Meridian Clear

Plan Detail

Plan Administrator: Azimuth Risk Solutions | AM Best Rating: A "Excellent" | Underwriter: Lloyd's of London

Exclusions


EXCLUSIONS— All charges, costs, expenses and/or (collectively, "Charges") incurred by the Participating Member and directly or relating to or arising from or in connection with any of the following acts, omissions, events, conditions, charges, consequences, claims, treatment (which would include diagnoses, consultations, tests, examinations and evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Scheme Administrator shall provide no Benefits and shall have no liability therefor:

30.1 War, Military Action or Act of Terrorism — The Scheme Administrator 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 of the following acts or events (collectively, "Occurrences"):

30.1.1 War, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not) or civil war; and/or

 30.1.2 Mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power; and/or

30.1.3 Any act of any person acting on behalf of or in connection with any organization with activities directed toward the overthrow by force of the government de jure or de facto or to the influencing of it by violence of any type; martial law or state of siege, or any events or causes that determine the proclamation or maintenance of martial law or state of siege; and/or

30.1.4 Act of Terrorism; and

30.2 Pre-Existing Condition — Any Illness, Injury, Mental or Nervous Disorder, sickness, disease, physical, or any other condition or ailment for which medical advice , diagnosis, care, or treatment (which would include but not limited to receiving services and supplies, consultations, diagnostic tests, or prescription medications) was recommended or received during the 730 days immediately preceding the Effective Date of Coverage ; any condition that manifested itself (whether known or unknown) in such a manner that would cause a reasonably prudent person to seek medical attention, treatment, advice, diagnosis, or care that with reasonable medical certainty; and

30.3 Wellness/Routine — Charges for Routine Physical Exams are excluded from coverage under this insurance until the Participating Member has maintained coverage under this insurance plan continuously for at least ninety (90) days, and except as otherwise expressly provided in the Master Policy and/or any Evidence of Insurance issued by the Master Policy. In no event will the Scheme Administrator reimburse the Participating Member for more than one Routine Physical Exam during any three hundred sixty four (364) day Coverage Period; and

30.4 Charges Incurred for Surgery, Treatment or Supplies —

30.4.1 Investigational, Experimental, or for Medical Research purposes; and/or

30.4.2 Charges for any Participating Member under the age of fourteen (14) days; and/or

30.4.3 Any treatment for or related to any congenital condition; and/or

30.4.4 Any charges that are not incurred by a Participating Member during his/her Coverage Period; and/or

30.4.5 Charges that are not submitted within the timely filing limits; and/or

 30.4.6 Treatment, services or supplies that are not Medically Necessary; and/or

30.4.7 Related to genetic medicine or genetic testing, which would include, without limitation, amniocentesis, genetic screening, risk assessment, prevention and/or to determine predisposition, genetic counseling, and/or gene therapy; and/or

30.4.8 Psychometric, behavioral and Educational testing; and/or

30.4.9 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 Effective Date of Coverage: 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 stones or 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/or

30.4.10 When Treatment is not administered or ordered by a Physician; and/or

30.4.11 Charges in excess of Usual, Reasonable, and Customary; and/or

30.4.12 Treatment performed or provided by a Relative of the Participating Member; and/or

30.4.13 Not expressly included as Eligible Medical Expenses as defined in Section 29 above; and

 30.4.14 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/or

30.4.15 Charges incurred for telephone consultations or due to a failure to keep a scheduled appointment; and/or

30.5 Charges Incurred While Confined Primarily to Custodial Care, Educational, or Rehabilitation Care; and/or

 30.6 Charges Incurred For Any Surgery, Treatment, or Supplies Relating To, Arising From or In Connection With, for, or as a Result of:

30.6.1 Weight modification or any Inpatient, Outpatient, Surgical or other treatment of obesity (which would include, without limitation, morbid obesity), which would include, without limitation, wiring of the teeth and all forms of bariatric Surgery by whatever name called, or reversal thereof, which would include, without limitation, intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling; and/or

30.6.2 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 Participating Member (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof); and/or

30.6.3 Cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and follows a Surgery that was covered under this insurance; and/or

