Medico Insurance Company Disclosures

Medicare Supplement insurance plan

Policy form numbers: MSA70A; MSA70F; MSA70N; MI-MSA21A21A(MO)-C; MI-MSA21D(MO)-C; MI-MSA21F(MO)-C; MI-MSA21M(MO)-C; MI-MSA21N(MO)-C; MI-MSA20A(NM); MI-MSA20D(NM); MI-MSA20F(NM); MI-MSA20A(MT); MI-MSA20F(MT); MI-MSA20N(MT); MI-MSA20A(OK)-C; MI-MSA20D(OK)-C; MI-MSA20F(OK)-C; MSA70A(VA)-1; MSA70F(VA)-1; MSA70G9VA)-1; MSA70N(VA)-1

In MD, MO, MS, MT, OK, coverage is available to qualified Medicare beneficiaries under the age of 65.

Short-Term Recovery Care insurance plan

Policy form numbers: NHA30-C; NHA30(OH)-C; NHA30(MO)-C; NHA30(OR)-C; NHA30(PA)-C; NHA30(TN)-C; NHA30(VA)-C; NHA30(ID)-C

Exceptions

We will NOT pay benefits for:
1. Loss that occurs while this policy is not in force
2. Intentional, self-inflicted injury or attempted suicide
3. Mental or nervous disorders without demonstrable organic disease (Subject to the other policy provi­sions, we will cover mental or nervous disorders, such as Alzheimer’s and related dementias, that have a demonstrable organic cause that manifest themselves after the effective date of the policy and while the insurance is in force.)
4. Alcoholism, drug addiction, or their complications, unless addiction resulted from narcotics prescribed by a physician
5. Loss to which a contributing cause was your commis­sion of or attempt to commit a felony or being engaged in an illegal occupation
6. Care or services provided by a member of your imme­diate family
7. Services for which you are not liable or for which no charge normally is made in the absence of insurance
8. Loss that occurs outside the territorial limits of the United States
9. Drugs or supplies

Pre-existing condition limitation

This policy will not provide coverage for pre-existing conditions if the loss occurs or the confinement begins within the first 180 days (in Wisconsin, 6 months) after your policy is effective.

Hospital Indemnity insurance plan

Policy form numbers: HIA60; HIA62; HIA60(MO); HIA62(MO); HIA60(OH); HIA62(OH); HIA63; HIA63(FL); HIA63(IL); HIA63(KS); HIA63(KS); HIA63(MT); HIA63(NC); HIA63(OK); HIA63(OR); HIA63(PA); HIA63(TX); HIA63(WI)

Exclusions and Limitations — HIA60 and HIA62 (may vary by state)

We will NOT pay benefits for:
1. Any loss that occurs while this policy is not in force
2. For treatment of complications of a noncovered loss
3. Treatment, services, or supplies that:
     a. Are not medically necessary as determined by us
     b. Are not prescribed by a physician as necessary to treat a sickness or injury
     c. Are determined to be experimental or investigational as determined by us
     d. Are received without charge or legal obligation to pay
     e. Would not routinely be paid in the absence of insurance
     f. Are received from any family member
4. Suicide or any suicide attempt while sane or insane or any intentionally self-inflicted injury
5. Alcoholism, drug addiction, or their complications, unless addiction resulted from narcotics prescribed by a physician
6. Injuries received or caused directly or indirectly while under the influence of a controlled substance, unless prescribed by a physician, or by intoxication as defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss was incurred
7. Loss to which a contributing cause was your commission of or attempt to commit a felony or being engaged in an illegal occupation
8. Service for which benefits are available for you under state or federal workers’ compensation
9. Loss that occurs outside the territorial limits of the United States
10. Any loss resulting from war, declared or undeclared, or actively serving in the armed forces or their auxiliary units, including any country’s National Guard or Army Reserve or their equivalent
11. Durable medical equipment (D.M.E.)
12. Prosthetics or orthopedic shoes
13. Drugs and self-administered drugs
14. Dental care or treatment (except expenses otherwise covered due to injury to sound natural teeth); ordinary dental care, dentures and dental implants; cosmetic surgery, except for reconstructive surgery that is incidental to or follows surgery
15. Vision surgery, including any complications arising therefrom, to correct visual acuity, including, but not limited to, lasik and other laser surgery, radial keratotomy services, or surgery to correct astigmatism, nearsightedness (myopia), and/or farsightedness (presbyopia)
16. Hearing services
17. Any loss resulting from any device for aerial navigation, except as a fare-paying passenger
18. Any loss resulting, either directly or indirectly, from your participation in a high-risk activity for professional purposes (does not include casual participation), including, but not limited to:
     a. Skydiving
     b. Hang gliding
     c. Parachuting
     d. Piloting experimental or ultralight aircraft
     e. Riding in any aircraft not licensed to carry passengers or not operated by a duly licensed pilot
     f. Riding in a hot air balloon
     g. Bungee jumping
     h. Rappelling
     i. Professional mountain and/or rock climbing
     j. Rodeo participation
19. Pregnancy, unless due to complications of pregnancy
20. Elective abortion, except for medically necessary abortions to preserve the life of the female upon whom the abortion is performed
21. Sex change, reversal of tubal ligation, or reversal of vasectomy
22. Cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part
23. Hospital confinement primarily for rest care, convalescent care, or rehabilitation

