Exclusions

Special Exclusions and Limitations: In addition to the EXCLUSIONS section, this insurance does not cover any charges, costs, expenses and/or claims incurred by the Insured Person relating to, arising from, as a consequence of, or in connection with, directly or indirectly, any of the following acts, omissions, events, occurrences or conditions:

(1) Diving by the Insured Person without holding a recognized certificate issued by an Authoritative Diving Body for the type of diving being undertaken, or not under professional instruction; and
(2) Diving without proper and well-maintained equipment in good working order and/or contrary to the guidelines, codes of good practice and/or recommendations as laid down by the Authoritative Diving Body under which the Insured Person has been certified; and
(3) Diving to depths greater than thirty (30) meters, or diving requiring decompression stops; and
(4) Solo diving; and
(5) Any form of cave diving; and
(6) Flying within twenty-four (24) hours of the last dive or diving within ten (10) hours of flying; and
(7) Diving for hire, reward, or treasure; and
(8) Diving while suffering from a cold, influenza or any other condition, Illness or Injury causing an obstruction of the sinuses or ears, or diving while otherwise medically unfit to dive; and
(9) Diving by an Insured Person under twelve (12) years of age or over sixty-five (65) years of age; and
(10) Willfully self-inflicted Injury or Illness, the effects of alcohol or drugs (other than as prescribed by a licensed Physician in full awareness of the Insured Person’s sub-aqua activities) and any self-exposure to needless peril (unless in an attempt to save human life); and
(11) Any condition for which the Insured Person was undergoing, recovering from or awaiting Treatment immediately prior to the sub-aqua activities; and
(12) Diving with artificial or other underwater breathing apparatus containing any gas other than compressed air.

It is a condition precedent to the Company’s liability under this insurance that any prospective diver applying for coverage under this insurance is medically fit to dive. If in any doubt, the Insured Person should refrain from participating in S.C.U.B.A. diving until medical advice and approval has been obtained from a qualified Physician.

R. HOSPITAL INDEMNITY - Subject to the Terms of this insurance and in the event the Insured Person has been Hospitalized in a facility outside the United States, during the Period of Coverage, the Company will pay the Insured Person the amount shown in the Schedule of Benefits/Limits for each overnight as an Inpatient in the Hospital, so long as the Treatment received during the overnight Hospitalization is considered to be an Eligible Medical Expense.

S. EXCLUSIONS - All charges, costs, expenses and/or claims (collectively “Charges”) incurred by the Insured Person and directly or indirectly relating to or arising or resulting from or in connection with any of the following acts, omissions, events, conditions, charges, consequences, claims, Treatment (including diagnoses, consultations, tests, examinations and evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Company shall provide no benefits or reimbursements and shall have no liability or obligation for any coverage thereof or therefor:

(1) War; Military Action - The Company shall not be liable for and will not provide coverage or benefits for any claim or Charges incurred with respect to any Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising or incurred in connection with or as a result of any of the following acts or events (collectively, “Occurrences”):

(a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war;
(b) mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power;
(c) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by violence of any type;
(d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege; and
(e) any use of radiological, chemical, nuclear or biological weapons or any other radiological, chemical, nuclear or biological events of any type (including in connection with an act of Terrorism).

Any claim, Charges, Illness, Injury or other consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether or not directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Occurrences shall be deemed and considered to be consequences for which the Company shall not be liable under the Master Policy or this Certificate, except to the extent that the Insured Person shall prove that such claim, Charges, Illness, Injury or other consequence happened independently of the existence of such abnormal conditions and/or Occurrences.

(2) Terrorism – The Company shall not be liable for and will not provide coverage or benefits for any claim or charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with any act of Terrorism. Further, the Company shall not be liable for and will not provide any coverage or benefits for any claim, charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with the following:

(a) the Insured Person’s active and voluntary planning or coordination of or participation in any act of Terrorism; and/or
(b) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning was issued or in effect on or within six (6) months prior to the Insured Person’s date of arrival in said location, post, area, territory or country; and/or
(c) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning becomes effective or is in effect on or after the Insured Person’s date of arrival in said location, post, area, territory or country, and the Insured Person unreasonably fails or refuses to heed such warning and thereafter remains in said location, post, area, territory or country.

(3) Pre-existing Conditions – (i) For medical conditions existing at the time of Application which are fully disclosed on the Application and are not excluded or restricted through a Rider attached to this Certificate and for medical conditions which existed but that were unknown at the time of Application, charges resulting directly or indirectly from or relating to any such Pre-existing Condition are excluded from coverage under this insurance until the Insured Person has maintained coverage under this insurance plan continuously for at least twenty-four (24) months, and thereafter such Charges are limited in coverage as provided in the SCHEDULE OF BENEFITS/LIMITS section; and (ii) Any expenses incurred, obtained, or received by an Insured Person for any Non-Disclosed conditions will be excluded under this insurance; and

