Exclusions and limitations for group benefits

The policy does not cover any loss that the following caused or contributed to:

Group Life:

1. Suicide, or attempted suicide, whether sane or insane, for the deceased person for which coverage was elected within the 2-year period immediately prior to the date of death.

Accidental Death and Dismemberment (AD&D):

1. Intentionally self-inflicted injury.

2. Suicide or attempted suicide, whether sane or insane.

3. War or act of war, whether declared or not.

4. Injury sustained while on full-time active duty as a member of the armed forces (land, water, air) of any country or international authority except Reserve National Guard Service; Symetra will refund the pro rata portion of any premium paid for the insured or insured’s dependents while the insured or insured’s dependents are in the armed forces on full-time active duty, for a period of two months or more. Written notice must be given to Symetra within 12 months of the date the insured or insured’s dependents enter the armed forces;

5. Injury sustained while on any aircraft except a civil or public aircraft, or military transport aircraft.

6. Injury sustained while on any aircraft:

a. As a pilot, crewmember or student pilot.

b. As a flight instructor or examiner.

c. If it is owned, operated or leased by or on behalf of the policyholder, or any employer or organization whose eligible persons are covered under the policy.

d. Being used for tests, experimental purposes, stunt flying, racing or endurance tests.

7. Injury sustained while taking drugs, including but not limited to sedatives, narcotics, barbiturates, amphetamines or hallucinogens, unless as prescribed by or administered by a physician.

8. Injury sustained while riding or driving in a scheduled race or testing any motor vehicle on tracks, speedways or proving grounds.

9. Injury sustained while committing or attempting to commit a felony.

10. Injury sustained while intoxicated.

11. Injury sustained while driving while intoxicated.

Intoxicated means:

1. the blood alcohol content;

2. the results of other means of testing blood alcohol level; or

3. the results of other means of testing other substances;

that meet or exceed the legal presumption of intoxication, or under the influence, under the law of the state where the accident occurred.

Reserve National Guard Service means the insured or insured’s dependents are:

1. Attending or en route to or from any active duty training of less than sixty (60) days.

2. Attending or en route to or from a service school of any duration.

3. Taking part in any authorized inactive duty training.

4. Taking part as a unit member in a parade or exhibition authorized by official orders.

Coverage, exclusions, and limitations vary by plan design and state of policy issue. Please refer to the plan document for complete details. Where available, the base policy form number is LGC-13000 8/06 for group life and accidental death and dismemberment (AD&D).

We will not cover a disability if it is due to:

1. War, declared or not, or any act of war.

2. Intentionally self-inflicted injuries or illness, while sane or insane.

3. Your active participation in a riot.

4. Your attempt to commit or your commission of a felony under federal or state law, or your being engaged in an illegal occupation.

5. An injury arising out of, or in the course of, any work for wage or profit.

6. A sickness for which you are entitled to benefits under any Workers’ Compensation Act, Occupational Disease Law, Compulsory Benefit Act, or similar law, unless you are a partner or sole proprietor not covered by any of these acts or laws.

7. Your service in the armed forces, military reserves or National Guard of any country or international authority, or in a civilian unit serving with such forces.

8. Cosmetic or reconstructive surgery, except for complications arising from any such surgery or for surgery necessary to correct a deformity caused by accidental injury or sickness.

9. An accident resulting from or caused by your operation of a motor vehicle while intoxicated according to the laws of the jurisdiction where the accident occurred.

10. An accident resulting from or caused by your being under the influence of drugs or any controlled substance, unless taken as prescribed by your doctor.

No benefits are payable for any period of disability during which you are incarcerated in a penal or correctional facility for a period of 30 or more consecutive days or for which you are not under the regular care of a doctor.

If the insured’s professional or occupational license or their certification is suspended, revoked or surrendered, loss of their license or certification, by itself, does not mean they are disabled.

Coverage, exclusions, and limitations vary by plan design and state of policy issue. Please refer to the plan document for complete details. Where available, the base policy form number is GDC-4000 12/05 for group short-term disability income insurance.

We will not cover a disability if it is due to:

1. War, declared or not, or any act of war.

2. Intentionally self-inflicted injuries or illness, while sane or insane.

3. Your active participation in a riot.

4. Your attempt to commit or your commission of a felony under federal or state law, or your being engaged in an illegal occupation.