30.6.4 Medical expenses for Injury or Illness resulting from Amateur Athletics, Contact Sports, intercollegiate, interscholastic, intramural, and club sports or athletic activities and Professional Sports which would include practice; mountaineering at elevations of 7,000 meters or higher, avalanche training, rock climbing, and caving; aviation (except when traveling solely as a passenger in a commercial aircraft), and hot air ballooning as a pilot; base-jumping, hang-gliding, parachuting, paragliding, parasailing, kite-surfing, sky surfing, bungee jumping, absailing, and zip lining; heli-skiing, snow skiing, or snowboarding, recreational downhill and/or cross country snow skiing or snowboarding, bobsleigh, skeleton or luge, and ice climbing; sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, or accompanied by a certified instructor at depths of less than 10 meters; white water rafting, spelunking or cave diving, surfing, body boarding, waterskiing, wakeboarding, windsurfing, knee boarding, kayaking, and jet skiing; off-road motorized vehicles which would include all-terrain vehicles, snowmobiles, motorized dirt bikes, and tractors; racing by any animal, skateboarding, BMX biking, mountain biking, and speed trials and speedway; any type of boxing or martial arts, powerlifting, and wrestling; big game hunting, wild safaris, running with the bulls, and horseback riding; Aussie rules football, jousting, modern pentathlon, and quad biking outdoor endurance events; and/or

30.6.5 Any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where such activity is undertaken against the advice or direction of any local authority or any qualified instructor, or contrary to the rules, recommendations and procedures of a recognized governing body for the sport or activity; and/or

30.6.6 Any Illness or Injury sustained while participating in any activity where such activity is undertaken against medical advice; and/or

30.6.7 Any Injury sustained or Illness suffered after the consumption of intoxicating liquor or drugs. This would include Illness or Injuries sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs, other than Prescription drugs taken in accordance with Treatment prescribed and directed by a Physician. For purposes of this exclusion, "vehicle" shall include both motorized devices for which a driver or operator license is required which would include watercraft, aircraft and non-motorized bicycles

30.6.8 Any willfully self-inflicted Injury or Illness; and/or

30.6.9 Any venereal disease; and/or

30.6.10 Treatment by a chiropractor; and/or

30.6.11 Orthoptics, visual therapy or visual eye training; and

30.6.12 Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy; and/or

30.6.13 Telephone consultations or failure to keep a scheduled appointment; and/or

30.6.14 Any testing for the for: HIV, seropositivity to the AIDS virus, AIDS-related Illnesses, ARC Syndrome and AIDS; and/or

30.6.15 Any Illness or Injury resulting from or occurring during the commission of a violation of law by the Participating Member, which would include, without limitation, the engaging in an illegal occupation or act; and/or

30.6.16 Any Substance Abuse; and/or

30.6.17 Any organ or tissue or other transplant or related services, Treatment or supplies, except for Covered Transplants as defined herein and covered pursuant to the Terms of this insurance; and/or

 30.6.18 Any artificial, non-human organs, or mechanical devices designed to replace human organs temporarily or permanently; and/or

30.6.19 Any efforts to keep a donor alive for a transplant procedure, whether or not the transplant procedure is a Covered Transplant; and/or

30.6.20 Any transplant Expenses Incurred outside the Scheme Administrator's approved independent Managed Transplant System Network; and/or

30.6.21 Any Covered Transplant in excess of one (1) during any three hundred sixty four (364) day period of coverage under this insurance plan, except re-transplantation Charges if incurred during the initial Covered Transplant Hospitalization; and

30.6.22 Allergy testing; and

30.6.23 Treatment or complications resulting from the Zika Virus; and

30.7 The Feet, Which Would Include, Without Limitation:

30.7.1 Orthopedic shoes, prescribed orthopedic devices to be attached to or placed in shoes; and/or

30.7.2 Treatment of weak, strained, flat, unstable or unbalanced feet; and/or

30.7.3 Metatarsalgia, bone spurs, hammertoes or bunions; and

30.7.4 Any treatment or supplies for corns, calluses or toenails provided, however, that claims for treatment or supplies for the feet may be eligible for coverage under this insurance at the sole option of the company and subject to all other Terms of this insurance when related to:

