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In which cases are incurred medical expenses ineligible for cover by Medical Insurance?
(02.21.2008)

In the following cases, the incurred medical expenses are ineligible for cover by the Municipal Medical Insurance Fund, the Local Supplemental Fund and/or the Individual Medical Account:

(1) If a participant sees a doctor or is dispensed medicine from a non-dedicated medical institution or is dispensed medicine from a non-dedicated drugstore;

(2) if a participant sees a doctor or is dispensed medicine that incurs expenses not corresponding to the Basic Medical Insurance treatment items, the medical service facilities, the eligible medicine treatment, and the payment standards;

(3) the employee is involved in suicide, a self-harmed injury, street fighting, weapons, a medical accident or a transport accident; and/or

(4) other cases defined in the State or municipal rules and regulations.