Are there exclusions and limitations with Medical Gap Insurance?
For an expense to be eligible under the medical expense insurance plan, it has to be covered under your FEHB medical plan. If an expense is denied by your FEHB medical plan, but would otherwise have been an eligible expense under the medical expense insurance plan, it will not be covered:
Benefits will not be paid for losses caused by or resulting from any one or more of the following:
- Declared or undeclared war or any act thereof
- Suicide or intentionally self-inflicted injury or any attempt threat, while sane or insane (while sane, in Colorado and Missouri)
- Any hospital confinement or other treatment for injury or sickness while an insured person is in the service of the armed forces of any country
- Confinement in a hospital or other treatment facility operated by an agency of the United States government or one of its agencies, unless the insured person is legally required to pay for the services
- Confinement or other treatment for injury or sickness which is not medically necessary
- Confinement or other treatment for dental or vision care not related to an accidental injury
- Confinement or other treatment for mental or nervous disorders
- Confinement or other treatment for alcoholism, drug addiction or complications thereof
- Any hospital confinement or other treatment for injury or sickness for which compensation is payable under any Worker's Compensation Law, any Occupational Disease Law, or similar legislation
- Any hospital confinement or other treatment for injury or sickness that is payable under any insurance that does not require deductible and/or coinsurance payments by the insured person
- Any hospital confinement or other treatment for injury or sickness for which benefits are not payable under the insured person's major medical plan
- Any hospital confinement or other treatment for injury or sickness if, on the insured person’s effective date of coverage, the insured person was not covered by a major medical plan
- An insured person engaging in any act or occupation which is a violation of the law of the jurisdiction where the loss or cause occurred. A violation of the law includes both misdemeanor and felony violations
- Prescription drugs
- Durable medical equipment, unless dispensed in a hospital, an outpatient surgical or emergency facility, a diagnostic testing facility, or a similar facility that is licensed to provide outpatient treatment
- Well newborn care, whether inpatient or outpatient
- Wellness or preventive care
- Pregnancy for a dependent, other than a covered dependent spouse.