30.7.4.1 An Injury to the foot arising from an Accident covered hereunder; or

30.7.4.2 An Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of treatment; and

30.8 Hair Loss:

30.8.1 Which would include without limitation, wigs; and/or

30.8.2 Hair transplants; and/or

30.8.3 Any drug that promises to promote hair growth, whether or not prescribed by a Physician; and

30.9 Any Sleep Disorders; and

 30.10 Any Exercise Programs — Whether or not prescribed or recommended by a Physician; and

 30.11 Nuclear or Atomic Radiation — Any exposure to any medical or non-medical radioactive material(s); and

30.12 Any Artificial or Mechanical Device — Designed to replace human organs temporarily or permanently; and

30.13 Fertility/Infertility — Charges incurred for treatment or supply that either promotes, prevents or attempts to promote or prevent conception; which would include, but not limited, to;

30.13.1 Artificial insemination; and 30.13.2 Oral contraceptives; and

30.13.3 Treatment for infertility or impotency; and

30.13.4 Vasectomy or reversal of vasectomy; and 30.13.5 Sterilization or reversal of sterilization; and

30.14 Sexual Dysfunction — 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

30.15 Dental Treatment — Charges incurred but not limited to;

30.15.1 Routine or general dental care; and

30.15.2 Charges incurred for treatment of the temporomandibular joint; and

30.16 Vision — Charges incurred but not limited to;

30.16.1 Eye Surgery, included, but not limited to, radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness or astigmatism; and

30.16.2 Charges for Treatment of cataracts or glaucoma

30.17 Hearing — Hearing aids, hearing implants and charges for any Treatment, supply, examination or fitting related to these devices; and

30.18 Accommodations — Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and

30.19 Taxes and Other Miscellaneous Fees — Any taxes, assessments, charges, fees or surcharges imposed by any governmental agency or authority:

30.19.1 Arising out of or as a result of any treatment or supplies received by the Participating Member; or

30.19.2 Based upon the Company's election hereunder, if any, to pay Benefits directly to providers; or

30.19.3 For any other reason; and

30.20 Non-Prescription and Over-The-Counter Medicine — Charges or Expenses Incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; or IV vitamin; drugs or medicines not approved by the US Food and Drug Administration or which are considered "off-label" drug use and for drugs or medicines not prescribed by a Physician, or that can otherwise be purchased over the counter; and

30.21 Disease Outbreak — Diagnosis, testing or treatment of Injury or Illness resulting from a disease outbreak in a country or location for which the United States Center for Disease Control and Prevention (CDC) has issued a Warning Level 3 if:

30.21.1 The warning has been in effect within one-hundred and eighty (180) days immediately prior to the Participating Member(s) date of arrival; and

30.21.2 Within ten (10) days following the date the warning is issued the Participating

30.22 Against Medical Advice — Any Charges and or services related to Inpatient, Outpatient or Emergency room services in which the Participating Member chooses not to comply with recommended treatment and or where the Participating Member terminates such services, or leaves the facility against medical advice (AMA); and

30.23 Rare Condition/Defect — Any claim, Charges, Illness, Injury or other consequence happening or arising during the existence of Rare Conditions/Defect (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 Scheme Administrator shall not be liable under the Evidence of Insurance , except to the extent that the Participating Member shall prove that such claim, Charges, Illness, Injury or other consequence happened independently of the existence of such Rare Conditions/Defect; and

30.24 Mental or Nervous Disorders — Charges for Inpatient Treatment of Mental or Nervous Disorders are excluded from coverage under this insurance.

30.25 Motorized Vehicle — Charges incurred for Injuries/Illness sustained while operating or riding on a two, three or four wheel cycle, bike, scooter, moped or Segway will be excluded when the following terms are not met:

30.25.1 Participating Members age sixteen (16) or older must have a valid drivers license; and

 30.25.2 Participating Member must be wearing a safety helmet; and

30.25.3 The motorized vehicle must have active auto insurance.