Atlas Group® Exclusions & Limitations

Pre-existing Condition Definition

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 Preexisting Condition.

What Is Excluded?

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

Charges for the following treatments and/or services and/or supplies and/or conditions are excluded from coverage hereunder:

  1. Routine pre-natal care, Pregnancy, child birth, and post natal care.
  2. 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.
  3. Charges incurred by or for any child under the age of 14 days.
  4. Diagnosis, testing or treatment related to birth defects and congenital illnesses. Birth defects are deemed to include hereditary conditions.
  5. Charges for the diagnosis, testing or treatment of Mental Health Disorders, as defined herein.
  6. Charges which are not Incurred, as herein defined, by a Member during his/her Certificate Period.
  7. Charges for treatment of any condition(s) when the purpose of departing the Home Country was to obtain treatment in the destination country/countries.
  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. Diagnosis, testing, treatment, services or supplies that are not administered by or under the supervision of a Physician, and products that can be purchased without a doctor's prescription.
  10. Diagnosis, testing, treatment, services or supplies which are not Medically Necessary as herein defined.
  11. Diagnosis, testing, 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, diagnosis, testing, 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, or any medical treatment in any establishment for the care of the aged, except rehabilitative care received upon direct transfer from an acute care Hospital.
  16. Diagnosis, testing or treatment of obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass Surgery.
  17. Modifications of the physical body intended to improve the psychological, mental or emotional well-being of the Member, including but not limited to sex-change Surgery.
  18. Surgeries, diagnosis, testing, 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. Diagnosis, testing or treatment for HIV, AIDS or ARC, and all diseases caused by and/or related to HIV.
  20. Any drug, test, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
  21. Any drug, test, treatment or procedure that either promotes, enhances or corrects impotency or sexual dysfunction.
  22. Willful and/or therapeutic termination of Pregnancy 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. Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations.
  25. Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
  26. Diagnosis, testing or treatment of the temporomandibular joint.
  27. Medical expenses for Injury or Illness resulting from:
    1. Amateur Athletics, Contact Sports, intercollegiate, interscholastic, intramural, and club sports or athletic activities and Professional Sports including practice;
    2. mountaineering at elevations of 7,000 meters or higher;
    3. aviation (except when traveling solely as a passenger in a commercial aircraft);
    4. base jumping, parachuting, parasailing, hang-gliding; sky surfing, paragliding, kite-surfing;
    5. off-road motorized vehicles including all-terrain vehicles, snowmobiles and motorized dirt bikes, and tractors;
    6. heli-skiing, snow skiing, or snowboarding, except for recreational downhill and/or cross country snow skiing or snowboarding (no cover provided while skiing away from prepared and marked in-bound territories and/or against the advice of the local ski school or local authoritative body);
    7. white water rafting;
    8. racing by any animal, motorized vehicle, or BMX;
    9. spelunking or cave diving;
    10. sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, or accompanied by a certified instructor at depths of less than 10 meters;
    11. avalanche training;
    12. Aussie rules football;
    13. big game hunting, running with the bulls;
    14. bobsleigh, skeleton or luge;
    15. any type of boxing or martial arts;
    16. hot air ballooning as a pilot;
    17. jousting;
    18. modern pentathlon;
    19. powerlifting;
    20. quad biking outdoor endurance events;
    21. speed trials; speedway;
    22. wrestling
  28. Injury sustained that is due wholly or partially to the effects of intoxication or drugs other than drugs taken in accordance with treatment prescribed by a Physician and except drugs prescribed for the treatment of substance abuse.
  29. Injury sustained while operating any motorized vehicle, aircraft or watercraft whether registered or not while under the influence of alcohol as defined under the law of the jurisdiction where the injury occurs or with a .08 BAC whichever is lower.
  30. Costs resulting from self-inflicted Injury or Illness and/or suicide or attempted suicide whether sane or insane.
  31. Diagnosis, testing or treatment of venereal disease, including all Sexually Transmitted Diseases and conditions.
  32. Routine medical examinations, including but not limited to vaccinations, immunizations, annual check-ups, the issue of medical certificates and attestations, and examinations as to the suitability of employment or travel.
  33. Diagnosis or treatment by a chiropractor.
  34. 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.
  35. Diagnosis, testing or treatment of Substance Abuse or addiction or conditions that may be attributed to Substance Abuse or addictions and direct consequences thereof.
  36. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
  37. Psychometric, intelligence, competency, behavioral and educational testing.
  38. Any services, diagnosis, testing, supplies, or treatment 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.
  39. Orthoptics and visual eye training.
  40. Diagnosis, testing, 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.
  41. Diagnostic testing or procedures, services, supplies, and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician.
  42. 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 for all Members subject to the limits set forth in the Schedule of Benefits and Limits.
  43. Exercise programs, whether or not prescribed or recommended by a Physician.
  44. Diagnosis, testing or treatment required as a result of complications or consequences of a treatment or condition not covered hereunder.
  45. Charges for travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, Emergency Reunion, Natural Disaster, Return of Minor Children, Political Evacuation, and Trip Interruption sections of this insurance.
  46. Diagnosis, testing or treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
  47. Organ or Tissue Transplants or related services.
  48. Diagnosis, testing or 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.
  49. Diagnosis, testing or treatment of all forms of cancer / neoplasm.
  50. Diagnosis, testing or treatment of sleep apnea or other sleep disorders.
  51. All expenses of any cryo preservation and implantation or re-implantation of living cells.
  52. All Emergency Medical Evacuation, Repatriation of Remains, or Local Burial or Cremation costs not approved or arranged in advance by Underwriters.
  53. Coverage for local cremation or burial is excluded from coverage if death occurs in the Member’s Home Country.
  54. Medical conditions while on duty as a member of a police or military force unit.
  55. Claims payable under any government system, including the Australian Medicare system, are excluded from coverage.
  56. The Accidental Death & Dismemberment benefit shall be excluded with respect to Accidents or loss caused by or contributed to by any of the following:
    1. War or act of war, whether declared or undeclared.
    2. The member's participation in a riot, insurrection or violent disorder.
    3. The member's service in the armed forces of any country.
    4. Suicide or attempted suicide or self-inflicted Injury, while sane or insane.
    5. The voluntary use of any chemical compound, poison or drug, unless used according to the directions of a Physician.
    6. Committing or attempting to commit a felony.
    7. Sickness, Mental Health Disorder, or Pregnancy.
    8. As the result of Intoxication as defined by the laws of the jurisdiction in which the accident occurred of the Member, whether directly or indirectly,
    9. Myocardial infarction or cerebrovascular accident (CVA / Stroke).
    10. Infection, except infection through a wound caused solely by an accident.
    11. Injury while riding, boarding, or alighting from an aircraft if the Member was operating the aircraft, learning to operate the aircraft, serving as a member of the aircraft crew, or if the aircraft was being used for any purpose other than passenger transportation.
    12. Medical or surgical treatment for any of the above.
    13. Any of the following activities:
      1. Amateur Athletics, Contact Sports, intercollegiate, interscholastic, intramural, and club sports or athletic activities and Professional Sports including practice. 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 (V) of this provision; and
      2. mountaineering at elevations of 7,000 meters or higher;
      3. aviation (except when traveling solely as a passenger in a commercial aircraft);
      4. base jumping, parachuting, parasailing, hang-gliding; sky surfing;
      5. off-road motorized vehicles including all-terrain vehicles, snowmobiles and motorized dirt bikes, and tractors;
      6. heli-skiing, snow skiing, or snowboarding, except for recreational downhill and/or cross country snow skiing or snowboarding (no cover provided while skiing away from prepared and marked in-bound territories and/or against the advice of the local ski school or local authoritative body);
      7. white water rafting;
      8. racing by any animal, motorized vehicle, or BMX;
      9. spelunking or cave diving;
      10. sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, or accompanied by a certified instructor at depths of less than 10 meters;
      11. avalanche training;
      12. Aussie rules football;
      13. big game hunting, running with the bulls;
      14. bobsleigh, skeleton or luge;
      15. any type of boxing or martial arts;
      16. hot air ballooning as a pilot;
      17. jousting;
      18. modern pentathlon;
      19. powerlifting;
      20. quad biking outdoor endurance events;
      21. speed trials; speedway;
      22. wrestling
  57. Services, testing diagnosis, supplies, or treatment that are not included as Eligible Expenses as described herein.

