Operating Engineers Health & Welfare Fund  


Expenses Not Covered By The Plan

 
Benefits are not provided for:
1. Expenses in connection with an injury or sickness which arises from or is sustained in the course of any occupation or employment.
2. Cases where medical services are provided by family members.  For example, if your brother is a doctor or dentist and provides services to you as an eligible participant, the claim will be denied.
3. Cosmetic surgery, except operations necessary to repair disfigurement due to an accident occurring while eligible, treatment of a congenital defect in a dependent child, and for breast reconstruction following mastectomy.
4. Any supplies or services (a) for which no charge is made; or (b) for which the person is not required to pay; or (c) furnished by a hospital or facility operated by the United States Government or any authorized agency thereof or furnished at the expense of such Government or agency, with the exception of Veterans Administration hospitals where the charges are for a non-service related illness or injury; or (d) which are provided without cost by any municipal, county, or other political subdivision; or for court-ordered hospital care.
5. Any charges in connection with pregnancy or a suspected pregnancy of a dependent child, including miscarriage and abortion.
6. Drugs and medical procedures not approved by the FDA.
7. Expenses incurred in accidents involving a third party to the extent recovery is made.
8. Non-prescription medications (over-the-counter items).
9. Services or supplies where no charge is made by the provider.
10. Charges in excess of "usual and customary", where applicable.
11. Charges for chelation therapy except in cases of acute arsenic, gold, mercury or lead poisoning.
12. Personal items while in the hospital.
13. Routine eye care for which benefits are provided through the Vision Service Plan.
14. Educational materials, and home care instructions.
15. Fees for filling out forms.
16. Fees for special reports.
17. Radial Keratotomy or Laser (Lasik, PRK) eye surgery unless you meet the Plan's vision requirements.
18. Charges for the following orthotic items:
  1. Custom made shoe inserts, unless prescribed for orthopedic foot treatment.
  2. Spinal pelvic stabilizers.
  3. Arch support or heel wedges.
  4. Shoes are not covered unless attached to a brace.
19. Any bodily injury or sickness for which you are not under the care of a doctor.
20. Conditions caused by or arising out of an act of war, armed invasion or aggression.
21. Telephone calls.
22. HCG injections.
23. Flu injections for participants under 65 years of age.
24. Claims submitted over one year from the date the service was rendered.
25. Expenses incurred for artificial insemination, in-vitro fertilization, the reversal of elective sterilization, and similar procedures, or treatment of infertility.
26. Weight control programs or liposuction.
27. Dietary Planning.
28. B-12 injections for most diagnoses.
29. Charges not related to an illness or injury.
30. Hair loss treatment.
31. Ambulance transportation for the patient's convenience.
32. Educational programs or vision therapy to correct learning disabilities such as dyslexia and similar problems.
33. Removal of silicone gel implants except in special cases approved by the Board of Trustees.
34. Expenses incurred for the care of schizophrenia, chronic psychosis, organic psychosis, and similar conditions unresponsive to therapeutic treatment or expenses are for the treatment of substance abuse disorders or for the treatment of fetal alcohol syndrome in a dependent child age 16 or younger.
35. Chiropractic treatment for dependent children under 16 years of age.
36. Doctors' additional charges for "Sunday/Holiday" and "after hour visits."