Patriot America

Plan Detail

Plan Administrator: International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius International

Exclusions


EXCLUSIONS

Except as expressly provided for in the BENEFIT SUMMARY, all Charges, costs, expenses and/or claims incurred by the Insured Person, and any claim for death or dismemberment benefits, 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, death and dismemberment, 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 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

(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 in excess of the amount shown in the BENEFIT SUMMARY 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

(b) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning or Emergency Travel Advisory 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

(c) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning or Emergency Travel Advisory 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: Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance.

4) 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.

5) MENTAL OR NERVOUS DISORDERS: Charges for Treatment of Mental or Nervous Disorders are excluded from coverage under this insurance.

6) PREVENTATIVE CARE: Charges for Routine Physical Examinations and immunizations are excluded from coverage under this insurance.

7) Charges for any Treatment or supplies that are:

(a) not incurred, obtained or received by an Insured Person during the Period of Coverage

(b) not presented to the Company for payment by way of a completed Proof of Claim within one hundred eighty (180) days from the date such Charges are incurred

(c) not administered or ordered by a Physician

(d) not Medically Necessary for the diagnosis, care or Treatment of the physical condition involved. This also applies when and if they are prescribed, recommended or approved by the attending Physician

(e) provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable

(f) in excess of Usual, Reasonable and Customary

(g) related to Hospice Care

(h) incurred by an Insured Person who was HIV + on or before the Initial Effective Date of this insurance, 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. This exclusion includes Charges for any Treatment or supplies 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

(i) provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician

(j) performed or provided by a Relative of the Insured Person

(k) not expressly included in the ELIGIBLE MEDICAL EXPENSES provision

(l) provided by a person who resides or has resided with the Insured Person or in the Insured Person's home

(m) 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

(n) for Congenital Disorders and conditions arising out of or resulting therefrom

 (8) Charges incurred for failure to keep a scheduled appointment

 (9) Charges incurred for Surgeries, Treatment or supplies which are Investigational, Experimental and for research purposes

 (10) Charges incurred 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

(11) Charges incurred for testing that attempts to measure aspects of an Insured Person’s mental ability, intelligence, aptitude, personality and stress management. Such testing may include but is not limited to psychometric, behavioral and educational testing

(12) Charges incurred for Custodial Care

(13) Charges incurred for Educational or Rehabilitative Care that specifically relates to training or retraining an Insured Person to function in a normal or near-normal manner. Such care may include but is not limited to job or vocational training, counseling, occupational therapy and speech therapy

(14) Charges for 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

(15) Charges for 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)

(16) Charges or Treatment for 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

(17) elective Surgery or Treatment of any kind

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

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

(20) any Illness or Injury sustained while taking part in, practicing or training for: Amateur Athletics; Professional Athletics; or athletic activities that are sponsored by any Governing Body or Authority, including the National Collegiate Athletic Association, any other collegiate sanctioning or Governing Body or the International Olympic Committee

(21) any Illness or Injury sustained while taking part in activities designated as Adventure Sports, which are limited to the following: abseiling; BMX; bobsledding; bungee jumping; canyoning; caving; hot air ballooning; jungle zip lining; parachuting; paragliding; parascending; rappelling; skydiving; spelunking; wildlife safaris; and windsurfing

(22) any Illness or Injury sustained while taking part in activities designated as Extreme Sports, which include but are in no way limited to the following (and include any combination or derivative of the following): BASE jumping; cave diving; cliff diving; downhill mountain biking and racing; extreme skiing; freediving; free flying; free running; free skiing; freestyle scootering; gliding; heli-skiing; ice canoeing; ice climbing; kitesurfing; mixed martial arts; motocross; motorcycle racing; motor rally; mountaineering above elevation of 4500 meters from ground level; parkour; piloting a commercial or non-commercial aircraft; powerbocking; scuba diving or sub aqua pursuits below a depth of 50 meters; snowmobile racing; truck racing; whitewater kayaking or whitewater rafting Class VI and higher difficulty; and wingsuit flying

(23) any Illness or Injury sustained while taking part in snow skiing, snowboarding or snowmobiling where the Insured Person is in violation of applicable laws, rules or regulations of a ski resort, out of bounds or in unmarked or unpatrolled areas

