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Plan Detail

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

Exclusions


LIMITATIONS

Pre-existing Conditions are defined as any medical condition, sickness, injury, illness, disease, mental illness or mental nervous disorder, regardless of the cause, including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting therefrom that with reasonable medical certainty existed at the time of application or any time prior to your effective date of coverage, whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to any medical condition, sickness, injury, illness, disease, mental illness or mental nervous disorder for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment prior to the effective date of coverage.
 
All pre-existing conditions will be considered, provided you have not:

This means that when you submit a claim, we will look back 24 months from the date of service. If you were not symptomatic, treated, medicated or diagnosed for the condition for which you received treatment in the last 24 months, the claim is payable. If you were treated, medicated or diagnosed for the condition within the last 24 months, the claim expense would be considered pre-existing and would not be covered.

EXCLUSIONS
 
The following conditions, treatments, supplies, services, and/or expenses are not covered.
  • Treatment of the following which manifest themselves or are recommended, or in which symptoms occur during the first 180 days of coverage: any breast condition, any prostate condition, reproductive system disorders, gall stones, kidney stones, any acne diagnosis or acne-related condition, any surgery that is not emergency in nature.
  • Pre-existing conditions as defined in this brochure.
  • Expenses for pregnancy within the first 364 days of coverage.
  • Claims not presented to us within 90 days of treatment.
  • Treatment that is not medically necessary; exceeds reasonable & customary charges; treatment provided at no cost to you or performed by a relative or anyone who lives with you; experimental treatment; non-medical expenses; phone consultations.
  • Suicide or any attempted suicide; self-inflicted injury or illness.
  • War or warlike operations.
  • Injury in organized, professional, amateur, or interscholastic athletics.
  • Routine physicals or procedures, unless listed in the schedule of benefits as covered.
  • Temporomandibular joint.
  • Vocational, speech, recreational or music therapy.
  • Cosmetic surgery except as a result of a covered accident.
  • Dental or eye treatment unless otherwise covered.
  • Injuries/illnesses due to alcohol, chemical, or drug use.
  • Custodial, rehabilitative, or nursing home care.
  • Congenital conditions.
  • Expenses in connection with the commission or attempt of a criminal offense.
  • Injury while taking part in mountaineering, hang gliding, parachuting, bungee jumping, racing by horse, motor or motorcycle, SCUBA diving (unless PADI, NAUI, YMCA, SSI or PDIC certified).
  • Venereal or sexually transmitted disease; HIV; AIDS.
  • Treatment, medication, or procedures to promote or prevent conception or prevent childbirth.
  • Chronic Fatigue Syndrome; occupational diseases; weight control.
  • Pregnancy expenses incurred by a dependent child.
Above is a review of the exclusions in the certificate. This brochure is intended as a brief summary of benefits and services and is not your policy. A complete description of the provisions, benefits, and exclusions are contained in the certificate of coverage, which is provided to you after your coverage has been issued. You may view a sample certificate of coverage online or request one from your agent or our customer service team at 1-800-335-0611. If there is any difference between this brochure and your certificate of coverage, the provisions of the certificate will prevail.