Plans for 50 or Fewer Employees - Exclusions & Limitations

The following exclusions and limitations apply to expenses incurred by all participants. The exclusions and limitations may vary by state.

Medical Benefit
No benefits will be paid for:

• Treatment for mental illness, functional or organic disorders, alcohol abuse or substance abuse treatment;
  
• Intentionally self-inflicted injuries, suicide or any attempt threat while sane or insane;
  
• Declared or undeclared war; or serving on full time active duty in the Armed Forces;
  
• Commission of a felony;
  
• Experimental treatment or surgery;
  
• Work-related injury or sickness;
  
• Eye examinations; ear examinations; or hearing aids; normal health checkups;
  
• Treatment in a hospital or facility owned and run by the United States Government;
  
• Dental care or treatment other than care of natural teeth and gums resulting from an accident;
  
• Cosmetic surgery;
  
• Air or ground ambulance service.

Dental Benefit
The plan will pay only for procedures specified on the Schedule of Covered Procedures in the Group Policy. The exclusions and limitations may vary by state. 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.

Short-Term Disability
No benefit is payable with respect to any Total Disability caused by or resulting from:

• Attempted suicide or intentionally self inflicted injury, while sane or insane; voluntary taking of poison; voluntary inhalation of gas; voluntary taking of drug or chemical; Release of nuclear energy;
  
• Operating, riding in, or descending from any aircraft (including a hang glider); This does not apply to the Insured while a passenger on a licensed, commercial, nonmilitary aircraft;
  
• Injury or sickness for which the insured has had or had a right to payment under any workers’ compensation or similar law
  
• Declared or undeclared war or act of war;
  
• Commission of or attempt to commit a felony, or participation in a riot;
  
• Engaging in an illegal occupation

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, whether sane or insane, within 24 months after the person’s coverage under the Policy became effective.

Vision Benefit No benefits will be paid for:

• Any materials, procedures or services caused by or resulting from declared or undeclared war; or serving on full-time active duty in the Armed Forces;
  
• Any materials, procedures or services provided under Workers’ Compensation or similar law;
  
• Medical or surgical treatment of the eyes or supporting structures;
  
• Non-prescription lenses, frames to hold such lenses, or non-prescription contact lenses, or industrial or athletic frames or lenses;
  
• Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing;
  
• Any materials, procedures or services provided by an immediate family member;
  
• 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.

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.”