Exclusions and Limitations — HIA63 (may vary by state)

No benefits will be paid for any expense not identified and included as a covered loss under the policy. You will be fully responsible for payment of any expense that is not a covered loss. We will not pay benefits for:
1. Any loss that occurs while this policy is not in force
2. For services or supplies not covered under this policy
3. For treatment of complications of a noncovered loss
4. Any treatment for loss that:
     a. Is not medically necessary
     b. Is not prescribed by a physician as necessary to treat a sickness or injury
     c. Is determined to be experimental or investigational
     d. Is received without charge or legal obligation to pay
     e. Would not routinely be paid in the absence of insurance
5. Suicide or any suicide attempt, while sane or insane, or any intentionally self‐inflicted injury
6. Alcoholism, drug addiction, or their complications, unless addiction resulted from narcotics prescribed by a physician.
7. Injuries received or caused directly or indirectly while under the influence of a controlled substance, unless prescribed by a physician, or by intoxication as defined by the laws and jurisdiction of the geographic area in which the loss or cause of loss was incurred
8. Loss to which a contributing cause was your commission of or attempt to commit a felony or being engaged in an illegal occupation.
9. Service for which benefits are available for you under state or federal workers’ compensation
10. Loss that occurs outside the territorial limits of the United States
11. Any loss resulting from war, declared or undeclared, or actively serving in the armed forces or their auxiliary units, including any country’s National Guard or Army Reserve or their equivalent
12. Durable medical equipment (DME), prosthetics, or orthopedic shoes
13. Drugs and self‐administered drugs
14. Physical therapy, occupational therapy, speech therapy, or manipulation of the spine, except as specifically provided elsewhere in this policy
15. Dental care or treatment (except expenses otherwise covered due to injury to sound natural teeth); ordinary dental care, dentures and dental implants; cosmetic surgery, except for reconstructive surgery that is incidental to or follows surgery
16. Vision surgery, including any complications arising therefrom, to correct visual acuity, including, but not limited to, LASIK and other laser surgery, radial keratotomy services, or surgery to correct astigmatism, nearsightedness (myopia), and/or farsightedness (presbyopia)
17. Hearing services
18. Any Loss resulting from any device for aerial navigation, except as a fare‐paying passenger
19. Any loss resulting, either directly or indirectly, from your participation in a high‐risk activity for pay, profit, or other commercial purposes, including, but not limited to:
     a. Sporting event
     b. Skydiving
     c. Hang gliding
     d. Parachuting
     e. Piloting experimental or ultralight aircraft
     f. Riding in any aircraft not licensed to carry passengers or not operated by a duly licensed pilot
     g. Riding in a hot air balloon
     h. Bungee jumping
     i. Rappelling
     j. Professional mountain and/or rock climbing
     k. Rodeo participation
     l. Organized contests, including, but not limited to, organized contests of speed, go‐cart racing, dirt bike racing, demolition derbies, and mountain bike racing. This exclusion also includes the practice, qualification, and/or testing for such activities
20. Pregnancy, unless due to complications of pregnancy
21. Abortion, except for medically necessary abortions performed to save the mother’s life
22. Sex change, reversal of tubal ligation, or reversal of vasectomy
23. Cosmetic or elective procedures that are not medically necessary, including, but not limited to organ donation, elective sterilization, and fertility treatments
24. Hospital confinement primarily for hospice care, rest care, convalescent care, or rehabilitation

