SSMC Employee Health Benefit Plan
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40. Facility Employees. Separate charges for services by members of the staff employed by a Hospital,
Skilled Nursing Fac ility, Convalescent Facility, Rehabilitation Facility, or by any Inpatient facility where
care is received.
41. Home Visits. Professional Provider charges for home visits. Exception: Covered professional nursing
visits and home visits that are part of approved Home Health Care Plan or Hospice Care Plan.
42. Free Care/Obligation to Pay. Services rendered by volunteers or other persons who normally do not bill
for their services. Services or Supplies received for which no charges would have been made without
coverage under the Plan or for which there is no legal obligation for payment by the Enrollee or Dependent.
Exception: Coverage to the extent federal and state law requires the Plan to allow benefits that would have
been otherwise payable.
43. Condition Due to Military Service. Services or Supplies for which benefits are, or can be, provided due
to related Illness or Injury arising from the past or present military service in the armed forces of any
government or international authority.
44. Hazardous Pursuit. Service or Supplies required due to Accidental Injuries sustained while the Covered
Person is engaged in any Hazardous Pursuit. Exception: Plan coverage would be provided for expenses
otherwise covered for treatment of an Injury that was the result of a medical condition (physical or mental)
or domestic violence.
45. Self-Inflicted Actions/Attempted Suicide. Services or Supplies required due to any conditions resulting
from self-inflicted actions or attempted suicide of the patient unless the patient has a diagnosed mental
condition that would have impaired his or her rational judgment at the time of such actions. Exception:
Plan coverage would be provided for expenses otherwise covered for treatment of an Injury that was the
result of a medical condition (physical or mental) or domestic violence.
46. Illegal Care. Services or Supplies considered illegal according to the laws of the state or country of
jurisdiction. If considered illegal according to the laws of the USA, benefits will not be paid even if the
excluded services are considered legal in the foreign country.
47. Out of USA. Services or Supplies Incurred outside the USA if the Covered Person traveled to the foreign
country or locality for the sole purpose of receiving the Services or Supplies.
48. Act of War/Riots. Services or Supplies received due to an Injury or Illness resulting from an act of war,
whether declared or undeclared or from participation in a civil insurrection or riot. Exception: Plan
coverage would be provided for expenses otherwise covered for treatment of an Injury that was the result of
a medical condition (physical or mental) or domestic violence.
49. Criminal Behavior/Unlawful Acts/Driving under Influence. Services or Supplies related to treatment of
any medical or dental conditions arising out of participation in, or leaving the scene of a felony crime. This
exclusion applies to criminal behavior considered felony crimes under the laws of the state in which the
criminal behavior occurred, such as felony driving while under the influence of alcohol or illegal drugs,
armed robbery, assault, murder. If a Covered Person is convicted for the felony act, then such conviction
will serve as proof that the Covered Person committed or was engaged in the unlawful felony act. If not
convicted, the Covered Person could still be deemed to have committed the unlawful felony act based on
the facts and circumstances involved, even if a criminal prosecution does not take place or if it does, the
Covered Person is found not guilty. Exception: Plan coverage would be provided for expenses otherwise
covered for treatment of an Injury that was the result of a medical condition (physical or mental) or
domestic violence.
