Avmed Health Insurance

Avmed Individual Health Insurance Exclusions and Limitations

These medical plans expressly excludes expenses for the following health care services. This is only a partial list of the Exclusions for health care services. No benefits are payable for expenses which:

• Are received prior to your Effective Date or after the date your coverage terminates;
• Are not within the service categories described in the “What Is Covered?” section, any Amendment, unless such Services are specifically required to be covered by applicable law;
• Are provided by a Physician or other health care Provider related to you by blood or marriage;
• Are which is not Medically Necessary as defined in the Contract and determined by AvMed;
• Are rendered at no charge;
• Are for Adult Wellness, including routine or preventive care unless provided for in the policy;
• Are for Anesthesia Administration Services;
• Are for Foot Care, including non-surgical treatment of foot-related ailments, shoe inserts designed to effect conformational changes in the foot or foot alignment;
• Are for Materinty/obstetrical Care, including inpatient and outpatient materinity/obstetrical care, prenatal care, delivery, or routine newborn care (unless optional coverage is selected, if available);
• Are for Assisted reproductive Therapy (Infertility); including any drug treatment or procedure that promotes conception.
• Are for Contraceptive medications, including injections,  devices, or other health care services, when provided for contraception unless medically necessary;
• Are for Behavioral Health Services;
• Are incurred for Cosmetic Services or aesthetic reasons, such as weight modification or surgical treatment of obesity;
• Are incurred for Eye Care, including eye surgery to correct nearsightedness, farsightedness, or astigmatism;
• Are for Complementary or Alternative Medicine services, including Nutritional therapy;
• Are for modification of the physical body, including breast reduction or augmentation, and genderreassignment surgery;
• Are for Weight Control services, including gastric surgeries and other procedures for the treatment of obesity or morbid obesity, as well as any related evaluations or diagnostic tests;
• Are in relation to, or incurred in conjunction with, investigational treatment.
• Are for exercise programs, including gym memberships or exercise equipment of any kind;
• Are for Dental expenses or oral surgery
• Are in relation to Hearing Aides (external or implantable) and services related to the fitting or provision of hearing aids, including tinnitus maskers, batteries and cost of repair;
• Are in relation to Transplant Services;
• Are in relation to Skilled Nursing Facilities;
• Are for rehabilitative Therapies;
• Are for Autopsy or postmortem examination services;