First Diagnosis Cancer insurance plan

Policy form numbers: MI-CAA28; MI-CAA29; MI-CAA28(ID); MICAA29(ID); MI-CAA28(IL); M-ICAA29(IL); MI-CAA28(MI); MI-CAA29(MI); MI-CAA28(MO); MI-CAA29(MO); MI-CAA28(MT); MI-CAA29(MT); MI-CAA28(NC); MI-CAA29(NC); MI-CAA28(NM); MI-CAA29(NM); MI-CAA28(OH); MI-CAA29(OH); MI-CAA28(OK); MI-CAA29(OK); MI-CAA28(OR); MI-CAA29(OR); MI-CAA28(PA); MI-CAA29(PA); MI-CAA28(TX); MI-CAA29(TX); MI-CAA28(WI); MI-CAA29(WI)

Exclusions and limitations (may vary by state):

This policy pays only for first diagnosis of internal cancer or malignant melanoma. We will NOT pay benefits for:
1. Skin cancer, other than malignant melanoma
2. 
Any disease, sickness, or incapacity, other than internal cancer or malignant melanoma
3. 
More than one first diagnosis benefit
4. 
Loss that occurs while this policy is not in force
5. 
A first diagnosis made outside the United States of America
6. 
Cancer first diagnosed during the 30-day waiting period. Cancer will not be a covered condition:
     a. When any medical advice, care, treatment, or clinical diagnosis received within the waiting period leads to a first diagnosis of cancer
     b. if tissue extracted during the waiting period leads to a first diagnosis of cancer
     
c. if cancer manifests itself before the policy has been in force for at least 30 days following the policy date. Cancer is manifested when symptoms exist.

Dental insurance and DVH insurance plans

Policy form numbers: DA108B; DA108P; DVA58; DVA59; DVA58(ID); DA108B(ID); DA108P(ID); DVA58(LA); DA108B(LA); DA108P(LA); DA108B(MO); DA108P(MO); DVA58(MT); DA108B(MT); DA108P(MT); DVA59(NC); DA108B(NC); DA108P(NC); DVA58(NM); DA108B(NM); DA108P(NM); DVA59(OH); DA108B(OH); DA108P(OH); DVA59(OK); DA108B(OK); DA108P(OK); DVA58(OR); DVA108B(OR); DVA58(PA); DA108B(PA); DA108P(PA); DVA58(TX); DA108B(TX); DA108P(TX); DVA59(WI); DA108B(WI); and DA108P(WI)

Exclusions and limitations (for AZ only):

