Liaison Majestic - Including USA

Plan Detail

Plan Administrator: Seven Corners | AM Best Rating: A "Excellent"  | Underwriter: Lloyd's of London.

Exclusions


Description of Exclusions

For Medical benefits, this Insurance does not cover:

  • Pre-existing Conditions which are excluded under this Certificate. This means that any claims for Pre-existing Conditions will not be covered for the duration of this Certificate.
    a. If you are a United States Resident and the United States is your Home Country, this exclusion is waived for Eligible Benefits incurred outside the United States as defined below:
    1. For persons less than age 65 with a Primary Health Plan as defined in the Certificate, Pre-existing Conditions are waived up to the medical maximum selected.
    2. For persons less than age 65 without a Primary Health Plan as defined in the Certificate, Pre-existing Conditions are waived up to the first $20,000.
    3. For persons age 65 and over, Pre-existing Conditions are waived up to the first $2,500 regardless of whether there is a Primary Health Plan. This waiver does not include coverage for known, scheduled, required, required or expected medical care, drugs, or Treatments existent or necessary prior to the effective date of this program.
    b. If you are a non-United States Resident and suffer a Myocardial Infarction or Stroke and are admitted to a Hospital, this exclusion is waived only in order to pay a $200 per night benefit for each night spent in the Hospital, up to the maximum stated in the SCHEDULE OF BENEFITS. The term “Myocardial Infarction” shall require an acute and emergent onset of the condition. The term “Stroke” shall require an acute and emergent onset of the condition.
  • Charges for Treatment(s) of the following Illness(es) or Surgery(ies), which Manifest(ed) themselves or are recommended, or symptoms occur during the first one hundred and eighty (180) days of Coverage hereunder beginning on the initial Effective Date: any condition of the breast; any Treatment of all forms of cancer/neoplasm; any condition of the prostate; disorders of the reproductive system; hysterectomy; gall stones or urologic stones (kidney, ureteral, bladder or urethral stones) and any associated complications; any acne diagnosis or acne related condition; asthma; allergies; tonsillectomy; back conditions; adenoidectomy; hemorrhoids; hemorrhoidectomy; hernia, or any Surgery(ies) that is(are) not Emergency in nature, as Emergency is defined hereunder. (Does not apply to United States Residents traveling outside of the United States)
  • Claims not received by Seven Corners within ninety (90) days of the date of service;
  • Charges for Treatment which exceed Usual, Reasonable and Customary charges; or Charges incurred for Surgeries or Treatments which are Investigational, Experimental, or for research purposes; expenses which are nonmedical in nature;
  • Expenses for vocational, speech, recreational or music therapy;
  • Durable medical equipment;
  • Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
  • Suicide or any attempt thereof; self-destruction or any attempt thereof; intentionally selfinflicted Injury or Illness;
  • Expenses as a result of or in connection with the commission of a felony or any other criminal or illegal activity as defined by the local governing body;
  • War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the Insured Person or the country in, or over, which the act occurs, Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the Insured Person whether war be declared with that state or not. For the purpose of this Exclusion; ii) Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals (including in connection with Terrorist Activity). iii) Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals (including in connection with Terrorist Activity). iv) Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals (including in connection with Terrorist Activity). Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;
  • Terrorist Activity. For the purpose of this Exclusion, Terrorist Activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist Activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of Terrorist Activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s).The Company shall not be liable for and will not provide coverage or benefits in excess of the maximum stated in the SCHEDULE OF 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; and provided, 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 direct or indirect involvement in the Terrorist Activity.
    b. The Terrorist Activity takes place in a country or location where the United States government has issued a travel warning that has been in effect within the six (6) months prior to the Insured Person’s date of arrival.
    c. The Insured Person unreasonably fails or refuses to depart a country or location following the date a warning to leave that country or location is issued by the United States government.
  • 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.
