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Atlas International & Atlas America Exclusions & Limitations

What Is Excluded?

The following charges, treatments, surgeries, medications, conditions and circumstances are excluded:

1. Pre-existing Conditions – Charges resulting directly or indirectly from any Pre-existing Condition, as herein defined, are excluded from this insurance, except charges resulting directly from an Acute Onset of Pre-existing Condition, as herein defined, are covered subject to the limits set forth in the Schedule of Benefits and Limits. A Pre-existing Condition is any:
   1. condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 2 years immediately preceding the Certificate Effective Date;
   2. condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 2 years immediately preceding the Certificate Effective Date;
   3. injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 2 years immediately preceding the Certificate Effective Date. For the purposes of the Complications of Pregnancy coverage offered hereunder, Pregnancy will not be included within the definition of a Pre-existing Condition. An Acute Onset is a sudden and unexpected outbreak or recurrence of a Pre-existing Condition, that occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence
2. Routine pre-natal care, Pregnancy, child birth, and post natal care.
3. False labor, edema, prolonged labor, prescribed rest during the period of Pregnancy, morning sickness and conditions of comparable severity associated with management of a difficult Pregnancy, and not constituting a medically distinct Complication of Pregnancy as herein defined, and all charges related to Pregnancy after the 26th week of Pregnancy.
4. Charges incurred by or for any child under the age of 14 days.
5. Treatment for or related to any congenital condition.
6. Charges for treatment of Mental Health Disorders, as defined herein.
7. Charges which are not incurred by a Member during his/her Certificate Period.
8. Charges for any benefit hereunder which are not presented to Underwriters for payment within 60 days beginning on the last day of the Certificate Period.
9. Treatment, services or supplies which are not administered by or under the supervision of a Physician.
10. Treatment, services or supplies which are not Medically Necessary as herein defined.
11. Treatment, services or supplies provided at no cost to the Member.
12. Charges which exceed Usual, Reasonable and Customary as herein defined.
13. Telephone consultations or failure to keep a scheduled appointment.
14. Surgeries, treatments, services or supplies which are Investigational, Experimental or for Research purposes.
15. All charges Incurred while confined primarily to receive Custodial Care, Educational or Rehabilitative Care.
16. Weight modification or surgical treatment of obesity, including wiring of the teeth and all forms of intestinal bypass Surgery.
17. Modifications of the physical body in order to improve the psychological, mental or emotional well-being of the Member such as sex-change Surgery.
18. Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is directly related to and follows a Surgery which was covered hereunder.
19. Treatment of Members who are HIV+, have AIDS or ARC.
20. Any drug, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal of sterilization.
21. Any drug, treatment or procedure that either promotes, enhances or corrects impotency or sexual dysfunction.
22. Abortions, except in connection with covered Complications of Pregnancy.
23. Dental Treatment, except for Emergency Dental Treatment necessary to replace sound natural teeth lost or damaged in an Accident covered hereunder or for the Emergency relief of Acute Onset of pain.
24. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, and all vision and hearing tests and examinations.
25. Eye surgery, such as radial keratotomy, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
26. Treatment of the temporomandibular joint.
27. Injury resulting from participation in the following activities:
    1. Amateur Athletics, Contact Sports, and professional sports or athletic activities. Non-contact and nonorganized/ non-sanctioned amateur sports or athletic activities engaged in by the Member solely for leisure, recreational, entertainment or fitness purposes are not excluded unless they are excluded by (b) through (j) of this provision; and
    2. mountaineering where ropes or guides are normally used or at elevations of 4,500 meters or higher; and
    3. aviation (except when traveling solely as a passenger in a commercial aircraft); and
    4. hang gliding, sky diving, parachuting or bungee jumping; and
    5. snow skiing or snowboarding, except for recreational downhill and/or cross country snow skiing or snowboarding (no cover provided whilst skiing away from prepared and marked in-bound territories and/or against the advice of the local ski school or local authoritative body); and
    6. racing by any animal or motorized vehicle; and
    7. spelunking; and
    8. subaqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, accompanied by a certified instructor, and at depths of less than 10 meters; and
    9. jet skiing; and
    10. any other sport or athletic activity which is undertaken for thrill seeking and exposes the Member to abnormal or extraordinary risk of Injury.
28. Injury sustained while under the influence of or due wholly or partly to the effects of intoxicating liquor or drugs other than drugs taken in accordance with treatment prescribed and directed by a Physician but not for the treatment of Substance Abuse.
29. Willfully self-inflicted Injury or Illness.
30. Venereal disease, including all sexually transmitted diseases and conditions.
31. Immunizations and Routine Physical Exams.
32. Treatment by a chiropractor.
33. Charges resulting from or occurring during the commission of a violation of law by the Member, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
34. Treatment of Substance Abuse.
35. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
36. Any services or supplies performed or provided by a Relative of the Member or any family member of the Member or any person who ordinarily resides with the Member.
37. Orthoptics and visual eye training.
38. Services or supplies which are not included as Eligible Expenses as described herein.
39. The following care, treatment or supplies for the feet: orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails.
40. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician.
41. Treatment of sleep disorders.
42. Exercise programs, whether or not prescribed or recommended by a Physician.
43. Treatment required as a result of complications or consequences of a treatment or condition not covered hereunder.
44. Charges for travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical or Political Evacuation, Repatriation of Remains, Emergency Reunion, Natural Disaster, and Trip Interruption sections of this insurance.
45. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
46. Organ or Tissue Transplants or related services.
47. Treatment for acne, other acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.

This is a summary of exclusions. For more details, or for a complete copy of the Master Policy, contact InsuranceQuest.

What If I Plan to Participate in a Sport or Athletic Activity that is Excluded?

The Optional Hazardous Sports Rider is available for the adventurous traveler. This Rider adds coverage for the Amateur sports listed in exclusion #27. The maximum coverage under this rider is the Overall Maximum Limit you select. The Accidental Death and Dismemberment benefit is deleted during the course of the activity.

What Are the Pre-Certification Requirements?

All Hospitalizations, Surgeries, Emergency Evacuations, Emergency Reunions, Trip Interruptions, Repatriation of Remains, Computerized Tomography (CAT Scan) and Magnetic Resonance Imaging (MRI) must be Pre-notified. Simply call, or have your Physician call, HCC Medical Insurance Services with all information relative to your claim. You may also pre-notify by submitting details through Client Zone. Be sure to have your ID number available. If you do not Pre-notify, medical expenses will be reduced by 50% and all other expenses will be forfeited.