5. Your service in the armed forces, military reserves or National Guard of any country or international authority, or in a civilian unit serving with such forces.

6. Cosmetic or reconstructive surgery, except for complications arising from any such surgery or for surgery necessary to correct a deformity caused by accidental injury or sickness.

7. An accident resulting from or caused by your operation of a motor vehicle while intoxicated according to the laws of the jurisdiction where the accident occurred.

8. An accident resulting from or caused by your being under the influence of drugs or any controlled substance, unless taken as prescribed by your doctor.

No benefits are payable for any period of disability during which you are incarcerated in a penal or correctional facility for a period of 30 or more consecutive days or for which you are not under the regular care of a doctor.

If the insured’s professional or occupational license or their certification is suspended, revoked or surrendered, loss of their license or certification, by itself, does not mean they are disabled.

Coverage, exclusions, and limitations vary by plan design and state of policy issue. Please refer to the plan document for complete details. Where available, the base policy form number is GDC-4000 12/05 for group long-term disability income insurance.

Exclusions

No benefit is payable for any illness, injury or disease that is not specifically named or described in the benefits section. Further, no benefit will be paid when the insured has a critical illness that is:

a. Diagnosed before the insured is covered under the policy.

b. Diagnosed after the insured’s coverage terminates, except as provided under the policy.

c. Diagnosed during any benefit waiting period.

d. Not diagnosed by a specialist.

e. Diagnosed by a physician outside the United States or its territories.

f. Diagnosed more than once while covered under the policy, except as provided under the Recurrence Benefit.

g. Contributed to or caused by: another covered critical illness, a complication of another critical illness, or treatment of another critical illness for which the insured has been paid a benefit under the policy.

h. Caused wholly or partly, directly or indirectly by:

i. Declared or undeclared war or act of war.

ii. Committing or attempting to commit an assault or felony.

iii. Inciting or taking part in any form of public violence.

iv. Intentionally self-inflicted injury, while sane or insane.

v. Full-time active duty as a member of the armed forces (land, water, air) of any country or international authority.

vi. Being intoxicated or under the influence of alcohol, drugs or any narcotic (including overdose) unless as prescribed by or administered by a physician.

vii. Alcoholism or drug addiction.

The following exclusions and limitations apply only if the plan includes a preexisting condition limitation:

Preexisting conditions limitation

No benefit will be paid for any critical illness caused by or resulting from a preexisting condition if it is diagnosed in the first 12 months after the insured’s coverage takes effect.

Benefit increases

If you increase the amount of your benefit during an annual enrollment period, the amount of the benefit increase will not be paid for any critical illness caused by or resulting from a preexisting condition if it is diagnosed in the first 12 months after your increase in coverage takes effect.

This is a summary of the exclusions and limitations that typically apply to critical illness plans. Please note that this is not an exhaustive list, and that the coverage, exclusions and limitations vary by plan design, state of policy issue and residence state of the certificate holder. Please refer to the plan document for complete details. Where available, the base policy form number is SBC- 04530 1/21 for critical illness insurance.

Whether an incident is considered an accident or not, benefits will not be paid for any expense for services or supplies:

1. For which no charges are incurred that an insurer is required to pay.

2. Received after termination of coverage, except as provided under this policy.

3. Received as a result of participating in any sport for pay or profit.

4. Received as a result of participating in parachuting, bungee jumping, rappelling, mountain climbing or hang gliding.

5. Received as a result of participating in any form of aeronautics, except as a fare-paying passenger in a licensed aircraft provided by a common carrier and operating between definitely established airports.

6. Received as a result of participating or driving in any organized scheduled race or speed test or while testing an automobile or any vehicle on any racetrack or speedway.

7. For hernia repair, including complications.

8. Related to cosmetic surgery, except for reconstructive surgery on an injured part of the body.

9. Related to dental care, except as required on account of injury resulting from an accident while covered under this policy.

10. Which are not medically necessary.

11. Considered durable medical equipment.

12. That are not approved or accepted as essential to the treatment of the injury by any of the following:

a. The American Medical Association.

b. The U.S. Surgeon General.

c. Department of Public Health.

d. The National Institute of Health.

