Medico Insurance Company Disclosures

Medicare Supplement insurance plan (Not available in all states)

Policy form numbers: MSA70A; MSA70F; MSA70N; MI-MSA20A(NM); MI-MSA20D(NM); MI-MSA20F(NM); MI-MSA20A(OK)-C; MI-MSA20D(OK)-C; MI-MSA20F(OK)-C; MSA70A(VA)-1; MSA70F(VA)-1; MSA70G(VA)-1; MSA70N(VA)-1; MMS2021W

Policy form numbers: MMS2021A; MMS2021F; MMS2021HF; MMS2021G; MMS2021HG; MMS2021N; MMS2021A(MI); MMS2021F(MI); MMS2021HF(MI); MMS2021G(MI); MMS2021HG(MI); MMS2021N(MI); MMS2021A(NC); MMS2021F(NC); MMS2021HF(NC); MMS2021G(NC); MMS2021HG(NC); MMS2021N(NC) ;MMS2021A(TN); MMS2021F(TN); MMS2021HF(TN); MMS2021G(TN); MMS2021HG(TN); MMS2021N(TN); MMS2021A(KS); MMS2021F(KS); MMS2021HF(KS); MMS2021G(KS); MMS2021HG(KS); MMS2021N(KS); MMS2021A(CO); MMS2021F(CO); MMS2021HF(CO); MMS2021G(CO); MMS2021HG(CO); MMS2021N(CO); MMS2021A(OH); MMS2021F(OH); MMS2021HF(OH); MMS2021G(OH); MMS2021HG(OH); MMS2021N(OH); MMS2021A(PA); MMS2021F(PA); MMS2021HF(PA); MMS2021G(PA); MMS2021HG(PA); MMS2021N(PA); MMS2021B(PA); MMS2021A(TX); MMS2021F(TX); MMS2021HF(TX); MMS2021G(TX); MMS2021HG(TX); MMS2021N(TX); MMS2021DISA(TX)

In CO, GA, KY, KS, LA , NC, OK, PA, TN, TX, and WI, coverage is available to qualified Medicare beneficiaries under the age of 65.

In Ohio, the agent or broker, and the insurance company have no connection or affiliation with and are not in any way sponsored by the federal or state government, the Social Security Administration, the Centers for Medicare and Medicaid services, or the Department of Health and Human Services. If you decide to purchase a Medicare Supplement insurance plan, you have the option of paying the premium directly to the insurance company. An outline of coverage is available upon request. The agent/broker is making the sale on behalf of Medico Insurance Company. You may verify the agent/broker and Medico Insurance Company by contacting: The Ohio Department of Insurance, 50 W Town Street Third Floor, Suite 300, Columbus, OH 43215. Consumer Hotline: 800-686-1526 or TDD Number: 614-664-3745. Contact the plan: Medico Insurance Company, P.O. Box 10386, Des Moines, IA 50306; 800-228-6080. 

Hospital Indemnity insurance plan (Not available in all states)

Policy form numbers: HIA63; HIA63(CO); HIA63(FL); HIA63(IL); HIA63(KS); HIA63(MI); HIA63(MO); HIA63(MT); HIA63(NC); HIA63(OH); HIA63(OK); HIA63(PA); HIA63(TN); HIA63(TX)-1; HIA63(VA); HIA63(WI)

Exclusions and limitations (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 (Not available in all states)

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.

Gold and Platinum Dental insurance plans (Not available in all states)

Policy form numbers: DEN2021, DEN2021(MI), DEN2021(NC), DEN2021(OH), DEN2021(PA), DEN2021(TX), and DEN2021(WI)

Exclusions and limitations (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 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 calendar 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
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. Any procedures performed to replace a tooth or teeth extracted or missing prior to the policy date.

DISC-001 Rev. 08/21

08/01/21