(4) Illness or Surgery Within 180 Days - Charges for Treatment of the following Illnesses or Surgeries which manifest themselves and/or involve procedures which take place and/or are recommended during the first one-hundred eighty (180) days of coverage under this insurance plan, beginning on the Initial Effective Date: acne, asthma, allergies, any condition of the breast, any condition of the prostate, tonsillectomy, adenoidectomy, hemorrhoids or hemorrhoidectomy, disorders of the reproductive system, diverticulitis, hysterectomy, hernia, intervertebral disc disease, gall bladder disease or gall stones and kidney stones. Note: Coverage and/or benefits for these Illnesses or Surgeries (or for similar or different Illnesses or Surgeries) may be separately or further limited and/or excluded under the Pre-existing Conditions exclusion and definition; and

(5) Maternity and Newborn Care - Charges for pre-natal care, delivery, post-natal care, and care of Newborns, including complications of Pregnancy, miscarriage, complications of delivery and/or of Newborns are excluded from this insurance; and

(6) Charges for any Treatment or supplies that are:

(a) not incurred, obtained or received by an Insured Person during the Period of Coverage; and/or
(b) not presented to the Company for payment by way of a complete Proof of Claim within ninety (90) days of the date such Charges are incurred; and/or
(c) not administered or ordered by a Physician; and/or
(d) not Medically Necessary; and/or
(e) provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable; and/or
(f) in excess of Usual, Reasonable, and Customary; and/or
(g) incurred by an Insured Person who was HIV + on or before the Effective Date of this insurance relating to or arising or resulting directly or indirectly from HIV, AIDS virus, AIDS related Illness, ARC Syndrome, AIDS and/or any other Illness arising or resulting from any complications or consequences of any of the foregoing conditions; whether or not the Insured Person had knowledge of his/her HIV status prior to the Effective Date, and whether or not the Charges are incurred in relation to or as a result of said status; and/or
(h) provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician; and/or
(i) performed or provided by a Relative of the Insured Person; and/or
(j) not expressly included as Eligible Medical Expenses; and/or
(k) provided by a person who resides or has resided with the Insured Person or in the Insured Person's home; and/or
(l) required or recommended as a result of complications or consequences arising from or related to any Treatment, Illness, Injury, or supply excluded from coverage or which is otherwise not covered under this insurance; and
(m) for Congenital Disorders and conditions arising out of or resulting there from; and

(7) Charges incurred for telephone consultations except those incurred using Teladoc or other Telemedicine consultations through an established Telemedicine protocol system will be considered individually based on medical necessity and appropriateness as determined by the Company under the plan; and

(8) Charges incurred due to a failure to keep a scheduled appointment; and

(9) Charges incurred for Surgeries or Treatment or supplies which are:

(a) Investigational, Experimental, or for research purposes, and/or
(b) related to genetic medicine, genetic testing, surveillance testing and/or wellness screening procedures for genetically predisposed conditions indicated by genetic medicine or genetic testing, including, but not limited to amniocentesis, genetic screening, risk assessment, preventive and prophylactic surgeries recommended by genetic testing, and/or any procedures used to determine genetic pre-disposition, provide genetic counseling, or administration of gene therapy; and

(10) Charges incurred for psychometric, behavioral, and educational testing; financial, relationship, and/or career counseling, services or assessments; or while confined primarily to receive Custodial Care, Educational or Rehabilitative Care; and

(11) Charges incurred for any Surgery, Treatment or supplies relating to, arising from or in connection with, for, or as a result of:

(a) weight modification or any Inpatient, Outpatient, Surgical or other Treatment of obesity (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms or procedures of bariatric Surgery by whatever name called, or reversal thereof, including without limitation intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling; and/or
(b) modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Insured Person (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof); and/or
(c) elective Surgery or Treatment of any kind; and/or
(d) cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and follows a Surgery which was covered under this insurance; and/or
(e) any Illness or Injury sustained while taking part in: Amateur Athletics, Professional Athletics, or other athletic activity that is sponsored or sanctioned by the National Collegiate Athletic Association (and/or any other collegiate sanctioning or governing body), or the International Olympic Committee, and Adventure Sports and activities not expressly covered hereunder or approved in writing by the Company, including, without limitation Collision Sports of any kind as well as the following (including any combination or derivative of the following): abseiling; athletic or sporting activities (except for activities that are non-Collision and engaged in by the Insured Person solely for recreational, entertainment or fitness purposes); aviation (except when travelling solely as a passenger in a commercial aircraft); BMX; BASE jumping; bobsledding; bungee jumping; canyoning; caving; hang gliding; heli-skiing; high diving; hot air ballooning; inline skating; jet skiing; jungle zip lining; kiteboarding; kayaking; luge; motocross (MOTO-X); mountain biking; mountaineering activities where specialized climbing equipment, ropes or guides are normally or reasonably should have been used; parachuting; paragliding; parascending; racing of any kind including without limitation by horse, motor, motorcycle, automobile, or any other motorized or non-motorized vehicle of any type or other means; rappelling; rock climbing; any rodeo activity; ski jumping; sky diving; snow skiing except for recreational downhill and/or cross country snow skiing (provided that there is no coverage for any Illness of Injury sustained while skiing in violation of applicable laws, rules or regulations; away from prepared and marked in-bound territories; and/or against the advice of the local ski school or local authoritative body); snowboarding; snowmobiling; spelunking; surfing; trekking; whitewater rafting; windsurfing; wildlife safaris; and any sub-aqua pursuits involving underwater breathing apparatus below a depth of 30 meters. Practice or training in preparation for any excluded activity which results in Illness or Injury will be considered as activity while taking part in such activity; and /or
(f) any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where participation in such activity is being compensated; undertaken for hire, without any required licenses, certifications, or equipment; and/or against the advice or direction of any local authority or any qualified instructor or contrary to the rules, standards, recommendations, and procedures of a recognized governing body for the sport or activity; and/or
(g) any Illness or Injury sustained while participating in any activity where such activity is undertaken in disregard of or against the recommendations, Treatment programs, or medical advice of a Physician or other healthcare provider; and/or
(h) any Injury or Illness sustained as a result of being under the influence of or due wholly or partly to the effects of alcohol, liquor, intoxicating substance, narcotics or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician but not for the Treatment of Substance Abuse; and/or
(i) any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician. For purposes of this exclusion, “vehicle” shall include motorized devices regardless of whether or not a driver or operator license is required (including watercraft and aircraft) and non-motorized bicycles and scooters for which no permit or license is required; and/or
(j) any willfully Self-inflicted Injury or Illness; and/or
(k) any sexually transmitted or venereal disease; and/or
(l) any testing for the following: HIV, seropositivity to the AIDS virus, AIDS related Illnesses, ARC Syndrome, AIDS; and/or
(m) any Illness or Injury resulting from or occurring during the commission of a violation of law by the Insured Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations; and/or
(n) any Substance Abuse; and/or
(o) biofeedback, recreational, sleep or music therapy; and/or
(p) orthoptics, visual therapy or visual eye training; and/or
(q) any non-surgical Illness or Treatment of the feet, including without limitation: orthopedic shoes; orthopedic prescription devices to be attached to or placed in shoes; Treatment of weak, strained, flat, unstable or unbalanced feet; metatarsalgia, bone spurs, hammer toes or bunions; and any Treatment or supplies for corns, calluses or toenails; except as otherwise expressly set forth; and/or
(r) hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician; and/or
(s) any sleep disorder, including without limitation sleep apnea; and/or
(t) any exercise and/or fitness program or equipment, whether or not prescribed or recommended by a Physician; and/or
(u) any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s); and/or
(v) any organ or tissue or other transplant or related services, Treatment or supplies, except as otherwise expressly set forth; and/or
(w) any artificial or mechanical devices designed to replace human organs temporarily or permanently after termination of Inpatient status; and/or
(x) any efforts to keep a donor alive for a transplant procedure, whether or not the transplant procedure is a Covered Transplant; and/or
(y) any transplant expenses incurred outside the Company’s approved independent Managed Transplant System Network; and/or
(z) any Covered Transplant in excess of one (1) during any twelve (12) month period of coverage under this insurance plan, except re-transplantation Charges if incurred during the initial Covered Transplant Hospitalization; and

(aa) any Illness or Injury resulting from or sustained after entering the Host Country and as a result of epidemics, pandemics, public health emergencies, natural disasters, or other disease outbreak conditions that may affect a person’s health and about which the World Health Organization has issued an Emergency Travel Advisory, US Centers for Disease Control & Prevention has issued a warning Level 3 (avoid nonessential travel), or similar governmental agency of the Insured Person’s Country of residence had published, communicated or issued a Travel Warning restriction, or official declaration informing the public about such health issues before the Insured Person traveled to the Host Country; and

(12) Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception or birth; including but not limited to: artificial insemination; oral contraceptives, Treatment for infertility or impotency; vasectomy or reversal of vasectomy; sterilization or reversal of sterilization; surrogacy or abortion; and

(13) Charges incurred for any Treatment or supply that either promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction; and

(14) Charges incurred for Dental Treatment, except for Emergency Dental Treatment necessary to repair or replace sound natural teeth lost or damaged in an Accident covered hereunder, or as necessary treatment of sudden, unexpected pain to sound natural teeth, and subject to the limits set forth in the Schedule of Benefits/Limits; and

(15) Charges incurred for eyeglasses, contact lenses, hearing aids, hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason; and

(16) Charges incurred for eye Surgery, such as but not limited to radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness, or astigmatism; and

(17) Charges incurred for Treatment or supplies for temporomandibular joint TMJ syndrome, craniomandibular syndrome, chronic TMJ pain, orthognathic Surgery, Le-Fort Surgery or splints; and

(18) Charges incurred by the Insured Person for the Treatment of his/her Newborns (or for supplies related thereto); and

(19) Charges incurred for any immunizations and/or routine physical exams except as otherwise expressly provided for hereunder; and

(20) Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and

(21) Except as otherwise expressly provided for in this insurance, Charges or expenses incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the U.S. Food and Drug Administration or which are considered “off-label” drug use; and for drugs or medicines not prescribed by a Physician.