Diplomat America

Plan Detail

Plan Administrator: Global Underwriters | AM Best Rating: A+ "Superior" | Underwriter: United States Fire Insurance Company

Exclusions


EXCLUSIONS AND LIMITATIONS

The Plan Document does not cover any loss resulting from any of the following unless otherwise covered under the Plan Document by Additional Benefits:

1) Suicide, attempted suicide (including drug overdose) self-destruction, attempted self-destruction or intentional self-inflicted Injury while sane or insane;
2) War or any act of war, declared or undeclared;
3) An Accident which occurs while the Plan Participant is on Active Duty Service in any Armed Forces, National Guard, military, naval or air service or organized reserve corps;
4) Injury sustained while in the service of the armed forces of any country. When the Plan Participant enters the armed forces of any country, We will refund the unearned pro rata premium upon request;
5) Voluntary, active participation in a riot or insurrection;
6) Medical expenses resulting from a motor vehicle accident in excess of that which is payable under any other valid and collectible insurance;
7) Organ transplants;
8) Treatment for an Injury or Sickness caused by, contributed to or resulting from the Plan Participant's voluntary use of alcohol, illegal drugs or any drugs or medication that is intentionally not taken in the dosage recommended by the manufacturer or for the purpose prescribed by the Plan Participant's Physician;
9) Commission or attempt to commit an assault or felony, or that occurs while being engaged in an illegal occupation;
10) Eligible Expenses for which the Plan Participant would not be responsible in the absence of the Plan Document;
11) Treatment of acne;
12) Charges which are in excess of Usual, Reasonable and Customary charges;
13) Charges that are not Medically Necessary;
14) Charges provided at no cost to the Plan Participant;
15) Treatment of HIV infection, HIV related illness and AIDS (acquired immune deficiency syndrome);
16) Expenses incurred for treatment while in Your Home Country;
17) Expenses incurred for an Accident or Sickness after the Benefit Period shown in the Schedule of Benefits or incurred after the termination date of coverage;
18) Regular health checkups; routine physical, immunizations or other examination where there are no objective indications or impairment in normal health;
19) Services or treatment rendered by a Physician, Registered Nurse or any other person who is employed or retained by the Participation Organization; or an Immediate family member of the Plan Participant;
20) Injuries paid under Workers’ Compensation, Employer’s liability laws or similar occupational benefits or while engaging in an occupation for monetary gain from sources other than the Participation Organization;
21) Benefits for enrolling solely for the purpose of obtaining Medical Treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a Physician;
22) Aggravation or re-injury of a prior Injury that the Plan Participant suffered prior to his or her coverage Effective Date, unless We receive a written medical release from the Plan Participant’s Physician;
23) Pre-existing conditions as defined in the definitions (This exclusion does not apply to Emergency Evacuation, Repatriation or Return of Mortal Remains);
24) Treatment of a hernia, including sports hernia, whether or not caused by a Covered Accident;
25) Pregnancy or childbirth, miscarriage; elective abortion; elective cesarean section; or any complications of any of these conditions;
26) Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof;
27) Charges incurred for Surgery or treatments which are, Experimental/Investigational, or for research purposes;
28) Expense incurred for treatment of temporomandibular joint (TMJ) disorders or craniomandibular joint dysfunction and associated myofacial pain;
29) Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury or pain resulting from an Accident while the Plan Participant is covered under the Plan Document, and rendered within 6 months of the Accident;
30) Eyeglasses, contact lenses, hearing aids braces, appliances, or examinations or prescriptions therefore;
31) Weak, strained or flat feet, corns, calluses, or toenails;
32) Private-duty nursing services;
33) The cost of the Covered Person’s unused airline ticket for the transportation back to the Plan Participant’s Home Country, where an Emergency Medical Evacuation or Repatriation and/or Return of Mortal Remains benefit is provided;
34) For the cost of a one way airplane ticket used in the transportation back to the Plan Participant's country where an air ambulance benefit is provided and medically necessary;
35) Treatment paid for or furnished under any other individual or group Plan Document, or other service or medical prepayment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for the treatment without cost to any individual;
36) Travel in or upon: A snowmobile; A water jet ski; Any two or three wheeled motor vehicle, other than a motorcycle registered for on-road travel; Any off-road motorized vehicle not requiring licensing as a motor vehicle; when used for recreation or competition. Unless Athletic Sports & Hazardous Activity Rider is purchased.
37) Injury sustained while taking part in: mountaineering; hang gliding; parachuting; bungee jumping; racing by horse, motor vehicle or motorcycle; snowmobiling; motorcycle/motor scooter riding; scuba diving, involving underwater breathing apparatus; water skiing; snow skiing; spelunking; parasailing; white water rafting; surfing, unless part of a school credit course; and snowboarding. Unless Athletic Sports & Hazardous Activity Rider is purchased.
38) Practice or play in any amateur, club, intramural, interscholastic, intercollegiate, sports contest or competition. Unless Athletic Sports & Hazardous Activity Rider is purchased.
39) Practice or play in any professional or semiprofessional sports contest or competition;
40) Rest cures or custodial care;
41) Treatment of Mental and Nervous Disorders;
42) Weight reduction programs or surgical treatment of obesity or treatment of venereal disease;
43) Elective or Cosmetic surgery and Elective Treatment or treatment for congenital anomalies (except as specifically provided), except for reconstructive surgery on a diseased or injured part of the body (Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness);
44) Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from:
a) While riding as a passenger in any Aircraft not intended or licensed for the transportation of passengers; or
b) While being used for any test or experimental purpose; or
c) While piloting, operating, learning to operate or serving as a member of the crew thereof; or
d) while traveling in any such Aircraft or device which is owned or leased by or on behalf of the Participation Organization of any subsidiary or affiliate of the Participation Organization, or by the Plan Participant or any member of his household.
e) A space craft or any craft designed for navigation above or beyond the earth's atmosphere; or
f) An ultra light, hang-gliding, parachuting or bungi-cord jumping;
Except as a fare paying passenger on a regularly scheduled commercial airline or as a passenger in a non-scheduled, private aircraft used for business or pleasure purposes.
45) Ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste, from combustion of nuclear fuel, the radioactive, toxic, explosive or other hazardous properties of any nuclear assembly or nuclear component of such assembly.
46) Plan Participant being exposed to the Utilisation of nuclear, chemical or biological weapons of mass destruction.

In addition to any of the exclusions listed above, for Eligible Expenses under Trip Interruption, this Insurance also does not cover the following:

1) The Plan Participant or Traveling Companion or Traveling Companion’s family making changes to personal plans; having business or contractual obligations; being unable to obtain necessary travel documents (passports, visas, etc.); being detained or having property confiscated by customs authorities; carrier caused delays (including bad weather);
2) Prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which the Plan Participant purchased their trip arrangements;
3) A Pre-Existing Condition existing prior to the Plan Participant’s departure from their Home Country.
In addition to any of the exclusions listed above, for Eligible Expenses under Baggage Loss and Delay, this Insurance also does not cover the following:
1) Animals;
2) Artificial teeth or limbs, hearing aids;
3) Sunglasses, contact lenses or eyeglasses;
4) Documents of any kind, including but not limited to documents, bills, currency, deeds, evidences of debt, letters of credit, stamps, credit cards, money, notes, securities, transportation or other tickets;
5) Professional or occupational equipment or property, whether or not electronic business equipment or;
6) Telephones or PDA devices, computer hardware or software.

No Benefit will be payable for Home Alteration and Vehicle Modification, as the result of: Any condition for which the Plan Participant Person is entitled to benefits under any Workers’ Compensation Act or similar law.