For Forms DA108B and DA108P:
No benefits will be paid for any expense not identified and included as a covered loss under the policy. You will be fully responsible for payment of any expenses that are not a covered loss. We will not pay benefits for:
1. Any loss that occurs while this policy is not in force
2. Amounts not reimbursed because of applicable policy year deductible, coinsurance, benefit maximums, or frequency limitations
3. Any loss that occurs during a waiting period
4. Amounts in excess of the reasonable and customary charge
5. Items, treatments, or services:
     a. Not covered under this policy, including any complications arising therefrom
     b. That are not prescribed by or performed by or under the direct supervision of a physician in accordance with generally accepted dental or medical standards, to include services not rendered, or that are not rendered within the scope of their license
     c. Not medically necessary as determined by us
     d. Deemed to be experimental or investigational as determined by us
     e. That would not routinely be paid in the absence of insurance
     f. Performed by an immediate family member
6. Separate fees for services that are considered an integral part of an entire service, such as pulp capping, surgical trays, sutures, or pre and post-operative care
7. Services or procedures that have not been completed
8. Any cosmetic items, treatments, or services provided primarily for the purpose of improving appearance, self-esteem, or body image, including characterizing and personalizing prosthetic devices and correction of congenital malformation
9. Any device, appliance, or service related to:
     a. Altering vertical dimension
     b. Restoring or maintaining occlusion
     c. Splinting teeth or stabilizing teeth for periodontal reasons
     d. Abrasion, attrition, bruxism, erosion, or abfraction
     e. Coping
     f. Tooth desensitization
     g. Maxillofacial prosthetics
10. Any surgical or nonsurgical treatments or services, including myofunctional therapy and physical therapy for any jaw joint problems, including, but not limited to: temporomandibular joint disorder (TMJ), craniomandibular disorder, craniomaxillary, or other conditions of the joint linking the jaw bone and skull or treatment of the facial muscles used in expressions and chewing functions, for symptoms including, but not limited to, headaches 
11. Occlusal, athletic, or night guards and related services
12. Orthodontic treatment or orthognathic surgery and related services
13. Ridge preservation, augmentation, bone grafts, and tissue regeneration when performed in edentulous sites (toothless areas)
14. Overdentures, precision or semi-precision attachments, and related services
15. Sealants, fluoride treatments, preventive resin restorations, or space maintainers and related services
16. Supplies, including, but not limited to, services or supplies for temporary or provisional crowns, bridges, or dentures, and duplicate or temporary devices, appliances, and prosthetics
17. Replacing a lost, stolen, or missing appliance or prosthetic device
18. Oral hygiene instructions, behavior modification, diet instruction, or infection control
19. Sterilization of equipment; disposal of medical waste or other requirements mandated by the Occupational Safety and Health Administration (OSHA) or other regulatory agencies
20. Treatment or diagnosis received while outside the continental United States, except Hawaii
21. Work-related sickness or injury for which you are eligible for any workers’ compensation, employers’ liability, or similar laws, whether or not benefits are claimed
22. Services for which no charge is made or for which you are not legally obligated to pay, including, but not limited to, services furnished through:
     a. Your employer, labor union, or similar group, in its dental or medical department or clinic
     b. A facility owned or run by any government body
23. Services furnished by or payable under any public program (except Medicaid) or paid for or sponsored by any government body
24. Telephone consultations, charges for failure to keep a scheduled appointment, copy fees, sales tax, charges for completion of a claim form, or any take-home supplies. If you use an external discount or coupon, the amount that is reduced from the billed charge is not a covered loss under this policy.
25. Ancillary charges, including, but not limited to, hospital, ambulatory surgical center, or similar facility, or use of provider office space
26. Any loss resulting from:
     a. War, declared or undeclared, or actively serving in the armed forces or their auxiliary units, including any country’s National Guard or Army Reserve or their equivalent
     b. Committing, attempting to commit, or participation in a felony or engaging in an illegal occupation
     c. Your participation in a riot, rebellion, or insurrection
     d. An intentionally self-inflicted injury while sane or insane
27. Impacted teeth
28. Prescription and non-prescription drugs, whether dispensed or prescribed, including chemotherapeutic agents
29. Speech therapy for any purpose
30. Laboratory and pathology tests and examinations, except as specifically listed in the benefits section of your policy
31. Oral surgery and related services, except as specifically listed in the benefits section of your policy
32. Full mouth debridement
33. Implantology and related services; implants, including removal of implants, and related services

For policies that include Vision insurance:
34. Any surgical procedure performed in the treatment of cataracts
35. Vision surgery to correct visual acuity, including, but not limited to, LASIK and other laser surgery, radial keratotomy (RK) services, or surgery to correct astigmatism, nearsightedness (myopia) and/or farsightedness (presbyopia), automated lamellar keratoplasty (ALK), conductive keratoplasty (CK), or other cosmetic procedures
36. Orthoptic or vision therapy training and any associated supplemental testing, medical or surgical treatment, or services of the eyes or supporting structures