13. For disease, illness or bacterial infection, except infection resulting directly from an accidental injury.

14. For an injury or illness caused wholly or partly, directly or indirectly by:

a. Declared or undeclared war or act of war.

b. Intentionally committing or attempting to commit an assault or felony.

c. Intentionally self-inflicted injury, while sane or insane.

15. Any illness or injury covered by any Workers’ Compensation Act or similar law.

This is a summary of the exclusions and limitations that typically apply to per-occurrence accident plans. Please note that coverage, exclusions, and limitations vary by plan design, state of policy issue, and residence state of the certificate holder. Please refer to the plan document for complete details. Where available, the base policy form number is LGC-10011P 10/11 for per-occurrence accident coverage.

In addition to the exclusions and limitations listed in the benefit section of the certificate, this section applies to all benefits under the policy. No benefits are payable under the policy for any injury that results from or is caused by:

1. Suicide or attempted suicide, whether sane or insane, or intentionally self-inflicted injury.

2. Declared or undeclared war or act of war.

3. Voluntary intoxication (as defined by the law of the jurisdiction in which the injury occurred) or while under the influence of any narcotic, drug or controlled substance, unless administered by or taken according to the instruction of a physician or medical professional.

4. Voluntary intoxication through use of poison, gas or fumes, whether by ingestion, injection, inhalation or absorption.

5. Committing or attempting to commit an assault or felony, or voluntary participation in a riot or insurrection.

6. Travel in or descent from any vehicle or device for aviation or aerial navigation, except as a fare-paying passenger in a commercial aircraft (other than a charter airline) on a regularly scheduled passenger flight, or a method of transportation that meets the definition of a common carrier.

7. Ride in or on any motor vehicle or aircraft engaged in acrobatic tricks/stunts (for motor vehicles), acrobatic/stunt flying (for aircraft), endurance tests or racing.

8. Participation in any organized sport in a professional or semiprofessional capacity.

9. Participation in bungee jumping, hang gliding, parachuting, parakiting, parasailing, sail gliding or skydiving.

10. Active duty service or training in the military (naval force, air force or National Guard/Reserves or equivalent) for service/training extending beyond 31 days of any state, country or international organization, unless specifically allowed by a provision of this certificate.

11. Disease or bodily/mental illness or degenerative process, or any related medical/surgical treatment or diagnostic procedures for such disease, illness or degenerative process.

In addition, we will not pay benefits for:

1. Any loss treated outside the United States, Canada or Mexico.

2. Any injury covered by any Workers’ Compensation Act or similar law.*

3. Additional optional coverages for the parents, grandparents or in-laws who have been added to the primary insured's plan on the optional parental caregiver benefits rider. The parents, grandparents or in-laws would not be eligible for the health screening/well-being assistance, child organized sport activity, catastrophic accident, family care, first responder, health care worker or health systems additional benefit riders.

*This exclusion doesn't apply if 24-hour per-day coverage is elected.

This is a summary of the exclusions and limitations that typically apply to Scheduled Benefit Accident plans. Please note that coverage, exclusions, and limitations vary by plan design, state of policy issue, and residence state of the certificate holder. Please refer to the plan document for complete details. Where available, the base policy form number is SBC-03510 1/18 for scheduled benefit accident coverage.

Wellness screening benefit rider base form number is SBC-03513-WEL 1/18. The enhanced wellness screening benefit rider form number is SBC-03515-WEL 6/23. Selected at application and available for an additional cost, this rider provides an insured with a benefit if the insured incurs an expense as a result of receiving any of the screening tests described in the rider.

Child organized sport activity benefit rider base form number is SBC-03513-COS 1/18. The enhanced rider form number is SBC-03513-COS 6/23. Selected at application, this rider provides an additional 25%, up to $10,000, for benefits payable under the policy if the accident occurred while an insured dependent child was participating in an organized sport. The insured must be insured by the policy on the date the accident occurred.

In addition to the exclusions and limitations listed in the benefits section of the certificate, this section applies to all benefits under the policy. Benefits will not be paid for services or supplies:

1. Received before the insured is covered for the benefit.

2. Received after termination of coverage, except as provided under the policy.

3. Which are not furnished or prescribed by a doctor.

4. Received for experimental or investigative treatment, procedures for research purposes, or practices when not generally recognized as accepted medical practices.

