SSMC Employee Health Benefit Plan
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50. Police Custody/Court Ordered Services. Services or Supplies Incurred while the Covered Person is in
police custody, jail or in prison or Services or Supplies related to court ordered professional evaluations for
Mental Illness or substance (drug and alcohol) abuse or other disorders.
51. Work-Related/Occupational Conditions. Services or Supplies received because of an occupational
Injury or an occupational Illness that entitles the Covered Person to benefits under a worker's
compensation, occupational disease law, or similar legislation. Services or Supplies received for Illnesses
or Injuries arising out of police or firefighter duties, whether volunteer or professional. Payment will not be
made even if you or your Dependent does not claim the entitled benefits. Note: This Plan will
automatically exclude expenses denied by the workers compensation health plan when due to late filing,
failure to provide documentation, failure to attend a hearing, or because the services related to the
occupational condition were not Medically Necessary.
52. Government Programs. Services or Supplies that could be provided by or paid by any governmental
(domestic of foreign) program (other than Medicaid) under which you or your Dependents are or could be
covered. Exception: Coverage to the extent that the government regulations for the Program require the
Plan to allow benefits that would have been otherwise payable. Medicare as specifically included in
Section VI - Medicare Integration with Plan Benefits. Note: If a Covered Person is not enrolled in
Medicare when Medicare becomes primary according to Medicare Secondary Payer rules, the Plan
estimates Medicare payment. These estimated amounts could reduce available benefits.
53. Government Facilities/Institutions. Services or Supplies received in an institution owned or operated by
federal, state or local or foreign governments for which no charges would have been made if this health
plan was not in effect. Military Hospitals for the care of active military personnel will not be covered.
Veteran Hos pitals will not be covered for the treatment of conditions related to military service.
Government facilities that do not meet the Plan definitions for coverage will not be covered.
54. No-fault Automobile Coverage. Services or Supplies to the extent they are covered under a mandatory
motor vehicle liability law that requires benefits be provided for personal Injury without regard to fault.
This applies whether or not a claim is made for payment under that coverage. Benefits under this Plan will
automatically be denied if the auto insurance or other payer of mandatory No-Fault Automobile Coverage
denies benefits due to late filing. Charges for Services or Supplies not paid by the no-fault coverage due to
its deductible, copayments or maximum payment limits will be covered under this Plan to the extent the
expenses would have otherwise been covered by this Plan.
55. Third Party Claim Settlement/Action. Services or Supplies for which payment is received or are
reimbursable because of claim settlement or legal action (third party claim or actions), other than under an
individual policy or plan issued to you or your Dependent. Exception: Conditional payments shown in
Section IX - Other Provisions and Procedures under Right of Subrogation. Failure to comply with the
conditions of the Plan's right to subrogation could result in denial of benefits.
56. Forms/Missed Appointments/Phone Calls/No Care Given. Medical summaries, invoice preparations,
completion of claim forms, or fees for missed appointments, telephone consultations and charges for
standby services. Services or Supplies not actually received by the patient or Incurred by someone other
than the patient unless specifically included in this Plan such as coverage limits for organ donors and
directed blood donations.
57. Mailing/Shipping/Handling. Charges for mailing, shipping or handling of any documents, medical
Supplies, equipment, drugs or any other items, whatever reason for use.