Exclusions and limitations (for AZ only):

For Forms DVA58 and DVA59:
Your policy does not cover any miscellaneous separate expense not considered an eligible expense. We will not pay benefits for any of the following:
1. Items, treatments, or services:
     a. Not listed as an eligible expense in the coverage schedule
     b. Not prescribed by or performed by or under the direct supervision of a dentist or a provider
     c. Not medically necessary
     d. Any experimental or investigational procedure or treatment
     e. Performed by a member of your or your spouse’s family (family includes parents, step-parents, in-laws, spouse or former spouse, domestic partner, children, siblings, aunts, uncles, cousins, nieces, nephews, grandparents, and guardians).
2. Services furnished primarily for cosmetic reasons, including but not limited to:
     a. Specialized techniques, characterizing and personalizing prosthetic devices
     b. Making facings on prosthetic devices for any tooth in back of the second bicuspid
     c. Replacements of restorations performed for cosmetic reasons
     d. Charges for radial keratotomy (RK), automated lamellar keratoplasty (ALK), conductive keratoplasty (CK), or other cosmetic procedures
3. Charges for any appliance or service that is used to:
     a. Change vertical dimension
     b. Restore or maintain occlusion
     c. Splint or stabilize teeth for periodontal reasons
     d. Treat disturbances of the temporomandibular joint (TMJ), unless mandated by state law (for AZ only)
4. Charges for any service performed as a result of abrasion, attrition, bruxism, erosion, or abfraction
5. Occlusal, athletic, or night guards
6. Orthodontic treatment; implantology and related services; implants and all related procedures, including removal of implants
7. Preventive root canal therapy
8. Full mouth debridement
9. Charges for any services that are considered to be an integral part of another service, such as pulp capping, surgical trays, or sutures
10. Ridge preservation, augmentation, bone grafts, and regeneration procedures performed in edentulous sites
11. Overdentures or precision attachments
12. Space maintainers and sealants
13. Preparation and fitting of preformed dowel or post for root canal tooth; pulp cap either directly
14. Duplicate or temporary devices, appliances, and services except as listed as an eligible expense
15. Replacing a lost, stolen, or missing appliance or prosthetic device
16. Application of chemotherapeutic agents
17. Oral hygiene, plaque control, diet instruction, or infection control
18. Charges for sterilization of equipment; disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies.
19. Treatment or diagnosis received while outside the territorial limits of the United States
20. Treatment which is:
     a. Due to an on-the-job or job-related illness or injury
     b. A condition for which benefits are payable by workers’ compensation or similar laws, whether or not benefits are claimed
21. Treatment for which no charge is made or for which you are not legally obligated to pay including, but not limited to, treatment (or charges made) by:
     a. Your employer, labor union, or similar group in its dental or medical department or clinic
     b. A facility owned or run by any government body
     c. Any public program, except Medicaid, paid for or sponsored by any government body
22. Telephone consultations, charges for failure to keep a scheduled appointment, X-ray copy fees, or charges for completion of a claim form.
23. Ancillary charges, including but not limited to, hospital; ambulatory surgical center or similar facility; or use of provider office space
24. Treatment resulting from:
     a. Your participation in a war or an act of war, declared or undeclared
     b. Your attempting to commit, or committing, an assault or felony
     c. Your unlawful participation in a riot, rebellion, or insurrection
     d. An intentionally self-inflicted injury while sane or insane
25. Fluoride treatments
26. Impacted wisdom teeth
27. Prescription drugs
28. Any surgical procedure performed in the treatment of cataracts
29. Charges in excess of the reasonable and customary charge
30. Services for which you are not liable or for which no charge normally is made in the absence of insurance
31. Loss that occurs while this policy is not in force

Final Expense Whole Life Insurance

Policy form numbers: LA04; LA05; LA04(ID); LA05(ID); LA04(MO); LA05(MO); LA04(OK); LA05(OK); LA04(OR); LA05(OR)

DISC-001

09-06-18