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What is Covered | Exclusions & Limitations | Eligibility Information

Exclusions and Limitations For CeltiCare Health Plans

(may vary by state)

In addition to other limitations on benefits and exclusions, benefits are not paid under any plan for a sickness or bodily injury resulting from:

• any act of war, declared or undeclared, or service in the military forces of any country, including non-military units supporting such forces;
• participation in a riot, felony, or other illegal act or being under the influence of alcohol, drugs or narcotics unless taken as prescribed by a physician;
• suicide or attempted suicide, or self-inflicted bodily injury while sane or insane;

No benefits are paid that are provided:

• free of charge in lieu of this insurance;
• by a government-operated hospital unless the insured person is required to pay;
• for treatment received outside the United States except for a medical emergency while traveling for up to a maximum of 90 consecutive days. 

Additionally, no benefits are paid for:

• sickness or bodily injury that arises out of, or as a result of, any work if the insured person is required to be covered under Worker's Compensation or similar legislation.  

Other Exclusions include:

• normal pregnancy and delivery, elective or repeat Cesarean section;
• routine physical examinations and "well baby" care of a dependent child unless CeltiCare Plus option is chosen.  "Well-baby" care is defined as charges not related to a sickness or bodily injury;
• treatment or surgical procedure relating to fertility, including diagnosis or treatment of infertility;
• birth control (except where state mandated);
• tubal ligations and vasectomies while hospital confined are not covered.  The reversal of a tubal ligation or vasectomy is not covered at any time;
• treatment or surgery for exogenous and endogenous or morbid obesity;
• gender reassignment (sex change or reassignment);
• eye refractions, vision therapy, glasses or fitting of glasses, contact lenses, surgical or non-surgical treatment to correct refractive eye disorders, or any treatment or procedure to correct vision loss;
• hearing aids, exams or fittings, surgical or non-surgical treatment or procedure to correct hearing loss;
• treatment or medication that is experimental or investigational;
• custodial care;
• treatment of drug addiction or chemical dependency;
• myringotomy or dilation and curettage and surgical treatment of tonsils, adenoids or hernia within first 6 months of coverage unless due to emergency.

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Important Note: The information contained on this web page and the other linked pages is not intended to provide full details of Celtic plans and may change at the discretion of Celtic Insurance Company.  Benefits and Plan details may vary by state.  Complete terms of coverage are outlined in the individual Certificate Booklets and set forth in the applicable insurance Policy and Trust agreement.   In applying for coverage, the primary insured agrees to be bound by the Certificate.  The benefits described in these pages and any accompanying literature are the standard benefits offered by Celtic.  Policy provisions vary in some states.

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