5. That are not approved or accepted as essential to the treatment of an illness or injury by any of the following:

a. The American Medical Association.

b. The U.S. Surgeon General.

c. Department of Public Health.

d. The National Institute of Health.

6. Related to cosmetic surgery or dental care done to beautify an insured without medical or dental indication of injury or illness.

7. Related to elective medical, dental, or surgical procedures done without medical or dental indication of illness or injury.

8. For reversal procedures in connection with previous male or female sterilization.

9. In the nature of educational or vocational testing or training.

10. For outpatient food, food supplements or vitamins.

11. For radial keratotomies.

12. For physical therapy, occupational therapy, speech therapy or chiropractic manipulations or modalities.

13. In connection with treatment of male or female infertility, in vitro and in vivo fertilization of an ovum, or artificial insemination.

14. For durable medical equipment.

15. For custodial care.

16. For surgical anesthesia.

17. For ancillary services in connection with surgery or other illness, except as stated in the policy.

18. Related to smoking cessation.

19. For the treatment of the following:

a. Codependency.

b. Social, occupational or religious maladjustments.

c. Compulsive gambling.

d. Chronic marital or family problems when not related to the primary focus of treatment that must be a diagnosable mental disorder.

20. For the treatment of obesity, weight reduction or dietetic control, except for morbid obesity or disease etiology.

21. For the following, except as specifically stated in the policy:

a. For dental treatment and oral surgery.

b. For treatment of mental disorders.

c. For treatment of substance abuse disorders.

d. For refractions, eyeglasses, or hearing aids or their fitting.

e. For routine physicals or general health exams, routine immunizations and vaccinations.

22. For treatment of temporomandibular joint dysfunction (TMJ) pain syndrome, orofacial, or myofascial syndrome, whether medical or dental in scope.

23. For an illness or injury caused wholly or partly, directly or indirectly by:

a. Declared or undeclared war or act of war.

b. Committing or attempting to commit an assault or felony.

c. Inciting or taking part in any form of public violence.

d. Intentionally self-inflicted injury, while sane or insane.

Inpatient Hospital Coverage

Inpatient hospital benefits will not be paid when services or supplies are received for:

1. Care received in an emergency room.

2. Care received in an outpatient hospital facility or clinic or urgent care facility.

3. Care received in a hospital for observation services lasting less than 24 hours.

4. Care received in any other portion of a hospital which provides services that do not require confinement.

5. Inpatient or outpatient surgical procedures.

This is a summary of the exclusions and limitations that typically apply to fixed-payment hospital indemnity plans. Please note that coverage, exclusions, and limitations vary by plan design, state of policy issue, and residence state of the certificate holder. Please refer to the plan document for complete details. Where available, the base policy form number is SBC-00500 8/12 for fixed-payment hospital insurance.

The following exclusions explain what is not covered and situations when coverage is not provided.

We will not pay benefits for any condition that is contributed to, caused by, or resulting from:

a. commission of or attempt to commit a felony, or voluntary participation in a riot or insurrection;

b. incarceration or imprisonment following conviction for a crime;

c. any condition diagnosed outside the United States, Mexico, or Canada, unless the Insured receives confirmation of the diagnosis in the United States, Mexico, or Canada;

d. active-duty service or training in the military (naval force, air force or National Guard/Reserves or equivalent) for service/training extending beyond 180 days of any state, country or international organization, unless specifically allowed by a provision of this Certificate;

e. involvement in any declared or undeclared war or act of war (not including acts of terrorism), while serving in the military or an auxiliary unit attached to the military, or working in an area of war whether voluntarily or as required by an employer.

In addition, we will not pay benefits for any of the following:

a. a Chronic Condition, except as specifically provided by a rider;

b. a Mental Illness, except as specifically provided by a rider;

c. a Maternity Condition, except as specifically provided by a rider;

d. “Not Covered” conditions as designated in the Conditions List.

This is a summary of the exclusions and limitations that typically apply to Symetra Health plans. Please note that coverage, exclusions, and limitations vary by plan design and residence state of the certificate holder. Please refer to the plan document for complete details. Where available, the base policy form number is SBC-05540 03/22 for Symetra Health.

Administration of Symetra Health is managed by a third-party administrator that provides enrollment, claims and billing administration.