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Exclusions

Limitations and Exclusions to Extended Health Benefits
No benefit is payable for:
1) expenses for which benefits are payable under a Workers' Compensation Act or a similar statute;
2) expenses incurred due to intentionally self-inflicted injuries;
3) expenses incurred due to civil disorder or war, whether or not war was declared;
4) expenses for services and products, rendered or prescribed by a person who ordinarily resides in the patient's home or who is related to the patient by blood or marriage;
5) expenses for which benefits are payable under a government plan;
6) expenses for benefits which are legally prohibited by the government from coverage;
7) out-of-province expenses for elective (non-emergency) medical treatment or surgery;
8) expenses for drugs which, in the insurer's opinion, are experimental;
9) expenses for dietary supplements, vitamins and infant foods;
10) expenses for contraceptives (other than oral & intrauterine devices);
11) drugs for the treatment of erectile dysfunction;
12) expenses for drugs if they are used for the treatment of infertility;
13) expenses for the services of a homemaker;
14) expenses for items purchased solely for athletic use;
15) dental expenses, except those specifically provided under eligible expenses for treatment of accidental injuries to natural teeth;
16) utilization fees which are imposed by the Provincial Health Care Plan for the use of a service;
17) expenses for the regular treatment of an injury or disease which existed before the member's or dependant's departure from his/her province of residence;
18) immunizations and vaccines (Hepatitis B will be covered, except for Recombivax HB preservative free - DIN 02245976 and DIN 02245977); or
19) any other exclusion identified in the policy contract.

Limitations and Exclusions to Dental Benefits
No benefit is payable for:
1) any cause for which the insured may apply for and receive protection, exemption or compensation under any Workers' Compensation Act;
2) self-inflicted injuries while sane or insane;
3) war, insurrection or hostilities of any kind, whether or not the insured was a participant in such actions;
4) participation in any riot or civil commotion;
5) committing or attempting to commit a criminal offence or provoking an assault;
6) any group or policyholder sponsored dental care or treatment;
7) any dental care or treatment for which the insured is not legally obliged to pay;
8) any dental care, treatment or supplies primarily for cosmetic purposes;
9) failing to keep scheduled appointments;
10) file transfers, the completion of claim forms or other documentation;
11) any dental treatment for the correction of temporomandibular joint dysfunction;
12) expenses for treatment of root canal therapy, inlays, onlays, crowns, veneers, and bridges started prior to becoming an insured member/dependant under this plan;
13) replacement of mislaid, lost or stolen appliances;
14) expenses for crowns, inlays, onlays and veneers placed on a tooth not functionally impaired by incisal angle or cuspal damage;
15) any charges incurred for other than metal only crowns or pontics, posterior to the second bicuspid tooth;
16) expenses for full mouth reconstructions for vertical dimension correction or to repair or restore teeth damaged or worn due to attrition or vertical wear or to restore occlusion;
17) any services or supplies for implantology, including tooth implantation and surgical insertion of fabricated implants;
18) any dental procedure which is not listed in the descriptions of dental benefits indicated herein;
19) charges that are in excess of the fees stated in the Dental Association General Practitioners' Fee Guide applicable to where the services were rendered;
20) where coverage for services is provided under any government plan;
21) where services would be provided without charge in the absence of this policy; or
22) any other exclusions identified in the policy contract.

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