All health insurance policies have exclusions and limitations in the policies that are issued upon underwriting acceptance. United Health One has pretty standard policy limitations and exclusions with subtle varieties in some states. This list concerns them from a national perspective.
This does not apply to covered persons under age 19.
Preexisting conditions will not be covered during the first 12 months after an individual becomes a covered person. This exclusion will not apply to conditions that are: (a) fully disclosed to Golden Rule in the individual’s application; and (b) not excluded or limited by United’s underwriters.
A preexisting condition is an injury or illness: (a) for which a covered person received medical advice or treatment within 24 months prior to the applicable effective date for coverage of the illness or injury; or (b) which manifested symptoms which would cause an ordinarily prudent person to seek diagnosis or treatment within 12 months prior to the applicable effective date for coverage of the illness or injury.
Limited Exclusion for AIDS or HIV-Related Disease
AIDS or HIV-related disease are treated the same as any other illness unless the onset of AIDS or HIV-related disease is: (a) diagnosed before the coverage has been in force for one year; or (b) first manifested before the coverage has been in force for one year. If diagnosed or first manifested before coverage has been in force for one year, AIDS or HIV-related disease claims will never be covered. Details of this limited exclusion are set forth in the policy and certificates.
No benefits are payable on United Health One’s individual policies for expenses which:
- Are due to pregnancy (except for complications of pregnancy) or routine newborn care.
- Are for diagnosis or treatment of mental disorders and substance abuse – inpatient and outpatient (unless optional coverage is selected or coverage is mandated by your state). This includes counseling and prescription drugs for ADD, ADHD, anxiety, depression and others.
- Are incurred while confined primarily for custodial, rehabilitative, or educational care or nursing services.
- Result from or in the course of employment for wage or profit, if the covered person is insured, or is required to be insured, by workers’ compensation insurance pursuant to applicable state or federal law. If you enter into a settlement that waives a covered person’s right to recover future medical benefits under a workers’ compensation law or insurance plan, this exclusion will still apply.
- Are in relation to, or incurred in conjunction with, experimental or investigation treatment.
- Are for unproven services.
- Are for dental expenses or oral surgery, eyeglasses, contacts, eye refraction, hearing aids, or any examination or fitting related to these.
- Are for modification of the physical body, including breast reduction or augmentation.
- Are incurred for cosmetic or aesthetic reasons, such as weight modification or surgical treatment of obesity.
- Would not have been charged in the absence of insurance.
- Are for eye surgery to correct nearsightedness, farsightedness, or astigmatism.
- Result from war, intentionally self-inflicted bodily harm (whether sane or insane), or participation in a felony (whether or not charged).
- Are for treatment of temporomandibular joint disorders, except as may be provided for under covered expenses.
- Are incurred for animal-to-human organ transplants, artificial or mechanical organs, procurement or transportation of the organ or tissue, or the cost of keeping a donor alive.
- Are for routine or preventive care unless provided for in the policy.
- Are incurred for marriage, family, or child counseling.
- Are for recreational or vocational therapy or rehabilitation.
- Are incurred for services performed by an immediate family member.
- Are not specifically provided for in the policy.
- Are incurred while your certificate is not in force.
- Are for any drug, treatment or procedure that promotes conception.
- Are for any procedure that prevents conception or childbirth.
- Result from intoxication, as defined by applicable state law in the state where the illness or injury occurred, or under the influence of illegal narcotics or controlled substances unless administered or prescribed by a doctor.
- Are for or related to surrogate parenting.
- Are for or related to treatment of hyperhidrosis (excessive sweating).
- Are for fetal reduction surgery.
- Are for alternative treatments, except as specifically identified as covered expenses under the policy/certificate, including: acupressure, acupuncture, aromatherapy, hypnotism, massage therapy, rolfing, and other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health.
- Benefits will not be paid for services or supplies that are not medically necessary to the diagnosis or treatment of an illness or injury, as defined in the policy.
- Expenses incurred by a covered person for treatment of tonsils, adenoids, middle ear disorders, hemorrhoids, hernia, or any disorders of the reproductive organs (except cancer) are not covered during the covered person’s first six months of coverage under the policy. This provision will not apply if treatment is provided on an “emergency” basis.
