UHC Hospital & Indemnity Coverage

This product provides limited benefits. Health ProtectorGuard is not major medical or comprehensive health insurance and does not provide the mandated coverage necessary to avoid a penalty under the Affordable Care Act.

Hospital Confinement
We will pay the Inpatient Hospital Confinement Benefit amount per covered person, for each day charged for hospital confinement as an inpatient under the orders of a doctor. Limited to 180 days per covered person, per calendar year.

Intensive Care Unit Confinement
We will pay the Intensive Care Unit Benefit for each day a covered person is charged for confinement in an intensive care unit as an inpatient under the orders of a doctor. Limited to 30 days per covered person, per calendar year.

Hospital Emergency Room
We will pay the Hospital Emergency Room Benefit amount, limited to once per covered person, per calendar year, for a charge for hospital emergency room care.

Ambulance
We will pay the Ambulance Benefit amount for each day a licensed professional ground or air ambulance service is used to transport a covered person to a hospital or emergency care facility due to an illness or injury. Limited to 2 days per covered person, per calendar year; covers emergency transportation or transportation between hospitals during a period of hospital confinement.

Doctor Office
We will pay the Office Visit Benefit amount for each day a covered person is charged for an office visit rendered in a doctor’s office while the covered person is not an inpatient. Limited to 4 days per covered person, per calendar year. No benefits are payable for doctor office visits that relate solely to alternative treatments, including acupressure, acupuncture, aroma therapy, hypnotism, massage therapy, rolfing, and other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health.

Urgent Care Center
We will pay the Urgent Care Center Benefit amount, limited to once per covered person, per calendar year, for urgent care received in an urgent care center.

Outpatient Pharmacy
We will pay the Outpatient Prescription Drug Benefit amount each day a covered person is charged for an outpatient prescription drug prescribed by a doctor and dispensed at a licensed pharmacy, while the covered person is not an inpatient. Limited to a maximum of $750 combined for brand name and generic prescriptions per covered person, per calendar year. “Prescription drug” means any medicinal substance whose label is required to bear the legend “Rx only.”

This is only a general outline of the coverage provisions and exclusions. It is not an insurance contract, nor part of the insurance policy/certificate. You will find complete coverage details in the policy/certificate.

General Exclusions
Benefits will not be paid for services or supplies that are not administered or ordered by a doctor and medically necessary to the diagnosis or treatment of an illness or injury, as defined in the policy.

No benefits are payable for expenses:

• For non-emergency services or supplies received from a provider who is not a network provider, except as specifically provided for by the policy.
• For a preexisting condition — A condition: (1) for which medical advice, diagnosis, care, or treatment was recommended or received within the 24 months immediately preceding the date the covered person became insured; or (2) that had manifested itself in such a manner that would have caused an ordinarily prudent person to seek medical advice within the 12 months immediately preceding the date the covered person became insured.
• A pregnancy existing on the effective date of coverage will also be considered a preexisting condition. NOTE: Even if you have had prior Golden Rule coverage and your preexisting conditions were covered under that plan, they will not be covered under this plan.
• That would not have been charged if you did not have insurance.
• Incurred while your coverage is not in force.
• Imposed on you by a provider (including a hospital) that are actually the responsibility of the provider to pay.
• For services performed by an immediate family member.
• For services or supplies provided prior to the effective date or after the termination date of coverage.
• For weight modification or surgical treatment of obesity, including wiring of the teeth and all forms of intestinal bypass surgery.
• For breast reduction or augmentation.
• For drugs, treatment, or procedures that promote conception; sterilization or reversals of sterilization; fetal reduction surgery or abortion (unless life of mother would be endangered).
• For treatment of malocclusions or disorders of the temporomandibular joint (TMJ) or craniomandibular disorders.
• For modification of the physical body to improve psychological, mental, or emotional well-being, such as sex-change surgery.
• Not specifically provided for in the policy, including telephone consultations, failure to keep an appointment, television or telephone expenses.
• For marriage, family, or child counseling; standby availability of a medical practitioner when no treatment is rendered.
• For hospital room and board and nursing services if admitted on a Friday or Saturday, unless for an emergency, or for medically necessary surgery scheduled for the next day.
• For dental expenses, including braces and oral surgery, except as provided in the policy/certificate.
• For cosmetic treatment; reconstructive surgery unless incidental to a covered injury or to correct a birth defect in a child covered since childbirth.
• For diagnosis or treatment of learning disabilities, attitudinal disorders, or disciplinary problems; nicotine addiction.
• For charges related to tissue or organ transplants, except as expressly provided under Transplant Services.
• For eye refractive surgery to correct nearsightedness, farsightedness, or astigmatism.
• While confined for rehabilitation, custodial care, educational care, or nursing services, except as provided in the policy/certificate.
• For eyeglasses, contact lenses, hearing aids, eye refraction, or visual therapy, except as provided in the policy/certificate.
• Due to pregnancy (except complications), except as provided in the policy/certificate.
• For treatment of mental disorders or substance abuse including court-ordered treatment, except as provided in the policy/certificate.
• For preventive or prophylactic care, including routine physical examinations, except as provided in the policy/certificate.
• Incurred outside of the U.S., except for emergency treatment.
• Resulting from declared or undeclared war; intentionally self-inflicted bodily harm; or participation in a riot or felony.
• For durable medical equipment or its fitting, implantation, or removal, except as provided in the policy/certificate.
• For surrogate parenting; treatments of hyperhidrosis (excessive sweating).
• For alternative treatments, including acupressure, acupuncture, aromatherapy, hypnotism, massage therapy, and rolfing, except as specifically covered by the policy/certificate.
• Resulting from intoxication or while under the influence of illegal narcotics or controlled substances, unless administered or prescribed by a doctor.
• For joint replacement, unless related to an injury covered by the policy/certificate.
• For non-emergency treatment of tonsils, adenoids, hemorrhoids, or hernia.
• For injuries sustained while participating in professional/semi-professional sports, parachute jumping, hang-gliding, racing or speed testing any motorized vehicle, scuba/skin diving (60+ feet), skydiving, bungee jumping, or rodeo sports.
• For injuries sustained while performing the duties of an aircraft crew member, including training on an aircraft.
• For vocational or recreational therapy, vocational rehabilitation, or occupational therapy, except as provided in the policy/certificate.
• Resulting from experimental or investigational treatments, or unproven services.
• Resulting from or during employment for wage or profit, if covered or required to be covered by workers’ compensation insurance under state or federal law.