Northwest Carpenters Health and Security Plan

General Limitations and Exclusions 

Summary

The following is a list of services and supplies which are limited or not covered by the Northwest Carpenters Health and Security Plan.
All benefits are subject to the provisions, definitions, and limitations and exclusions of this plan. Please refer to the specific benefit description for additional limitations and exclusions. No benefits are provided for the following or for any direct or indirect complications or consequences thereof while covered by the plan, unless specifically stated otherwise below or unless specifically provided for in the description of the benefit:

1. Services or supplies not considered medically necessary. The fact that a procedure, service or supply may be furnished, prescribed, recommended, or approved by a provider does not, in itself, make it medically necessary or make the charge a covered expense, even though it is not specifically listed as an exclusion. A service or supply may be medically necessary in part only.
2. Charges exceeding the maximum allowable fee as determined by this plan.
3. Services or supplies not recommended and approved by a covered physician or other covered provider; elected by the patient and not approved by the covered physician or other covered provider; not covered as a result of a benefit reduction under the medical review program; that exceed benefit maximums; or that exceed vision and dental scheduled amounts.
4. Services or supplies outside the scope of the provider’s license, registration or certification, or that are furnished by a provider that is not currently licensed, registered or certified in the jurisdiction in which the services or supplies were received.
5. Services or supplies that are experimental or investigative.
6. Any claim for services or supplies received by Carpenters Health and Security Trust 12 months or more after the date of service, including claims that require additional information to process and the additional information is not provided until 12 months or more after the date of service.
7. Services or supplies received when a plan benefit is not in effect, or when you or a dependent is not covered under this plan.
8. Services or supplies not substantiated by medical records; charges for failure to keep a scheduled appointment; charges for telephone consultations (except as provided under Telehealth, or charges for the completion or submission of any forms, reports or medical records including the preparation and presentation of medical or psychological reports or physical examinations required primarily for the protection and convenience of the patient or third party.
9. Illnesses, injuries or conditions arising out of, or occurring in the course of, any occupation for wage or profit, regardless of whether benefits are recovered or recoverable through payment, adjudication or settlement of a claim under a workers’ compensation law, occupational disease law, or similar law, even if the patient fails to make timely application for or waives the right to such benefits, or even if workers’ compensation insurance was not purchased or the patient fails to make timely application.
10. Services or supplies for which there are no charges made to the patient or for charges that would not have been made or that the patient would have had no obligation to pay in the absence of this plan, Medicare, or any federal, state or governmental program, except where required by law. This provision does not apply to benefits payable under Medicare at any time when compliance with federal law requires that the benefits of this plan must be determined before benefits are available under Medicare.
11. Charges or lost wages for any injury or illness caused by the act or omission of another person (known as the “third party”) where a potential opportunity for recovery exists, including, but not limited to, an injury or illness potentially covered by any liability policy of a third party or first party coverage available under an automobile insurance policy (i.e., coverage for underinsured or uninsured motorist), homeowners or renters policy or commercial premises policy (please see Trust’s Right to Reimbursement).
12. Illnesses or injuries sustained in any of the following circumstances, provided that this exclusion does not apply to illnesses or injuries sustained as a victim of domestic violence:
    1. While engaged in an assault, battery or felony for which the participant is charged.
    2. While performing any acts of violence or physical force that would not be performed by a reasonably prudent person in similar circumstances.
    3. While participating in a riot.
    Being under the influence of a chemical substance will not be considered to affect the person’s ability to form intent.
13. Expenses incurred while a person is in the custody of, or confined by, any enforcement officer or agency.
14. Court-ordered care or assessments; or care in lieu of incarceration.
15. Detention centers; reform schools; programs such as “outward bound” or “wilderness survival”; recreational or vocational therapy including any treatment or therapy that is not medical but rather is general life or social skills and is not performed by licensed providers in an appropriate treatment setting.
16. Any injury sustained while practicing for, or competing in, a professional or semiprofessional athletic contest while covered under the plan. Semiprofessional athletics means an athletic activity for pay, that requires an unusually high level of skill and a substantial time commitment from individuals who are nevertheless not engaged in the activity as a full-time occupation.
17. Cosmetic surgery, reconstructive surgery, or plastic surgery, including services, supplies or drugs or any portion thereof which improves, alters or enhances the texture or appearance of the skin, or the relative size or portion of any part of the body whether or not for psychological or emotional purposes, or is not needed to correct or improve a bodily function. The following are examples of what are not covered services or supplies: surgery for sagging skin of the eyelids (blepharochalasis), face, neck, abdomen, hips, or extremities (meloplasty, rhytidectomy or lipectomy); reshaping of the nose (rhinoplasty) or ears (otoplasty); and silicon or collagen injections to any part of the body.
18. Biofeedback or neurofeedback, except as provided under Habilitative Care, Rehabilitative Care, or TMJ and MPDS Treatment.
