Medical Coverage Exclusions & Limitations
No Benefit shall be payable for Accident Medical, Sickness Medical, In-Hospital Indemnity, Unexpected Recurrence, Dental, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Return of Minor Child, Emergency Medical Reunion, as the result of:
- Pre-existing Conditions: Any Injury or Illness which meets the following criteria (unless covered under the Unexpected Recurrence benefit):
- a condition that would have caused a person to seek medical advice, diagnosis, care or treatment during the thirty-six (36) months prior to the Effective Date of coverage under this policy;
- a condition for which medical advice, diagnosis, care or treatment was recommended or received during the thirty-six (36) months prior to the Effective Date of coverage under this policy. For U.S. citizens traveling outside the United States and Canada, the Pre-existing Condition period is twelve (12) months instead of thirty-six (36) months. This exclusion does not apply to Emergency Evacuation/Repatriation or Return of Mortal Remains.
- Injury or Illness which is not presented to the Company for payment within 3 months of receiving Treatment;
- Charges for Treatment which is not Medically Necessary;
- Charges provided at no cost to You;
- Charges for Treatment which exceeds Reasonable and Customary charges;
- Charges incurred for Surgery or treatments which are, Experimental/Investigational, or for research purposes;
- Services, supplies or treatment, including any period of Hospital confinement, which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
- Suicide, or any attempt thereof, while sane or self destruction or any attempt thereof, while sane;
- War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the insured person or the country in, or over, which the act occurs,
Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped
power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond
reasonable doubt to have been the act of agents of a state foreign to the nationality of the insured person whether war be declared with that state or not, Terrorist activity. For the purpose of this
- Terrorist activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s).
- Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals.
- Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals.
- Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals. Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;
- Injury sustained while participating in professional athletics, including but not limited to the event, games, practice, conditioning and any other activity related to professional athletics;
- Injury sustained while participating in amateur or interscholastic athletics, including but not limited to the event, games, practice, conditioning and any other activity related to amateur or interscholastic athletics; this exclusion does not apply to non-competitive, recreational or intramural activities. Note: A sponsored and/or organized Amateur or Interscholastic Athletic event includes training camps, team sports, or any formal grouping of people participating in one or multiple events that may/may not require a fee for participation.
- Routine physicals, immunizations or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or x-ray examinations, except in the course of a disablement established by a prior call or attendance of a Physician;
- Treatment of the temporomandibular joint;
- Vocational, speech, recreational or music therapy;
- Services or supplies performed or provided by a relative of Yours, or anyone who lives with You;
- Cosmetic or plastic Surgery, except as the result of a covered Accident; for the purposes of this plan, treatment of a deviated nasal septum shall be considered a cosmetic condition;
- Elective Surgery which can be postponed until You return to Your Home Country, where the objective of the trip is to seek medical advice, treatment or Surgery;
- Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids;
- Eye refractions or eye examinations for the purpose of prescribing corrective lenses for eyeglasses or for the fitting thereof, unless caused by Accidental bodily Injury incurred while covered hereunder;
- Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent;
- Injury sustained or Disablement due wholly or partly to the Insured being intoxicated as defined and determined by the laws of the state where the Injury occurred; or to the Insured being under the influence of any narcotic, unless administered on the advice of a Physician;
- Any Mental and Nervous disorders or rest cures;
- Congenital abnormalities and conditions arising out of or resulting there from;
- Expenses which are non-medical in nature;
- Expenses as a result of or in connection with intentionally self-inflicted Injury or Illness;
- Expenses as a result of or in connection with the commission of a felony offense;
- Injury sustained while taking part in mountaineering, hang gliding, parachuting, bungee jumping, racing by any animal or motor vehicle or motorcycle, snowmobiling, motorcycle motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing and snowboarding (except for recreational downhill and/or cross country snow skiing or snowboarding. No cover provided while skiing/boarding in any violation of applicable laws, rules or regulations, away from prepared and market in-bound territories; and/or against the advice of the local ski school or local authoritative body); and any other sport or athletic activity which is undertaken for thrill seeking and exposes the insured to abnormal or extreme risk of injury.
- Treatment paid for or furnished under any other individual or group policy or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government plan or facility set up for treatment without any cost to You;
- Treatment of venereal disease;
- Dental care, except as the result of Injury to natural teeth caused by Accident, unless otherwise covered under this plan;
- Routine Dental Treatment;
- For Pregnancy or Illness resulting from Pregnancy, childbirth, or miscarriage;
- For miscarriage resulting from Accident;
- Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof;
- Treatment for human organ tissue transplants and their related treatment;
- Expenses incurred while in Your Home Country, except as provided under the Home Country Coverage;
- Expenses incurred during a Hospital emergency visit which is not of an emergency nature;
- Covered Expenses incurred for which the Trip to the Host Country was undertaken to seek medical treatment for a condition;
- Covered Expenses incurred during a Trip after Your Physician has limited or restricted travel;
- This plan does not insure against loss or damage (including death or injury) and any associated cost or expense resulting directly from the discharge, explosion or use of any device, weapon or material employing or involving nuclear fission, nuclear fusion or radioactive force, or chemical, biological, radiological or similar agents, whether in time of peace or war, and regardless of who commits the act.
- Sex change operations, or for treatment of sexual dysfunction or sexual inadequacy;
- Weight reduction programs or the surgical treatment of obesity;
- Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), Aids-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV).