EXCLUSIONS
In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits Section or Conditions of Coverage Section:
1. intentionally self-inflicted injury, suicide, or any attempt while sane or insane;
2. commission or attempt to commit a felony or an assault;
3. commission of or active participation in a riot or insurrection;
4. declared or undeclared war or act of war or any act of declared or undeclared war unless specifically provided by this Policy;
5. flight in, boarding or alighting from an Aircraft, except as a passenger on a regularly scheduled commercial airline;
6. voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;
7. injuries compensable under Workers’ Compensation law or any similar law;
8. operating any type of vehicle or Conveyance while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the Insured Person has been provided a written warning against operating a vehicle or Conveyance while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as defined by the motor vehicle laws of the state in which the Covered Loss occurred;
9. the Insured Person’s intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in His blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether He is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officer’s report, or similar items will be considered proof of the Insured Person’s intoxication;
10. medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice unless it occurs during treatment of a Covered Injury;
11. benefits will not be paid for services or treatment rendered by any person who is:
a. employed or retained by the Policyholder;
b. living in the Insured Person’s household;
c. an Immediate Family Member of either the Insured Person or the Insured Person’s Spouse; or
d. the Insured Person.
RIDER EXCLUSIONS AND LIMITATIONS
If coverage is purchased after the Insured Person’s arrival in the United States, coverage under this Rider is limited to Accident only during an Insured Person’s 14 days of coverage commencing on the Insured Person’s Effective Date. Full coverage will take place after the 14th day.
The Company will not pay Covered Medical Services for any loss, treatment or services resulting from the following.
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Expenses incurred during travel for the purposes of seeking medical care or treatment, or while on a waiting list for specific treatment or while traveling against the advice of a Physician.
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Expenses incurred within the Insured Person’s Home country or country of regular domicile,
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Pre-existing Conditions, except for the Acute Onset as specifically provided in the Rider Schedule.
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Routine physical or other examinations where there is not objective indications of impairment for normal health or well baby care.
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Dental treatment, except as the result of Covered Injury to sound, natural teeth as stated in the Rider Schedule.
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Cosmetic or plastic surgery or treatment for congenital abnormalities, except reconstructive surgery as a result of a as the result of a Covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a Covered Injury or Sickness
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eye refractions or eye examinations for the purpose of prescribing corrective lenses or for the fitting thereof; eyeglasses, contact lenses.
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Hearing examination or hearing aids or other treatment for Hearing Defects and problems. Hearing Defects means any physical defect of the ear which does or can impair normal hearing.
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Treatment by any Immediate Family member or member of the Insured Person’s household. “Immediate family member “means an Insured Person’s spouse, child, brother, sister, grandparents or in laws.
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Services, supplies, or treatment including any period of Hospital Confinement which is not recommended, approved, and certified as Medically Necessary and reasonable by a Physician, or expenses which are non-medical in nature;
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In connection with alcoholism and drug addiction, or use of any drug or narcotic agent unless prescribed by a Physician;
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the commission of a felony offense;
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Charges for Covered Medical Expenses for which the Insured Person would not be responsible for in the absence of this Rider;
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Any expense paid or payable by any Other Health Care Plan;
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Any treatment provided under any mandatory government program or facility set up for treatment without cost to any individual
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Treatment , services supplies or facilities in a Hospital owned or operated by the Veteran’s Administration, or b) a national government or any of its agencies( this exclusion does not apply to treatment when a charge is made which the Insured Person is required by law to pay)
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Elective treatment, exams or surgery; elective termination of pregnancy.
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Expenses for services, treatment or surgery deemed to be experimental and which are not recognized and generally accepted medical practices in the United States.
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Expenses payable by any automobile insurance policy without regard to fault.
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Organ or tissue transplants and related services.
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Expenses incurred for services related to the diagnostic treatment of infertility or other problems related to the inability to conceive a child, including but not limited to, fertility testing and in-vitro fertilization.
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Birth control including surgical procedures and devices.
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Expenses incurred in connection with weak, strained or flat feet, corns, calluses or toenails.
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Birth defects and congenital anomalies, or complications which arise from such conditions.
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Sexually transmitted diseases or immune deficiency disorders and related conditions. This exclusion does not apply to the care or treatment of Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV) infection, or any illness or disease arising from these medical conditions.
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specific named hazards: piloting any aircraft;
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Expenses incurred for any treatment if the Insured Person is travelling against the advice of a Physician.
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Expenses incurred after the date insurance terminates for an Insured Person under this Policy
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Any mental or nervous disorders or rest cures;
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Duplicates services actually provided by both a certified nurse- midwife and Physician.
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Expenses payable under any prior Policy which was in force for the person making the claim.
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Expenses incurred in a Hospital emergency room visit which is not of an emergency nature.
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Expenses incurred for chiropractic care-outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertical column.
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Injury sustained while participating in club, intramural, intercollegiate, interscholastic, professional or semi-professional sports.
In addition, benefits will not be paid for services or treatment rendered by any person who is:
1. employed or retained by the Policyholder;
2. living in the Insured Person’s household;
3. an Immediate Family Member of either the Insured Person or the Insured Person’s Spouse;
4. the Insured Person
If we determine the benefits paid under this Rider are eligible benefits under any Other Health Care Plan, We may seek to recover any expenses covered by the Other Health Care Plan to the extent that the Insured person is eligible for reimbursement.
This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit US companies from proving insurance, including but not limited to, the payment of claims. All other terms and conditions of the Policy and this Rider remain unchanged.