Plans for 50 or Fewer Employees - Exclusions & Limitations

These are the standard limitations and exclusions. As they may vary by state, please see your summary plan description (SPD) for a more detailed listing.

MEDICAL AND ACCIDENTAL LOSS OF LIFE, LIMB OR SIGHT BENEFIT
No benefits will be paid for loss caused by or resulting from:

• Intentionally self-inflicted injuries, suicide or any attempt while sane or insane;
• Declared or undeclared war;
• Serving on full-time active duty in the armed forces;
• The covered person's commission of a felony;
• Work-related injury or sickness, whether or not benefits

With regard to the accidental loss of life, limb or sight benefit - sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, or bacterial or viral infection regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning.
No benefits will be paid for:

• Eye examinations for glasses; any kind of eye glasses, or vision prescriptions;
• Hearing examinations or hearing aids;
• Dental care or treatment other than care of sound, natural teeth and gums required on account of injury to the covered person resulting from an accident that happens while such person is covered under the policy, and rendered within 6 months of the accident;
• Services rendered in connection with cosmetic surgery, except cosmetic surgery that the covered person needs for breast reconstruction following a mastectomy or as a result of an accident that happens while such person is covered under the policy. Cosmetic surgery for an accidental injury must be performed within 90 days of the accident causing the injury and while such person's coverage is in force;
• Services provided by a member of the covered person's immediate family.

Dental
The plan will pay only for procedures specified on the Schedule of Covered Procedures in the group policy. Many procedures covered under the plan have waiting periods and limitations on how often the plan will pay for them within a certain time frame. For more detailed information on Covered Procedures or limitations, please contact HospitalityCare Customer Service at 1-888-583-3057.

Vision
No benefits will be paid for any materials, procedures or services provided under Workers' Compensation or similar law; non-prescription lenses, frames to hold such lenses, or non-prescription contact lenses; any materials, procedures or services provided by an immediate family member or provided by you; charges for any materials, procedures, and services to the extent that benefits are payable under any other valid and collectible insurance policy or service contract whether or not a claim is made for such benefits.

Prescription Drugs
No benefits will be paid for over the counter products or medications or for drugs and medications dispensed while you are in a hospital.

Short-Term Disability
No benefits are payable under this coverage in the following instances:

• Attempted suicide or intentionally self-inflicted injury;
• Voluntary taking of poison; voluntary inhalation of gas; voluntary taking of a drug or chemical. This does not apply to the extent administered by a licensed physician. The physician must not be you or your spouse, you or your spouse's child, sibling or parent; or a person who resides in your home;
• Declared or undeclared war or act of war;
• Your commission of or attempt to commit a felony, or any loss sustained while incarcerated for the felony;
• Your participation in a riot;
• If you engage in an illegal occupation;
• Release of nuclear energy;
• Operating, riding in, or descending from any aircraft (including a hang glider). This does not apply while you are a passenger on a licensed, commercial, nonmilitary aircraft;
• Work-related injury or sickness.

Short-Term Disability benefits are not available to persons who work in California, Hawaii, New Jersey, New York or Rhode Island.

Term Life
No Life Insurance benefits will be payable under the policy for death caused by suicide or self-destruction, or any attempt at it within 24 months after the person's coverage under the policy became effective.

Policy termination No benefits will be paid for any expense incurred after the date the policy terminates.

MEDICAL/RX PLAN UNDERWRITTEN BY COMPANION LIFE INSURANCE COMPANY, COLUMBIA, SC.

VISION AND DENTAL PLANS, TERM LIFE AND SHORT-TERM DISABILITY PLANS UNDERWRITTEN BY BCS LIFE INSURANCE COMPANY AND BCS INSURANCE COMPANY, OAKBROOK TERRACE, ILLINOIS.

Plan administered by Planned Administrators, Inc (PAI) PO BOX 6702 Columbia, SC 29260-6702

** The benefits and limitations shown are not a complete list of all benefits, limitations, and exclusions. Please refer to your policy for a complete list of all benefits, limitations, and exclusions. Policy available www.choicehospitalitycare.com

"THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR LIMITED BENEFITS POLICY AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS PLAN IS NOT DESIGNED TO COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS. IT CONTAINS SPECIFIC DOLLAR LIMITS THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE COST OF SERVICES EXCEEDS THOSE LIMITS, THE BENEFICIARY AND NOT THE INSURER IS RESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS. THE SPECIFIC DOLLAR LIMITS ARE NOTED IN THE PLAN DESIGNS.”