Columbia University Health Services

The Columbia Student Medical Insurance Plan neither covers nor provides benefits for the following:

1.  Pre-Existing Conditions under the Basic Accident and Sickness Benefit for dependents; and under the Comprehensive Accident and Sickness Benefit for students and dependents, until the individual has been continuously insured under the Columbia Student Medical Insurance Plan or comparable coverage for more than 12 months.

2.  Expenses incurred as a result of dental treatment, except for:

            (a) Injury to sound, natural teeth

            (b) Extraction of impacted wisdom teeth as provided elsewhere in the Policy

            (c) Treatment of dental abscesses.

3.  Expenses incurred for services normally provided without charge by the Policyholder's health service, infirmary, hospital, or by health care providers employed by the Policyholder.

4.  Expenses incurred for eye refractions, vision therapy, eyeglasses, contact lenses (except when required after cataract surgery) or other vision or hearing aides, or prescriptions or examinations except as required for repair caused by a covered Injury.

5.  Expenses incurred for plastic surgery, reconstructive surgery, cosmetic surgery, or other services and supplies which improve, alter, or enhance appearance, whether or not for psychological or emotional reasons. This exclusion will not apply to extend the need to:

(a) Improve the function of a part of the body that is not a tooth or structure that supports the teeth, and is malformed as a result of a severe birth defect (including harelip and webbed fingers or toes), or as direct result of disease, (including removal of lesions resulting from port-wine stains), or from surgery performed to treat a Sickness or Injury;

(b) repair an Injury (including reconstructive surgery for a prosthetic device for a Covered Person who has undergone a mastectomy). Surgery must be performed in the Policy Year of the Accident which causes the Injury, or in the next Policy Year.

6.  Expenses incurred as a result of an Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a scheduled airline maintaining regular, published schedules on a regularly established route.

7.  Expenses incurred as a result of Injury due to participation in a riot. Participation in a riot means taking part in a riot in any way, including inciting the riot or conspiring to incite it. It does not include actions taken in self-defense, so long as they are not taken against persons who are trying to restore law and order.

8.  Expenses incurred as a result of Injury sustained or Sickness contracted while in the service of the armed forces of any country. Upon the Covered Person entering the armed forces of any country, the unearned pro-rata premium will be refunded to the Policyholder.

9.  Expenses incurred as a result of an Injury or Sickness for which benefits are payable under any Workers-Compensation or Occupational Disease Law.

10. Expenses for Injuries sustained as a result of a motor vehicle accident to the extent that mandatory automobile no-fault benefits are recovered or recoverable whether or not a claim is made for such benefits.

11. Expenses incurred for treatment provided in a governmental hospital unless there is legal obligation to pay such charges in the absence of insurance.

12. Expenses incurred as a result of commission of a felony.

13. Expenses incurred as a result of preventative medicines, serums, vaccines, or oral contraceptives, unless otherwise provided in the Policy.

14. Charges for or related to artificial insemination, in vitro fertilization, or embryo transfer procedures; elective sterilization or its reversal; or elective abortion unless otherwise provided in the Policy. Coverage is provided for elective termination of pregnancy through enrollment in the Health Service Program .

15. Expense incurred for a treatment, service, or supply which is not Medically Necessary as determined by Aetna for the diagnosis, care, or treatment of the Sickness or Injury involved. This applies even if they are prescribed, recommended, or approved by the person’s attending Physician or dentist.

In order for a treatment, service, or supply to be considered Medically Necessary, the service or supply must:

• be care or treatment which is likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply both as to the Sickness or Injury involved and the person's overall health condition
• be a diagnostic procedure which is indicated by the health status of the person and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the Sickness or Injury involved and the person's overall health condition; and
• as to diagnosis, care, and treatment, be no more costly (taking into account all health expenses incurred in connection with the treatment, service, or supply), than any alternative service or supply to meet the above tests.

