W. Va. Code R. § 114-17-5

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-17-5 - Prohibited Policy Provisions

5.1. Excluded coverage by type. -- No Medicare Supplement or Limited Benefit Medicare Supplement policy or contract shall limit or exclude coverage by type of illness, accident, treatment or medical condition except as to the following, where not inconsistent with Medicare:

(a) Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic strain or symptomatic complaints of the feet;

(b) Mental or emotional disorders, alcoholism and drug addiction;

(c) Illness, treatment or medical condition arising out of:

(1) War or act of war (whether declared or undeclared);

(2) Participation in a felony, riot or insurrections;

(3) Service in the armed forces or units auxiliary thereto;

(4) Suicide (sane or insane), attempted suicide or intentionally self-inflicted injury;

(5) Aviation.

(d) Cosmetic surgery, except that "Cosmetic Surgery" shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part;

(e) Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;

(f) Treatment provided in a governmental hospital; benefits provided under Medicare or other governmental program (except Medicaid), any state or federal workers' compensation, employer's liability or occupational disease law or any motor vehicle no-fault law; services rendered by employees of hospitals, laboratories or other institutions; services performed by a member of the covered person's immediate family and services for which no charge is normally made in the absence of insurance;

(g) Dental care or treatment;

(h) Eye glasses, hearing aids and examination for the prescription or fitting thereof;

(i) Rest cures, custodial care, transportation and routine physical examination;

(j) Territorial limitations:

Provided, That Medicare Supplement or Limited Benefit Medicare Supplement policies or contracts may not contain limitations or exclusions of the types included in Subdivisions (a), (e), (i) or (j) above that are more restrictive than those of Medicare. Medicare Supplement or Limited Benefit Medicare Supplement policies or contracts may exclude coverage for any expense to the extent of any benefit available to the insured under Medicare.

5.2. Waivers. -- No Medicare Supplement or Limited Benefit Medicare Supplement policy or contract may use waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.

W. Va. Code R. § 114-17-5