Limitations and Exclusions
Pre-Existing Conditions: No Program benefits will be payable for a Disability or Hospital Confinement directly or indirectly contributed to, caused by, or resulting from a Pre-Existing Condition unless the Disability or Hospital Confinement starts after the Covered Person has been covered under the Program for twenty-four (24) consecutive months.
Mental or Nervous Disorders Benefit Limitation: The Maximum Benefit Period for a Disability directly or indirectly contributed to, caused by, or resulting from Mental or Nervous Disorders is twenty-four (24) months of Income Protection Benefit payments for a single period of Disability and forty-eight (48) cumulative months over Your lifetime.
Foreign Medical Treatment Limitation: You or a covered Dependent do not qualify for any Program benefits during a Period of Disability or Hospital Confinement in which the Covered Person is hospitalized or receiving medical treatment outside of the United States (including its territories), or Canada, unless We agree in writing to provide Program coverage.
Occupational Conditions Limitations: The Maximum Benefit Period is twelve (12) months of Program benefit payments during a single period of Occupational Disability.
Specific Conditions Limitations: Monthly Income Benefits will be limited to twenty-four (24) months during Your lifetime, if You are Disabled due to any of the following:
- Carpal Tunnel Syndrome, which is a disorder that results from injury to the median nerve as it passes from the forearm into the hand through a narrow passageway in the wrist called the carpal tunnel. As the nerve passes through the tunnel, it is susceptible to repetitive stress injury or overuse injury;
- Prolonged or chronic fatigue, such as Chronic Fatigue Syndrome, chronic Epstein-Barr virus, myalgic encephalomyelitis, Fibromyalgia Syndrome, or similar diseases or syndromes;
- Chemical Sensitivity or environmental disorders;
- Neuromusculoskeletal or soft tissue disorders, including but not limited to any disease or disorder of the spine or extremities and their surrounding soft tissue, including sprains or strains, joints, and adjacent muscles, unless the Disability has objective evidence of: a) seropositive arthritis; b) spinal tumors, malignancy, or vascular malformations; c) radiculopathies; d) myelopathies; e) traumatic spinal cord necrosis; or f) musculopathies; or
- Symptoms which are not supported, documented, or diagnosed through conventional medical tests.
The Program will not pay benefits for any Injury, Sickness, Mental or Nervous Disorders, or resulting Disability or Hospital Confinement:
- Caused by war, declared or undeclared, or acts of war or Your taking part in a riot or civil disorder;
- Which occurs while You are in the military, naval, or air force of any country or international organization. Premium adjustments/refunds will not be made for periods greater than one hundred and eighty (180) days. You therefore, should promptly inform us if You are not covered because of this Exclusion;
- Caused by pregnancy, childbirth, elective abortion, or post-partum depression; including false labor, premature labor, high-risk Pregnancy or delivery, occasional spotting, Physician-prescribed rest, morning Sickness, hyperemesis gravidarum, pre-eclampsia or placenta previa, or similar conditions that occur in a difficult Pregnancy, except when loss results from Complications of Pregnancy (see definition of Complications of Pregnancy on page 12);
- Which You intentionally inflict on yourself while sane or insane;
- Caused by engaging in an illegal act, or in resisting or fleeing arrest;
- Caused by the voluntary taking of poison or inhalation of gas, except for the involuntary or unintentional ingestion of poison or inhalation of poisonous gases or fumes;
- Caused from any accident in which You were the driver or pilot where Your blood alcohol content exceeds the legal limit of the jurisdiction in which the accident took place, whether or not You were charged;
- Caused by You being under the influence of any narcotic, barbiturate or hallucinatory drug unless administered under the advice of a Physician and taken in accordance with the prescribed dosage;
- For any period of time for which You are incarcerated, whether or not the Disability commenced while incarcerated;
- Caused by a Drug or Alcohol Disorder; or
- Hospital Confinement (under the Hospital Confinement Benefit) which results from cosmetic surgery, except for reconstructive surgery incidental to or following surgery for trauma or infection, or other Sickness of the part of the body reconstructed, or to treat a congenital malformation of a child.
We do not pay benefits for any Disability that started before Your coverage under this Program.
Available only to full-time active federal employees.
You are eligible to enroll if you are under age 62, are actively at work* as a permanent full-time employee of a federal agency, and reside in the U.S. at the time of enrollment.
*If your regular place of employment is your home or other residence, you would not be considered actively at work.