Exclusions & Limitations
- Are pre-existing conditions covered?
Pre-existing conditions are not covered. The preexisting conditions limitation includes conditions that were treated or produced symptoms, within five years prior to the effective date of your TriMed STM Coverage Period. However, any condition covered during subsequent consecutive TriMed STM coverage periods will be covered, whether or not it is a pre-existing condition.
- Is there a free look period?
If you are not completely satisfied with this coverage, and you have not filed a claim, you may return the Certificate of Insurance within 10 days and receive a premium refund.
- What services are not covered?
The following is a partial list of services or charges not covered by TriMed STM:
- Any services that are not medically necessary
- Eye exams, eyeglasses, hearing aids and surgery
- Dental or orthodontic services
- Treatment of foot conditions
- Conditions resulting from an act of war
- Maternity and newborn treatment prior to discharge, any infertility treatments or sterilization treatments
- Spinal manipulation or adjustment
- Services performed by family members or for which a charge would otherwise not be incurred
- Medical care received outside of the United States, Canada or it’s possessions
- Services payable by Medicare or Worker’s Compensation coverage
- Cosmetic surgery, treatment for acne, hair loss or varicose veins
- Transplant services to the transplant donor
- Routine physical exams and tests, preventive care and immunizations
- Experimental or investigational services
- Learning disorders, attention deficit disorder, hyperactivity or autism
- Mental or nervous disorders, depression or suicide attempt
- Alcohol or drug dependency and disorders
- Obesity treatments
- Sleep disorders
- Over-the counter-medications and prescription drugs
- Participation in school or organized competitive sports or any high risk sport
- Certain surgeries during the first six months
The limitations and exclusions may vary by state. Please see the Certificate of Insurance for detailed information about these and other plan limitations and exclusions.
- How can I have additional coverage after the 12 month Coverage Period is complete?
When your Coverage Period is almost over, you will receive an application form to apply for another 12 month Coverage Period.* If you re-apply within 30 days prior to the termination date of your coverage, and your application is approved in underwriting, a new Coverage Period will be issued, effective day following the termination date of your Coverage Period. We will issue you a new Certificate of Insurance and new deductible and coinsurance will apply. However, the pre-existing conditions limitation will not apply to any condition(s) that were covered during a prior Coverage Period. Any other pre-existing conditions will remain subject to the pre-existing conditions limitation as described in the Certificate of Insurance.
*The coverage and rates may be different and are subject to state availability. You must be under age 65 to reapply for coverage.
- When does coverage terminate?
Coverage ends when the premium is not paid when due; or you cease to be a member of the association; or the group master policy terminates; or you enter full-time active duty in the Armed Forces; or you become eligible for Medicare; or the elected Coverage Period expires; or Standard Security Life Insurance Company determines fraud or misrepresentation has been made in filing a claim for benefits; or a dependent ceases to be eligible.
- What is a usual, reasonable and customary charge?
Usual, Reasonable and Customary means with respect to fees or charges, fees for medical services or supplies which are usually charged by the provider for the service or supply given and the average charge for the service or supply in the locality in which the service or supply is received; whichever is less, or with respect to treatment or medical services, treatment which is reasonable in relationship to the service or supply given and the severity of the condition. In reaching a determination as to what amount should be considered as Usual, Reasonable and Customary for services and supplies; we may use and subscribe to a standard industry reference source that collects data and makes it available to its member companies.
- Do I need precertification?
Pre-admission certification prior to eligible inpatient hospitalization or surgery by the covered individual within 48 hours is required. This is not a guarantee of benefits. Failure to precertify will result in a benefit reduction of 50%. Call 1-800-367-9938 for precertification.
- Is there an extension of benefits after the plan terminates?
If a member, or insured dependent is receiving benefits for a hospital confinement on the date that the Certificate ofInsurance terminates (for other than non payment of premium), benefits will continue in accordance with the terms of the Certificate of Insurance for as long as that confinement remains. However, in no event will coverage continue beyond the end of 90 days following the date the coverage terminates when the Insured becomes eligible for other coverage for the same conditions or the maximum benefits have been reached. Benefits payable are subject to a new Deductible Amount and satisfaction of Coinsurance Limit.
This website provides a brief description of the benefits, exclusions and other provisions of the group Master Policy Form SSL-STMP-1104. For complete listing, see the Policy/Certificate of Insurance. Benefits may vary by state. TriMed STM is not available in all states.
Association membership may be required in some jurisdictions.
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