This plan is underwritten by the United States Life Insurance Company in the City of New York, NAIC No. 70106, domiciled in the state of New York with a principal place of business of One World Financial Center, 200 Liberty Street, New York, NY 10281. It is currently authorized to transact business in all states, plus dc, except PR. This summary is a brief description of benefits only and is subject to the terms, conditions and limitations of Group Policy G-201223 and
G-207.513, Form no. G-24034 and G-24078.
The underwriting risks, financial and contractual obligations and support associated with products issued by the The States Life Insurance Company in the City of New York (United States Life) are its responsibility.
No benefits are payable for charges for: 1. services or supplies for which an Insured Person is not required to pay or charges made only because insurance exists (subject to the right, if any, of the United States government to recover Reasonable and Customary Charges for care provided in a military or veterans hospital); 2. a diving accident or Injury for which benefits are paid or payable under Workers Compensation or any Occupational Disease or similar law whether such benefits are insured or self-insured; 3. any act of war, declared or not; 4. Custodial Care; 5. drugs and medicine that may be obtained without written prescription and/or not furnished by and administered during a Hospital confinement as an Inpatient; 6. charges that are more than the Reasonable and Customary Charges for the services and supplies furnished; 7. hospital services and supplies when confinement is solely for diagnostic testing purposes; 8. nervous, emotional, or mental disorders; 9. a diving accident or Injury that occurs after drug or alcohol use unless such drug was prescribed by a physician; 10. medical examinations not required for any Injury or illness; 11. routine eye or hearing exams, eye refractions, eye glasses, contact lens, hearing aids, or any type of external appliances used to improve visual or hearing acuity and their fittings; 12. cosmetic or reconstructive procedures, and any related services or supplies, that alter appearance but do not restore or improve impaired physical functions; 13. care, treatment, services, or supplies: a. not prescribed by a Physician; b. not Medically necessary; c. that are considered experimental in the United States or provided mainly for the purpose of medical or other research; d. received from a Nurse that do not require the skill and training of a Nurse; e. received in a Hospital owned or operated by the United States government or any of its agencies (subject to the right, if any, of the United States government to recover Reasonable and Customary Charges for care provided in a military or veterans hospital); f. provided or paid for by any governmental plan or law not restricted to the government’s civilian employees and their dependents, except Medicaid; or g. ordered by a Family member; or 14. a diving accident or Injury for which charges are compensable under Other Medical Expense Insurance or any services, supplies, or treatments provided under any federal, state, or other governmental plan or law or paid under the Workers Compensation or Occupational Disease Act or Laws. No benefit payment is made for charges incurred after the date this Group Policy terminates except as provided under the “Extended Benefits” provision.