- Covered expenses will not include more than what was determined to be the eligible expense for a service or supply.
- Transplants eligible for coverage under the Transplant Expense Benefit are limited to two transplants in a 10-year period.
- Charges for an assistant surgeon are limited to 20% of the primary surgeon’s covered fee.
- Covered expenses for surgical treatment of TMJ, excluding tooth extractions, are limited to $10,000 per covered person.
- Covered outpatient expenses relating to diagnosis or treatment of any spine or back disorders are limited to 15 visits per person, per calendar year. CAT scans and MRI tests are not subject to this limitation.
- Covered expenses are limited to no more than a 34-day supply for any one outpatient prescription drug order or refill.
- When using an in-network physician or facility, non-covered expenses may not be eligible for a network provider discount.
Conditions Prior to Legal Action
To help resolve disputes before litigation, the policy requires that you provide us United Health One with written notice of intent to sue as a condition prior to legal action. This notice must identify the source of the disagreement, including all relevant facts and information supporting your position. Unless prohibited by law, any action for extra-contractual or punitive damages is waived if the contract claims at issue are paid or the disagreement is resolved or corrected within 30 days of the written notice.
Continued Eligibility Requirements
A covered person’s eligibility will cease on the earlier of the date a covered person:
- Ceases to be a dependent; or
- Becomes insured under an individual plan providing medical or hospital, surgical, or medical services or benefits. (This does not apply to stand-alone cancer, ICU, or accident-only policies.)
For purposes of this coverage, eligible dependents are your lawful spouse and eligible children. Eligible children must be under 26 years of age at time of application.
Unless United Health One agrees to an earlier date, the effective date will be the later of:
(a) the requested effective date, or
(b) 15 days after the application is received by Golden Rule.
Eligible expense means a covered expense as determined below:
For Network Providers (excluding Transplant Benefits): the contracted fee with that provider.
For Non-Network Providers
– When a covered expense is received as a result of an emergency or as otherwise approved by us, the eligible expense is the lesser of the billed charge or the amount negotiated with the provider.
– Except as provided above (excluding Transplant Benefits), the fee charged by the provider for the services; or the fee that has been negotiated with the provider; or the fee established by us by comparing rates from one or more regional or national databases or schedules for the same or similar services from a geographical area determined by us; or 110% of the fee Medicare allows for the same or similar services provided in the same geographical area; or a fee schedule that United Health develops.
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the covered person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
- Serious impairment to bodily functions; or
- Serious dysfunction of any bodily organ or part.
Coordination of Benefits (including Medicare)
If, after coverage is issued, a covered person becomes insured under a group plan or Medicare, benefits will be determined under the Coordination of Benefits (COB) clause. COB allows two or more plans to work together so that the total amount of all benefits will never be more than 100% of covered expenses. COB also takes into account medical coverage under auto insurance contracts.
United Health One may adjust the premium rates from time to time. Premium rates are set by class, and you will not be singled out for a premium change regardless of your health. The policy plan, age and sex of covered persons, type and level of benefits, time the certificate has been in force, and your place of residence are factors that may be used in setting rate classes. Premiums will increase the longer you are insured.
You may renew coverage by paying the premium as it comes due. They may decline renewal only:
- For failure to pay premium; or
- If we decline to renew all certificates just like yours issued to everyone in the state where you are then living.
Termination of a Covered Person
A covered person’s coverage will terminate on the date that person no longer meets the eligibility requirements or if the covered person commits fraud or intentional misrepresentation.
Coverage will not be issued as a supplement to other health plans that you may have at the time of application. Plans are subject to health underwriting. If you provide incorrect or incomplete information on your insurance application your coverage may be voided or claims denied.
MISSTATEMENT OF TOBACCO USE:
The answer to the tobacco question on the application is material (legally important) to our correct underwriting. If a covered person’s use of tobacco has been misstated on the covered person’s application for coverage under this policy, we have the right to rescind that person’s coverage, subject to the Rescissions provision in the policy/certificate.