I:\Legal\LEGAL\ST PATRICK HOSPITAL-Medical\Plan Document ...

GENERAL PLAN EXCLUSIONS AND LIMITATIONSThe following general exclusions and limitations apply to all Expenses Incurred under this Plan:1. Charges for services rendered or started, or supplies furnished prior to the effective date ofcoverage under the Plan, or after coverage is terminated under the Plan, except as specificallyprovided for in the Plan provisions.2. Charges which are caused by or arising out of war or act of war, (whether declared orundeclared), civil unrest, armed invasion or aggression or caused during service in the armedforces of any country.3. Charges for services or supplies which are obtained from any governmental agency without costby compliance with laws or regulations enacted by any governmental body.4. Charges by the Covered Person for all services and supplies resulting from any Illness or Injurywhich occurs in the course of employment for wage or profit, or in the course of any volunteerwork when the organization, for whom the Covered Person is volunteering, has elected or isrequired by law to obtain coverage for such volunteer work under state or federal workers’compensation laws or other legislation, including Employees’ compensation or liability laws of theUnited States (collectively called “Workers’ Compensation”). This exclusion applies to all suchservices and supplies resulting from a work-related Illness or Injury even though:A. Coverage for the Covered Person under Workers’ Compensation provides benefits foronly a portion of the services Incurred;B. The Covered Person’s employer/volunteer organization has failed to obtain suchcoverage required by law;C. The Covered Person waived his/her rights to such coverage or benefits;D. The Covered Person fails to file a claim within the filing period allowed by law for suchbenefits;E. The Covered Person fails to comply with any other provision of the law to obtain suchcoverage or benefits; orF. The Covered Person is permitted to elect not to be covered by Workers’ Compensationbut failed to properly make such election effective.G. The Covered Person is permitted to elect not to be covered by Workers’ Compensationand has affirmatively made that election.This exclusion will not apply to household and domestic employment, employment not inthe usual course of the trade, business, profession or occupation of the Covered Person oremployer, or employment of a Dependent member of an employer’s family for whom anexemption may be claimed by the Employer under the Internal Revenue Code.5. Charges for which the Covered Person is not, in the absence of this coverage, legally obligated topay, or for which a charge would not ordinarily be made in the absence of this coverage.6. Charges for non-prescription vitamins or nutritional supplements.Western Montana Providence Health & Services - SPD 38Group #2000204 - January 1, 2011