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Plan Detail

Plan Administrator: Seven Corners | AM Best Rating: A "Excellent"  | Underwriter: Llyod's of London & Tramont Insurance Company Ltd.

Exclusions


MEDICAL BENEFIT EXCLUSIONS

Below is a summary of items excluded from coverage. Please see your Certificate of Coverage for a complete listing.

• Pre-existing Conditions;

a) If you are a U.S. resident, this exclusion is waived as shown in the Schedule of Benefits for Waiver of Pre-existing Conditions.

b) If you are a non-U.S. resident under age 70, this exclusion is waived for an Acute Onset of a Pre-existing Condition as shown in the Schedule of Benefits. The above exceptions do not include coverage for known, scheduled, required, or expected medical care, drugs, or treatments existent or necessary & prior to the coverage start date of this program.

The remaining exclusions will not receive benefits from these waivers.

• Charges for treatment which exceed reasonable & customary charges; surgeries or treatments which are investigational, experimental, or for research purposes; expenses which are non-medical in nature;

• Claims not received within 90 days of the date of service;

• Expenses for vocational, occupational, sleep, speech, recreational or music therapy;

• Durable medical equipment;

• Expenses which were not recommended approved & certified as medically necessary & reasonable by a physician;

• Suicide or any attempt thereof, or self destruction or any attempt thereof, intentionally self-inflicted Injury or Illness;

• Expenses as a result of, or in connection with, the commission of a felony offense or any other criminal or illegal activity as defined by the local governing body;

• Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), civil war; nuclear, chemical, biological; (details in program summary);

• Terrorist Activity in excess of $50,000;

• Injury sustained while participating in professional athletics, including but not limited to the event, games, practice, conditioning and any other activity related to professional athletics;

• Injury sustained while participating in amateur or interscholastic athletics, including but not limited to the event, games, practice, conditioning and any other activity related to amateur or interscholastic athletics; this exclusion does not apply to non-competitive, recreational or intramural activities. Note: A sponsored and/or organized amateur or interscholastic athletic event includes

Training camps, team sports, or any formal grouping of people participating in one or multiple events that may/may not require a fee for participation;

• Routine physicals, inoculations, or other examinations including but not limited to laboratory, diagnostic, or x-ray examinations where there are no objective indications or impairment in normal health;

• Occupational Diseases, including but not limited to diseases related to asbestos exposure, and the complications thereof, including asbestosis and mesothelioma related to asbestos exposure;

• Diagnosis or treatment of the temporomandibular joint;

• Chiropractic care or acupuncture;

• Any services, supplies, or treatment prescribed, performed or provided by a relative or family member of yours or any person who ordinarily resides with you. This includes but is not limited to prescription medication & any diagnostic testing;

• False teeth, dentures or dental appliances, normal ear tests & hearing aids, hearing implants, cosmetic or plastic surgery (including deviated nasal septum), routine dental expenses, dental expenses except as specifically provided in the Dental Emergency Treatment benefit, eye refractions or eye examinations for the purpose of prescribing corrective lenses for eye-glasses or for the fitting thereof, unless caused by accidental bodily injury incurred while insured hereunder; eyeglasses, contact lenses; eye surgery when the primary purpose is to correct nearsightedness, farsightedness or astigmatism;

• Treatment in connection with alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency or use of any drug or narcotic agent; injury occurring while under the influence of or disablement due wholly or partly to liquor, chemicals, or drugs or narcotic agent, unless administered under the advice of a physician & said narcotic agent was taken in accordance with proper dosing as directed by the physician;

• Mental & nervous disorder or rest cures;

• Learning disabilities, attitudinal disorders, or disciplinary problems;

• Congenital abnormalities & conditions arising out of or resulting there from;

• Expenses for a hospital emergency room visit which is not of an emergency nature;

• Injury sustained while taking part in mountaineering, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle, motorcycle/ motor scooter riding (whether as a passenger or driver), scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, wakeboard riding, jet skiing, windsurfing, snowmobiling, snow skiing and snowboarding, & any other sport, recreational, athletic, or adventure activity which is undertaken for thrill seeking and exposes the insured to abnormal or extreme risk of injury &/or is in violation of applicable laws, rules, or regulations; (See optional Hazardous Sports Coverage to include some of these sports.)

• Treatment paid for or furnished under any other individual, government, or group policy; charges provided at no cost to you;

• Diagnosis & treatment of venereal or sexually transmitted disease;

• Pregnancy expenses or Illness resulting from pregnancy, childbirth, miscarriage; miscarriage due to an accident or complications of pregnancy; or postnatal care;

• Drug, treatment or procedure that promotes or prevents conception or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof;

• Expenses incurred while you are in your home country (except after approved Emergency Medical Evacuation/Repatriation or if covered under the Home Country Coverage benefit);

• Expenses incurred when travel was undertaken to seek medical treatment for a condition or after your physician has limited or restricted travel;

• 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;

• Treatment for human organ tissue transplants & related treatment;

• Weight reduction programs or the surgical treatment of obesity, including but not limited to wiring of the teeth & any intestinal bypass surgery;

• Modifications of the physical body intended to improve your psychological, mental or emotional well-being, including but not limited to sex-change surgery; any drug, treatment, or procedure that promotes, enhances or corrects impotency or sexual dysfunction;

• Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or the Human Immunodeficiency Virus (HIV);

• Exercise programs;

• Treatment required as a result of complications or consequences of a treatment or condition not covered on this plan;

• Travel accommodations, except as provided for in the Local Ambulance, Emergency Medical or Political Evacuation, Return of Mortal Remains, Return of Minor Children, Emergency Reunion, Natural Disaster, and Interruption of Trip sections of this insurance;

• Diagnosis or treatment incurred as a result of exposure to non-medical nuclear radiation &/or radioactive materials;

• Diagnosis or treatment for acne, moles, skin tags, disease of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of the sebaceous glands, hypertrophic & atrophic conditions of skin, nevus;

• Treatment, services or supplies that are not administered by or under the supervision of a physician & products that can be purchased without a doctor’s prescription;

• Sleep apnea or other sleep disorders.