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Exclusions & Limitations
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 precertification?
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 precertify will result in a benefit
reduction of 50%.
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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