Atlas International

Plan Detail

Plan Administrator: Tokio Marine HCC Medical Insurance Services Group | AM Best Rating: A "Excellent" | Underwriter: Lloyd's

Exclusions


WAR, TERRORISM, BIOLOGICAL, CHEMICAL, NUCLEAR EXCLUSION

Notwithstanding any provision to the contrary within this insurance or any endorsement or rider attached hereto, it is agreed that this insurance excludes loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss, damage, cost or expense:

Underwriters will pay Eligible Medical Expenses for treatment of Injuries and Illnesses resulting from an Act of Terrorism, up to the limit set forth in the Schedule of Benefits and Limits, provided all of the following conditions are met:

For the purpose of this insurance, an “Act of Terrorism” means an act, including but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

This insurance also excludes coverage for loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (1), (2) or (3) above.

If Underwriters allege that by reason of this exclusion, any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be upon the Member.

In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.

OTHER EXCLUSIONS

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 or treatment related to birth defects and congenital illnesses. Birth defects are deemed to include hereditary conditions.
  5. Charges for the diagnosis 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, 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, treatment, services or supplies which are not Medically Necessary as herein defined.
  11. Diagnosis, 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, 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 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, 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 or treatment for HIV, AIDS or ARC, and all diseases caused by and/or related to HIV.
  20. Any drug, 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, 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 or treatment of the temporomandibular joint.
  27. Medical expenses for Injury or Illness resulting from:
    • Amateur Athletics, Contact Sports, intercollegiate, interscholastic, intramural, and club sports or athletic activities and Professional Sports including practice;
    • mountaineering at elevations of 7,000 meters or higher;
    • aviation (except when traveling solely as a passenger in a commercial aircraft);
    • base jumping, parachuting, parasailing hang-gliding; sky surfing;
    • off-road motorized vehicles including all-terrain vehicles, snowmobiles and motorized dirt bikes, and tractors;
    • 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);
    • white water rafting;
    • racing by any animal, motorized vehicle, or BMX;
    • spelunking or cave diving;
    • sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, or accompanied by a certified instructor at depths of less than 10 meters;
    • avalanche training;
    • Aussie rules football;
    • big game hunting, running with the bulls;
    • bobsleigh, skeleton or luge;
    • any type of boxing or martial arts;
    • hot air ballooning as a pilot;
    • jousting;
    • modern pentathlon;
    • powerlifting;
    • quad biking outdoor endurance events;
    • speed trials; speedway;
    • wrestling
  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 except drugs prescribed by a Physician for the treatment of Substance Abuse.
  29. Costs resulting from self-inflicted Injury or Illness and/or suicide or attempted suicide whether sane or insane.
  30. Diagnosis or treatment of venereal disease, including all Sexually Transmitted Diseases and conditions.
  31. 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.
  32. Diagnosis or 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. Diagnosis or treatment of Substance Abuse or addiction or conditions that may be attributed to Substance Abuse or addictions and direct consequences thereof.
  35. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
  36. Psychometric, intelligence, competency, behavioral and educational testing.
  37. Any services, diagnosis, 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.
  38. Orthoptics and visual eye training.
  39. Diagnosis, 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. 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.
  41. 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.
  42. Exercise programs, whether or not prescribed or recommended by a Physician.
  43. Diagnosis or 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 Evacuation, Repatriation of Remains, Emergency Reunion, Natural Disaster, Return of Minor Children, Political Evacuation, and Trip Interruption sections of this insurance.
  45. Diagnosis or 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. Diagnosis 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.
  48. Diagnosis or treatment of all forms of cancer / neoplasm.
  49. Diagnosis or treatment of sleep apnea or other sleep disorders.
  50. All expenses of any cryo preservation and implantation or re-implantation of living cells.
  51. All Emergency Medical Evacuation, Repatriation of Remains, or Local Burial or Cremation costs not approved or arranged in advance by Underwriters.
  52. Coverage for local cremation or burial is excluded from coverage if death occurs in the Member’s Home Country.
  53. Medical conditions while on duty as a member of a police or military force unit.
  54. Claims payable under any government system, including the Australian Medicare system, are excluded from coverage.
  55. The Accidental Death & Dismemberment benefit shall be excluded with respect to Accidents occurring while the Member is participating in any of the following:
    • Amateur Athletics, Contact Sports, intercollegiate, interscholastic, intramural, and club sports or athletic activities and Professional Sports including practice. Non-contact and non-organized/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
    • mountaineering at elevations of 7,000 meters or higher;
    • aviation (except when traveling solely as a passenger in a commercial aircraft);
    • base jumping, parachuting, parasailing, hang-gliding; sky surfing;
    • off-road motorized vehicles including all-terrain vehicles, snowmobiles and motorized dirt bikes, and tractors;
    • 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);
    • white water rafting;
    • racing by any animal, motorized vehicle, or BMX;
    • spelunking or cave diving;
    • sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, or accompanied by a certified instructor at depths of less than 10 meters;
    • avalanche training;
    • Aussie rules football;
    • big game hunting, running with the bulls;
    • bobsleigh, skeleton or luge;
    • any type of boxing or martial arts;
    • hot air ballooning as a pilot;
    • jousting;
    • modern pentathlon;
    • powerlifting;
    • quad biking outdoor endurance events;
    • speed trials; speedway;
    • wrestling
  56. Services, diagnosis, supplies, or treatment that are not included as Eligible Expenses as described herein.