SSMC Employee Health Benefit Plan
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SECTION V - PLAN EXCLUSIONS
All claims are subject to a review to decide whether services are covered according to Plan limitations. A second opinion
consultation does not guarantee benefits. You must comply with requests for additional medical documentation as deemed
necessary by the Claims Administrator to evaluate a claim for benefits. Failure to submit requested documentation or
information or to provide a signed release for pertinent medical records could result in denial of benefits. The Claims
Administrator confidentially maintains all medical documents in accordance with applicable New York State and federal
laws. Treatment decisions are independent from payment decisions. The patient's Physician is responsible for determining
whether treatment should be rendered despite whether the charges are totally or partially included in, or excluded from,
coverage under the Plan.
In addition to limitations and exclusions shown elsewhere in this SPD, charges for the following expenses will
not be paid by the Plan, unless specifically shown otherwise for Plan coverage. Also, see Section X -
Definitions.
1. Plan coverage not in Effect. Services or Supplies Incurred while an individual is not eligible and enrolled
in the Plan or Incurred before the Plan became effective or after the Plan is canceled. Services or Supplies
that are not covered according to Plan limitations and exclusions in effect at the time expenses were
Incurred.
2. Unreasonable Charges. Charges determined to be more than the Usual, Customary, and Reasonable
Charges, according to Plan provisions. See Section X - Definitions under Usual, Customary and
Reasonable Charges.
3. Not Physician Approved/Not under Care of Physician. Services or Supplies not recommended or
approved by a Physician, or received while not under the regular or ongoing care and treatment of the
ordering Physician or given by Providers that are not covered by the Plan.
4. Not Medical Necessity/Preventive Care/Routine Screening. Services or Supplies that are not Medically
Necessary for the treatment of an Illness or Injury, according to Plan provisions or related to preventive
care or routine screening including, but not limited to, well child or adult care such as routine physicals,
screening exams, premarital exams, school exams, camp or sport exams; or for tests unrelated to symptoms
or treatment of Illness or Injury; inoculations, immunizations, vaccinations, or other preventive shots;
precautionary services or standby services even when ordered by the Doctor or due to Hospital regulations.
Exception: Limited preventive care expenses specifically included for coverage.
5. Blood Products/Donations. The cost of blood, blood plasma, other blood products and blood processing
and storage charges when they are available free of charge. Services or Supplies for autologous or direct
blood donations and storage when done as precautionary measures in case the need for blood arises.
Exception: Charges by a Hospital, Ambulatory Surgery center or certified blood bank for services
connected with autologous or direct blood donations before Surgery as specifically included in the Plan.
6. Investigative or Experimental/Biofeedback/Alternative Care. Services or Supplies related to research
studies or care considered Investigative or Experimental at the time expenses are Incurred. See Section X -
Definitions under Investigative or Experimental. Services or Supplies connected with care such as
holistic medicine, biofeedback, hypnotherapy, environmental ecology, and other alternate type medicines
are not covered unless specifically included as Covered Expenses. Transplants using artificial organs,
animal or human organs or other tissues will be considered Investigative unless the procedures are
specifically covered by and meet the Centers for Medicare & Medicaid Services (CMS) coverage criteria in
effect at the time expenses are Incurred. Autologous bone marrow or stem cell rescue or other
hematopoietic support procedures for any conditions unless procedures are specifically covered by and
