UFCW Midwest - Midwest Health and Pension Funds

United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

General Exclusions and Limitations

This Plan contains some general exclusions and limitations that apply to all benefits provided by the Plan. No benefits are payable under the Plan for the following:

  • accidental injury or sickness arising out of or in the course of any occupation or employment, or which is compensable under any Workers’ Compensation or Occupational Disease Act or Law, except in the case of Life and AD&D benefits
  • services, supplies or treatments that are not medically necessary
  • services, supplies or treatments that are experimental or investigative or do not meet accepted standards of medical practice
  • expenses incurred while coverage is not in force
  • accidental injury or sickness caused by war or any act of war, declared or undeclared, or by participating in a riot, or as the result of the commission of a felony
  • examinations or treatment ordered by a court in connection with a legal proceeding or obtained for the purpose of receiving favorable consideration by a court or similar body, unless such examinations or treatment would otherwise qualify as a covered expense
  • any expenses that exceed the usual and customary charge
  • any expenses over the maximum benefit amounts
  • any deductible or co-pay amounts
  • expenses that you would not have been charged had there been no coverage
  • expenses for which there is no legal obligation or financial liability to pay
  • physical examinations or medical certificates required for employment
  • any service, supply or treatment that is provided in a U.S. government hospital or in any other hospital operated by a government unit, except for those provided by the Veterans Administration when services are provided to a veteran for a disability that is not service-connected, or unless you or your eligible dependent is legally required to pay
  • any service, supply or treatment that is not recommended and approved by a legally qualified physician
  • any service, supply or treatment that is received outside the United States or Canada, except for emergency care
  • diagnosis, testing or treatment of infertility
  • diagnosis, testing or treatment of obesity, except as described in the Comprehensive Medical Expense Benefit section under Weight Loss Treatment
  • reversal of a surgical procedure
  • services provided by a person who normally resides in your household or who is a parent, spouse, child, brother or sister of the eligible employee-member or his or her dependent
  • educational services, supplies or equipment (except for Nutritional Counseling as described in the Comprehensive Medical Expense Benefit section), including but not limited to, computers, software, printers, books, tutoring and visual aids even if they are required because of an injury or illness
  • dental treatment, except as provided under the Dental Benefit, and except for removal of tumors, treatment of fractures, direct surgery on the temporomandibular joint itself or surgery to correct a malocclusion of the jaw due to a skeletal deformity
  • expenses for which the Fund has not received complete documentation of the claim, including medical reports and records if needed
  • expenses payable by another group medical plan under the Plan’s Coordination of Benefits provision
  • charges for failure to keep a scheduled visit, completion of a claim form or routine supplemental report, phone calls, handling fees and personal items
  • charges for more than one medical office visit, hospital room, or wound-care facility charge billed on the same day by the same provider
  • anything excluded under any other provision of the Plan

If you are employed by more than one employer participating in this Fund, the benefits provided to you will be no greater than if you were employed by only one employer.

If you or your eligible dependent are covered under more than one plan classification, the benefits provided will be payable under the plan classification providing the largest benefit.
  

(Updated 11/23/15)