In determining if a service or supply is appropriate under the circumstances, Aetna will take into consideration: information relating to the affected person's health status; reports in peer reviewed medical literature; reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; generally recognized professional standards of safety and effectiveness in the United States for diagnosis, care, or treatment; the opinion of health professionals in the generally recognized health specialty involved; and any other relevant information brought to Aetna's attention.

In no event will the following services or supplies be considered to be Medically Necessary:

• those that do not require the technical skills of a medical, a mental health, or a dental professional; or
• those furnished mainly for the personal comfort or convenience of the person, any person who cares for him or her, or any persons who is part of his or her family, any healthcare provider, or healthcare facility; or
• those furnished solely because the person is an inpatient on any day on which the person's Sickness or Injury could safely, and adequately, be diagnosed or treated while not confined; or those furnished solely because of the setting, if the service or supply could safely and adequately be furnished in a Physician's or a dentist's office or other less costly setting.

16. Expenses incurred for routine physical exams, routine vision exams, routine dental exams, routine hearing exams, immunizations, or other preventive services and supplies, except to the extent coverage for such exams, immunizations, services, or supplies is specifically provided in the Policy.

17. Expenses incurred for any services rendered by a member of the Covered Person's immediate family.

18. Expenses incurred for services normally provided without charge by the school and covered by the school fee for services.

19. Expenses incurred for custodial care. Custodial care means services and supplies furnished to a person mainly to help him or her in the activities of daily life. This includes room and board and other institutional care. The person does not have to be disabled. Such services and supplies are custodial care without regard to:

• By whom they are prescribed;
• By whom they are recommended, or;
• By whom or by which they are performed.

20. Expenses for treatment of an Injury to the extent benefits are payable under any state no-fault automobile coverage or any first-party medical benefits payable under any other mandatory no-fault law.

21. Expenses incurred for which no member of the Covered Person's immediate family has any legal obligation for payment.

22. Expenses incurred for or in connection with: procedures, services, or supplies that are, as determined by Aetna, to be experimental or investigational. A drug, a device, a procedure, or treatment will be determined to be experimental or investigational if:

• There are insufficient outcomes data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or Injury involved; or
• If required by the FDA, approval has not been granted for marketing; or
• A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational, or for research purposes; or
• The written protocol or protocols used by the treating facility, or the protocol or protocols of any other facility studying substantially the same drug, device, procedure, or treatment, or the written, informed consent used by the treating facility or by another facility studying the same drug, device, procedure, or treatment states that it is experimental, investigational, or for research purposes.

However, this exclusion will not apply with respect to services or supplies (other than drugs) received in connection with a disease if Aetna determines that:

• The disease can be expected to cause death within one year in the absence of effective treatment; and
• The care or treatment is effective for that disease, or shows promise of being effective for that disease, as demonstrated by scientific data. In making this determination, Aetna will take into account the results of a review by a panel of independent medical professionals. They will be selected by Aetna. This panel will include professionals who treat the type of disease involved.

       Also, this exclusion will not apply with respect to drugs that:

• Have been granted treatment investigational new drug (IND) or Group c/treatment IND status; or
• Are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute;
• If Aetna determines that available, scientific evidence demonstrates that the drug is effective, or shows promise of being effective, for the disease.

23. Expenses for treatment of Injury or Sickness to the extent payment is made, as a judgment or settlement, by any person deemed responsible for the Injury or Sickness (or their Insurers).

24. Expenses incurred for or related to services, treatment, education testing, or training related to learning disabilities or developmental delays.

25. Expenses incurred for or related to sex change surgery or to any treatment of gender identity disorders.

26. Expense for charges that are not Reasonable Charges, as determined by Aetna.

27. Expenses for treatment of covered students who specialize in the mental health care field, and who receive treatment as part of their training in that field.

28. Expenses for: (a) care of flat feet; (b) supportive devices for the foot; (c) care of corns, bunions, or calluses; (d) care of toenails; and (e) care of fallen arches; weak feet; or chronic foot strain; except that (c) and (d) are not excluded when Medically Necessary; because the Covered Person is diabetic or suffers from circulatory problems.

Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the coverage.