standard Security Life Insurance Company of New York
determines fraud or misrepresentation has been made in
filing a claim for benefits; or a dependent ceases to be
eligible; you cease to be a member of the association or the
group master policy terminates.
Do
I need pre-certification?
Pre-admission certification prior to eligible inpatient
hospitalization or surgery by the covered individual within
48 hours is required. This is not a guarantee of benefits.
Failure to pre-certify will result in a benefit reduction of
50%. Call 1-800-367-9938 for pre-certification.
This website provides a
brief description of the benefits, exclusions and other
provisions of the policy Form SSL-STMP-1104. For complete
listing, see the Policy/Certificate of Insurance. Secure STM
is not available in all states.
Association membership may be required in some
jurisdictions.
©2005 HPA, Inc. All rights reserved.
SM STM-1 3/05
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