  • Occupational Diseases, including but not limited to disease(s) related to asbestos exposure, and the complications thereof, including asbestosis and mesothelioma related to asbestos exposure;
  • Routine physicals, innoculations, 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;
  • Diagnosis or Treatment of the temporomandibular joint;
  • Chiropractic care or acupunture;
  • Services, supplies, or Treatment prescribed, performed or provided by a Relative of the Insured Person or any family member of the Insured Person or anyone who lives with the Insured Person. This includes but is not limited to prescription medication and any diagnostic testing;
  • Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids, cosmetic or plastic Surgery (including deviated nasal septum), routine dental expenses, 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;
  • Treatment in connection with alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency or use of any drug or narcotic agent; Injury sustained while under the influence of or Disablement due wholly or partly to the effects of intoxicating liquor, chemicals, or drugs or narcotic agent,unless administered under the advice of a Physician and said narcotic agent was taken in accordance with the proper dosing as directed by the physician;
  • Any Mental and Nervous disorders or Rest Cures;
  • Congenital abnormalities and conditions arising out of or resulting therefrom;
  • Learning disabilities, attitudinal disorders, or disciplinary problems;
  • Expenses incurred during a hospital emergency room visit which is not a Medical Emergency;
  • Injury sustained while taking part in Mountaineering, hang gliding, paragliding, Parachuting, paragliding, zip lining, parasailing, bungee jumping, racing by any animal or motor vehicle or motorcycle, snowmobiling, motorcycle/motor scooter riding (whether as a passenger or driver), scuba diving involving underwater breathing apparatus (unless SSI, PADI or NAUI certified), water skiing, wakeboard riding, jet skiing, windsurfing, snow skiing and snowboarding (except for recreational downhill and/or cross country snow skiing or snowboarding. No cover provided while skiing/boarding in any violation of applicable laws, rules or regulations, away from prepared and market in-bound territories; and/or against the advice of the local ski school or local authoritative body); and any sport or athletic activity which is undertaken for thrill seeking and exposes the Plan Participant to abnormal or extreme risk of injury; Hazardous Sports Coverage: the following are covered if the required premium has been paid: motorcycle/motor scooter riding (whether as a passenger or a driver), hang gliding, Parachuting, zip lining, parasailing, bungee jumping, water skiing, wakeboard riding, jet skiing, windsurfing, snowmobiling, and spelunking.
  • Treatment paid for or furnished under any other individual, government, or group policy or charges provided at no cost to the Insured Person;
  • Diagnosis and or Treatment of venereal or sexually transmitted disease, including all sexually transmitted diseases and conditions and any and all consequences thereof;
  • Pregnancy expenses or Illness resulting from Pregnancy, childbirth, or miscarriage; or for miscarriage resulting from an Accident or complications of Pregnancy; or for postnatal care;
  • 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;
  • Expenses incurred while the Insured Person is in their Home Country (except after approved Emergency Medical Evacuation / Repatriation or if treatment is a follow-up to a covered disablement during coverage (see Home Country Coverage Benefit) or if the expenses pertain to the Home Country Coverage Benefit);
  • Expenses incurred for which travel was undertaken to seek Medical Treatment for a condition; or incurred after the Insured Person’s physician has limited or restricted travel;
  • 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;
  • Treatment for human organ or tissue transplants and their related Treatment;
  • Weight reduction programs or the surgical Treatment of obesity, including but not limited to wiring of the teeth and all forms of intestinal bypass Surgery;
  • Modifications of the physical body intended to improve the psychological, mental or emotional well-being of the Insured, 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, whether or not prescribed or recommended by a Physician;
  • Treatment required as a result of complications or consequences of a Treatment or condition not covered hereunder;
  • Charges for travel accommodations, except as provided for in the Local Ambulance, Emergency Medical or Political Evacuation, Return of Mortal Remains, Return of Minor Child(ren), Emergency Medical 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 and/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 and atrophic conditions of skin, nevus;
  • 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;
  • Treatment of sleep apnea or other sleep disorders.