19. Custodial care; nonmedical self-help or related testing; exercise or maintenance level programs; or work hardening.
20. Services or supplies provided by an institution which is primarily a rest home, a home for the aged, a nursing home, a convalescent home, or any of like character.
21. Services or supplies related to the correction of the gum, teeth or tissues of the mouth for dental purposes, including services or supplies related to the removal, repair, replacement, restoration, or repositioning of teeth lost or damaged in the course of biting or chewing, except as provided under Dental Treatment Under Medical Benefits, Oral Surgery, TMJ and MPDS Treatment or Dental Benefits.
22. Services or supplies in connection with the correction of developmental or congenital abnormalities of the jaw or malocclusion of the jaw by orthognathic surgery with or without bone grafting performed by either a physician or dentist, except as provided under Orthognathic Surgery, TMJ and MPDS Treatment or Dental Benefits.
23. Vision related problems including, but not limited to: visual analysis therapy or training related to muscular imbalance of the eye; orthoptics including special purpose vision aids; subnormal vision aids; aniseikonic lenses; tonography; or radial keratotomy or any other eye surgery when the primary purpose is to correct refractive errors such as, but not limited to, myopia (nearsightedness), hyperopia (farsightedness) or astigmatism (blurring); except as provided under Vision Benefits.
24. The difference between the charge for the private room and a hospital’s average charge for a semiprivate room, unless medically necessary; private or special duty nurses, regardless of where the services are rendered; or room and board for any day in which the patient is released from the hospital on a temporary pass, or for any charge related to a late discharge from the hospital when the late discharge is for patient or provider convenience.
25. Services or supplies for pregnancy-related conditions (including routine testing) for dependent daughters including complications thereof, except prenatal services during pregnancy that are covered preventive benefits under the Patient Protection and Affordable Care Act.
26. Services or supplies in connection with the diagnosis or treatment of reproductive or sexual dysfunctions and defects whether or not the consequence of an illness or injury, including but not limited to, impotency (except as provided under Erectile Dysfunction; frigidity; reversal of surgical sterilization; infertility, including but not limited to, in vitro fertilization, artificial insemination, embryo transfer, microinjections, zona drilling, or other artificial means of conception; fertility drugs (including, but not limited to, Clomid, Pergonal, Serophene, or HCG when associated with any artificial means of conception); or consecutive follicular ultrasounds, cycle therapy and corresponding lab tests when associated with any artificial means of conception.
27. Obesity treatment regardless of diagnosis, including weight control programs, dietary or nutritional services or supplies, surgery or complications of surgery, prescription drugs, or wiring of the jaw or similar procedures, except to the extent covered by the plan.
28. Diet substitutes or nutritional supplements or services, except to the extent covered by the plan.
29. Personal convenience items including, but not limited to, telephones, televisions, guest accommodations, educational materials, bath aids, raised toilet seats, heating pads, enuresis (bed wetting) training equipment, whirlpool baths, exercise equipment, muscle stimulators, weights, keyboard communication devices, adjustable beds, three-wheeled scooters, customized car seats and strollers, feeding chairs, orthopedic chairs, personal hygiene items, blood pressure devices, deluxe items such as motorized equipment, air conditioners, humidifiers, or air filter systems.
30. Naturopathic, homeopathic, holistic, hypnosis, clinical ecology, or herbalistic treatment by any provider; hair, mineral, or gastric analysis; or chelation therapy (except for acute arsenic, gold, mercury or lead poisoning) by any provider.
31. Services or supplies in connection with routine foot care, including hygienic care; trimming of nails; paring, excision, cauterization or radiation of corns or calluses; weak or fallen arches; flat or pronated feet; metatarsalgia; massage; casting, taping or manipulative procedures of the foot; over-the-counter orthotics including insoles, inlays or arch supports.
32. Any warranty or service contract; or freight, postage or delivery charges.
33. Marriage counseling, family counseling, or social adjustment counseling, except as medically necessary to treat a documented mental health condition or substance use disorder.
34. Career counseling, pastoral counseling, or financial counseling.
35. Physical, speech, respiratory, or occupational therapy, unless prescribed by a physician (or chiropractor in the case of a spinal condition) prior to commencement of treatment. The physician or chiropractor must include the frequency and duration of treatment needed.
36. Services or supplies that are the result of errors in medical care, provided the errors are clearly identifiable, preventable, and serious in their consequences for the patient.
37. Services or supplies that are not listed as covered under this plan.
38. Services, supplies and prescription drugs that are contrary to internal guidelines or medical protocols (including guidelines and protocols used for diagnosis, treatment, prescription or billing practices) that are utilized by the plan’s utilization reviewer, prescription drug program, or Board of Trustees in determining coverage for specific services, supplies and prescription drugs.
39. Charges for services or supplies that are limited or excluded under the specific benefit.
40. Charges for services or supplies which are not provided or billed in accordance with generally accepted professional standards and/or medical practice, including up-coding, unbundling, duplication, excessive, or improperly coded billing charges.
41. Charges for services or supplies billed or charged in breach of or contrary to the provider’s PPO network agreement or in breach of or contrary to provider guidance or policies established by the PPO network.
42. Private duty nurse.

Last Updated: 04/25/2023