North Carolina General Statutes 135-48.52. General limitations and exclusions
The Plan shall not provide coverage for or pay any benefits for any of the following:
(1) Charges to the extent paid, or which the individual is entitled to have paid, or to obtain without cost, in accordance with any government laws or regulations except Medicare. If a charge is made to any such person which he or she is legally required to pay, any benefits under this Plan will be computed in accordance with its provisions, taking into account only such charge. “Any government” includes the federal, State, provincial, or local government, or any political subdivision thereof, of the United States, Canada, or any other country.
Terms Used In North Carolina General Statutes 135-48.52
- Employer: shall mean the State of North Carolina, the county board of education, the city board of education, the State Board of Education, the board of trustees of the University of North Carolina, the board of trustees of other institutions and agencies supported and under the control of the State, or any other agency of and within the State by which a teacher or other employee is paid. See North Carolina General Statutes 135-1
- following: when used by way of reference to any section of a statute, shall be construed to mean the section next preceding or next following that in which such reference is made; unless when some other section is expressly designated in such reference. See North Carolina General Statutes 12-3
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Plan: includes all comprehensive health benefit plans offered under the Plan. See North Carolina General Statutes 135-48.1
- Service: shall mean service as a teacher or State employee as described in subdivision (10) or (25) of this section. See North Carolina General Statutes 135-1
- Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
- state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories, so called; and the words "United States" shall be construed to include the said district and territories and all dependencies. See North Carolina General Statutes 12-3
- United States: shall be construed to include the said district and territories and all dependencies. See North Carolina General Statutes 12-3
(2) Charges for services rendered in connection with any occupational injury or disease arising out of and in the course of employment with any employer, if (i) the employer furnishes, pays for or provides reimbursement for such charges, or (ii) the employer makes a settlement payment for such charges, or (iii) the person incurring such charges waives or fails to assert his or her rights respecting such charges.
(3) Charges for any services rendered as a result of injury or sickness due to an act of war, declared or undeclared, which act shall have occurred after the effective date of a person’s coverage under the Plan.
(4) Charges for any services with respect to which there is no legal obligation to pay. For the purposes of this item, any charge which exceeds the charge that would have been made if a person were not covered under this Plan shall, to the extent of such excess, be treated as a charge for which there is no legal obligation to pay; and any charge made by any person for anything which is normally or customarily furnished by such person without payment from the recipient or user thereof shall also be treated as a charge for which there is no legal obligation to pay.
(5) Charges during a continuous hospital confinement which commenced prior to the effective date of the person’s coverage under this Plan.
(6) Charges for services unless a claim is filed within 18 months from the date of service.
(7) Charges for sexual dysfunction or hair growth drugs or for nonmedically necessary drugs used for cosmetic purposes. (2011-85, s. 2.10.)