(24) any Illness or Injury sustained while taking part in backcountry skiing

(25) any Illness or Injury sustained while taking part in skiing off-piste

(26) any Illness or Injury sustained while taking part in Collision Sports

(27) any artificial or mechanical devices designed to replace human organs temporarily or permanently after termination of Inpatient status

(28) any Illness or Injury sustained while taking part in athletic or recreational activities where the Insured Person is not physically or medically fit or does not hold the necessary qualifications to engage in said activities

(29) 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

(30) 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

(31) 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

(32) any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs in excess of the applicable blood/alcohol legal limit, 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

(33) any willfully Self-inflicted Injury or Illness

(34) any sexually transmitted or venereal disease

(35) any testing for the following when not Medically Necessary: HIV, seropositivity to the AIDS virus, AIDS-related Illnesses, ARC Syndrome, AIDS

(36) 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

(37) any Substance Abuse

(38) biofeedback, acupuncture, music, occupational, recreational, sleep, speech, or vocational therapy

(39) orthoptics, visual therapy or visual eye training

(40) 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

(41) hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician

(42) any sleep disorder, including without limitation sleep apnea

(43) any exercise and/or fitness program or equipment, whether or not prescribed or recommended by a Physician

(44) any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s)

(45) any organ or tissue or other transplant or related services, Treatment or supplies

(46) any efforts to keep a donor alive for a transplant procedure

(47) Charges incurred for eyeglasses, contact lenses, hearing aids or hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason, except as otherwise expressly provided for hereunder

(48) 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

(49) Charges incurred for Treatment or supplies for temporomandibular joint (TMJ) including but not limited to TMJ syndrome, craniomandibular syndrome, chronic TMJ pain, orthognathic Surgery, Le-Fort Surgery or splints

(50) Charges incurred in the Insured Person’s Country of Residence, except as otherwise expressly provided for in this insurance

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

(52) any infection of the urinary tract (including, without limitation, infection of the kidney, ureter, bladder, prostate or urethra) and any complication, medical condition or other Illness directly or indirectly arising therefrom, that occurs within ninety (90) days of the Effective Date of this Insurance and that requires Treatment of the Insured Person in a Hospital as an Inpatient

(53) Charges and all costs related to or arising from or in connection with all trips to the Destination Country undertaken for the purpose of securing medical Treatment or supplies

(54) Charges incurred for Dental Treatment, except as specifically provided for hereunder

(55) Wear and tear of teeth due to cavities and chewing or biting down on hard objects, such as but not limited to pencils, ice cubes, nuts, popcorn, and hard candies

(56) Dental Injury without associated face, skull, neck and/or jaws Injury or that can be evaluated and Treated in a dental office

(57) Dental Treatment for services which provide oral care maintenance including tooth repair by fillings, root canals, tooth removal and x-rays

(58) Charges for Treatment of an Illness or Injury for which payment is made or available through a workers' compensation law or a similar law

(59) Charges incurred for massage therapy

(60) Charges incurred for Personal Liability legal fees or out-of-pocket costs associated and/or related to the determination and/or settlement of a legal liability

(61) Accidental Death or Dismemberment when the Insured Person’s death or dismemberment is caused directly or indirectly by, results from, or where there is a contribution from, any of the following:

(a) bodily or mental infirmity, Illness or disease

(b) infection, other than infection occurring simultaneously with, and as a direct result of, the accidental Injury.

Economic Sanctions: The Company will not cover any person as an Insured Person if such cover would result in the Company being exposed to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws, or regulations of the European Union, United Kingdom or the United States of America.

Any Illness or Injury incurred in the Destination Country, Affected Area or Country of Residence as a result of a Public Health Emergency of International Concern,  Epidemic, Pandemic other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, unless coverage is expressly provided under the PUBLIC HEALTH EMERGENCY provision of this insurance.

Any Treatment for an Illness or Injury requiring an unapproved U.S. Food and Drug Administration (FDA) medical product, services, Surgery, Surgical Procedure, prescription medication, drug, biological product, Durable Medical Equipment (DME) or device when an Emergency Use Authorization(EUA) is in place issued by the U.S. Food and Drug Administration (FDA)

Charges incurred at a Hospital or Facility when the Insured Person checks himself or herself out Against Medical Advice of their Physician and leaves before reaching a Medically Necessary specified end point of Treatment.

Charges Incurred for the worsening of an Illness or Injury after the Insured Person left a Hospital or Facility Against Medical Advice or was a Discharge Against Medical Advice.