There are two levels of underwriting when all medical conditions have been disclosed and they have not been specifically excluded or restricted by a rider (subject to the foregoing limits and the other terms of the plan*).
The Silver, Gold and Gold Plus plan options provide a $50,000 lifetime benefit for eligible pre-existing conditions that existed at or prior to the effective date, subject to a maximum of $5,000 per period of coverage after coverage has been in effect for 24 continuous months. This benefit is payable whether or not you have received consultation or treatment for the condition(s) during the 24-month period of continuous coverage.
The following illnesses which exist, manifest themselves, or are treated or have treatment recommended prior to or during the first 180 days of coverage from the initial effective date are considered preexisting conditions and are subject to the waiting period and other limitations of coverage described above: acne, asthma, allergies, tonsillectomy, back conditions, adenoidectomy, hemorrhoids or hemorrhoidectomy, disorders of the reproductive system, hysterectomy, hernia, gall bladder or gall stones and kidney stones, any condition of the breast, and any condition of the prostate.
On the Platinum plan option, conditions that are fully disclosed on the application and have not been excluded or restricted by a rider will be covered the same as any illness. Conditions, including any complications therefrom, that are not fully disclosed on the application will not be covered.
Flexible Underwriting Rider
Where you may have otherwise been declined for coverage, the Flexible Underwriting Rider allows us to extend coverage to you. After 24 months of continuous coverage, a disclosed pre-existing condition which has not been specifically excluded by a rider will be covered the same as any other pre-existing condition, so long as in that 24 month period no treatment has been received for that condition. If treatment has been sought or should have been sought, then the 24 month period starts over from the treatment date.
Other Exclusions & Limitations*
- Adult routine physical examinations are excluded under the Silver plan option, and for the first 12 months for the Gold and Gold Plus plan option, and for the first 6 months for the Platinum plan option
- Out-patient mental and nervous is excluded for the first 12 months on all plan options
- In-patient mental and nervous is excluded under the Silver plan option and for the first 12 months for the Gold, Gold Plus and Platinum plan options
- Maternity, newborn and congenital disorders (unless the maternity rider or Platinum plan option is purchased - see the Summary Schedule of Benefits on page 6) Note: all Maternity expenses including prenatal, delivery, postnatal, newborn and congenital disorders are excluded when the pregnancy is a result of fertility treatment even if you have Maternity coverage
- Organ transplants not specifically listed n Devices to correct sight are excluded under the Silver, Gold and Gold Plus plan options
- Devices to correct hearing n Treatment or supplies not medically necessary
- Treatment not ordered or received by a physician
- Treatment by a relative or family member
- Treatment as a result of war, riot or terrorism
- Treatment resulting from illegal activities
- Organized amateur or professional sports
- Services and treatment eligible for payment by any government or other insurance
- Investigational, experimental or research procedures
- Routine foot care
- Elective cosmetic or plastic surgery
- Drug and alcohol abuse treatment
- Speech therapy
- Custodial care
- Weight modification
- Treatment of impotency
- Contraceptive medication or treatment
- Persons HIV+ at effective date
* See certificate wording for a definition of pre-existing conditions and a complete list of exclusions and limitations, and for all other specific terms and conditions of the plan. Certificate wording is available upon request.
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.