Exclusions And Limitations
The Limited Accident & Sickness Indemnity Plan will not pay benefits for any loss or injury that is caused by, or results from:
- intentionally self-inflicted injury
- suicide or attempted suicide
- war or any act of war, whether declared or not
- service in the military, naval or air service of any country
- commission of, or attempt to commit, a felony, an assault or other illegal activity
- commission of or active participation in a riot, or insurrection
- an accident if the covered person is the operator of a motor vehicle and does not possess a valid motor vehicle operator's license, except while participating in Driver's Education Program
- travel or activity outside the United States, except for a medical emergency
-
alcoholism, the voluntary use of illegal drugs, the intentional taking of
over the counter medication not in accordance with recommended dosage and
warning instructions, intentional misuse of prescription drugs, unless
specifically provided herein
- while the covered person is legally intoxicated (as determined by that state's laws) or while under the influence of any drug unless administered under the advice and consent of a physician
- injury to a covered person resulting from that covered person's willful violation of the Participating Organization's rules or regulations. Willful violation includes, but is not limited to: a) working without protective clothing, helmets, gloves, etc. required by the Participating Organization's rules or regulations; or b) participating in any activity that is in violation of the Participating Organization's rules or regulations
- Pre-existing Conditions occurring within the first 6 months of coverage
(applies to Hospital and Surgery benefits only)
- elective abortion. Elective abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed
- mental illness disorders (except as provided by the policy)
- cosmetic surgery, except for reconstructive surgery needed as the result of an injury or sickness
- Experimental or Investigational drugs, services, supplies or any
procedure held to be Experimental or Investigatory by the Company at the
time the procedure is done. For the purposes of this exclusion,
"Experimental or Investigational" means medical services, supplies or
treatments provided or performed in a special setting for research
purposes, under a treatment protocol or as part of a clinical trial (Phase
I, II or III). The covered service will also be considered Experimental or
Investigational if the Covered Person is required to sign a consent form
that indicates the proposed treatment or procedure is part of a scientific
study or medical research to determine its effectiveness or safety. Medical
treatment, that is not considered standard treatment by the majority of the
medical community or by Medicare, Medicaid or any other government financed
programs or the National Cancer Institute regarding malignancies, will be
considered Experimental or Investigational. A drug, device or biological
product is considered Experimental or Investigational if it does not have
FDA approval or approval under an interim step in the FDA process, i.e., an
investigational device exemption or an investigational new drug exemption
- treatment for being overweight, gastric bypass or stapling, intestinal
bypass, and any related procedures, including complications
- treatment or services provided by a private duty nurse, unless provided for in the
policy
- treatment by a family member or member of the covered person's family
- routine dental care and treatment, except for treatment of injury as specified in the
policy
- work-related injuries or injuries covered under Workers' Compensation,
Employer's Liability Laws or similar occupational benefits or while
engaging in activity for monetary gain from sources other than the
Participating Organization
- piloting or serving as a crewmember or riding in any aircraft except as a fare-paying passenger on a regularly scheduled or charter airline (for AD&D benefit only)
-
bungi-cord jumping, parachuting, skydiving, parasailing, hang-gliding (for
AD&D benefit only)
- flight in, boarding or alighting from an
Aircraft except as a fare-paying passenger on a regularly scheduled
commercial airline (for AD&D benefit only)
- travel in or on any
on-road and off-road motorized vehicle not requiring licensing as a motor
vehicle (for AD&D benefit only)
- travel in any Aircraft owned,
leased or controlled by the Participating Organization, or any of its
subsidiaries or affiliates. An Aircraft will be deemed to be "controlled"
by the Participating Organization if the Aircraft may be used as the
Participating Organization wishes for more than 10 straight days, or more
than 15 days in any year (for AD&D benefit only)
Exclusions Specific To Dental Benefits:
(Applicable to Large Employer Plans only)
No benefits will be paid for expenses incurred:
- for services and supplies not listed in the Schedule of Benefits or not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental
-
for any treatment program which began prior to the date the
insured is covered under the policy except for comprehensive
orthodontic treatment or as provided in the Schedule of Benefits
- for services or supplies payable under any medical
expense, auto or no-fault plan
- for any condition covered under any Worker's Compensation Act or similar law
- for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance
- for services subject to a waiting period that were incurred during the waiting period
- for charges resulting from changing from one provider
to another while receiving treatment, or from receiving
treatment from more than one provider for one dental
procedure to the extent that the total charges billed exceed
the amount incurred if one provider had performed all
services
- for drugs or the dispensing of drugs except injectable
antibiotics administered by a Dentist as a result of dental
treatment
- for oral hygiene instruction; plaque control; acid etch; prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes)
- for implants; myofunctional therapy; athletic mouth guards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia
- except as may be provided in the Schedule of Benefits, for services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits
- for the replacement of retainers
-
during travel or activity outside the United States
- for services which result from the voluntary use of
illegal drugs, the intentional taking of over-the-counter
medication not in accordance with recommended dosage and
warning instructions, intentional misuse of prescription
drugs
This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit the insurance company from providing insurance, including, but not limited to, the payment of claims.