What Are the Pre-Certification Requirements?

The following expenses must always be Pre-certified:

  • Inpatient care
  • any Surgery or Surgical Procedure
  • care in an Extended Care Facility
  • Home Nursing Care
  • Durable Medical Equipment
  • artificial limbs
  • Computerized Tomography (CAT Scan)
  • Magnetic Resonance Imaging (MRI)

To comply with the Pre-certification requirements, the Member must:

  1. Contact the Plan Administrator at the telephone number contained in the Member's Certificate as soon as possible before the expense is to be incurred; and
  2. Comply with the instructions of the Plan Administrator and submit any information or documents they require; and
  3. Notify all Physicians, Hospitals and other providers that this insurance contains Pre-certification requirements and ask them to fully cooperate with the Plan Administrator.

If the Member complies with the Pre-certification requirements, and the expenses are Pre-certified, Underwriters will pay Eligible Medical Expenses subject to all terms, conditions, provisions and exclusions herein. If the Member does not comply with the Pre-certification requirements or if the expenses are not Pre-certified:

  1. Eligible Medical Expenses will be reduced by 50%; and
  2. The Deductible will be subtracted from the remaining amount; and
  3. The Coinsurance will be applied.

Emergency Pre-certification - In the event of an Emergency Hospital admission, Pre-certification must be made within 48 hours after the admission, or as soon as is reasonably possible.

Pre-certification Does Not Guarantee Benefits - The fact that expenses are Pre-certified does not guarantee either payment of benefits or the amount of benefits. Eligibility for and payment of benefits are subject to all the terms, conditions, provisions and exclusions herein.

Concurrent Review - For Inpatient stays of any kind, the Plan Administrator will Pre-certify a limited number of days of confinement. Additional days of Inpatient confinement may later be Pre-certified if a Member receives prior approval.

Patient Protection and Affordable Care Act (“PPACA”): This insurance is not subject to, and does not provide certain of the insurance benefits required by, the United States PPACA. PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney or tax professional to determine if PPACA’s requirements are applicable to you. The policy contains the plan benefits, including a lifetime maximum that you have selected. Please review your choices to ensure that you have sufficient coverage to meet your medical needs.