$5,000 per person
Provides reimbursement for non-refundable trip payments and deposits if a trip is interrupted for illness, death or other unforeseen circumstances.
32.19 Trip Interruption — Subject to the Limits set forth in the Schedule of Benefits and Limits, and subject to the Conditions and Restrictions contained in this provision, the Scheme Administrator will pay the following Trip Interruption benefits:
32.19.1 The cost of an economy one-way air or ground transportation ticket for the Participating Member to the terminal serving the area of the Participating Member’s Principal Residence, subject to the following Conditions and Restrictions:
188.8.131.52 The Participating Member must be in compliance with all conditions and provisions of this insurance; and
184.108.40.206 Trip Interruption benefits must be approved in advance and coordinated by the Scheme Administrator; and
220.127.116.11 The Scheme Administrator will provide Trip Interruption benefits only following receipt of proof of one or more of the following events: Destruction, after departure from the Home Country, resulting from fire or weather of more than forty (40) percent of the Participating Member’s Principal Residence, or death of a parent, Spouse, sibling or Dependent Child; and
18.104.22.168 The cost of an economy one-way air and/or ground transportation ticket for the Participating Member from the area where the Participating Member was hospitalized following an Emergency Medical Evacuation to the area where the Participating Member was initially evacuated from or to the terminal serving the area of the Participating Member’s Principal residence; and
22.214.171.124 The Scheme Administrator will provide Trip Interruption benefits only following a covered Emergency Medical Evacuation when the attending Physician states that it is Medically Necessary for the Participating Member to return to his or her Home Country or to the area from which he or she was initially evacuated for continued treatment, recuperation and recovery.
POLICY DEFINITIONS — Certain words and phrases used in the Master Policy and the Evidence(s) of Insurance issued by the Master Policy are defined below. Other words and phrases may be defined elsewhere in the Master Policy or Evidence(s) of Insurance issued by the Master Policy, which would include where they are first used.
Accident: A sudden, unintentional and Unexpected occurrence caused by external, visible means and resulting in physical Injury to the Participating Member.
AIDS: Acquired Immune Deficiency Syndrome, as the term is defined by the United States Centers for Disease Control and Prevention.
Amateur Athletics: An amateur or other non-professional sporting, recreational or athletic activity that is organized, sponsored and/or sanctioned, and/or involves regular or scheduled practices, games and/or competitions. This definition does not include athletic activities that are non-contact and engaged in by the Participating Member solely for recreational, entertainment or fitness purposes.
Application: The fully answered and signed individual or Family Application/Enrollment form submitted by or on behalf of the Participating Member for acceptance into, Extension of coverage under or reinstatement in this insurance plan, which, by this reference, shall be incorporated in and become a part of the Master Policy and/or Evidence of Insurance. Any insurance agent/broker assigned to or assisting with the Application is the representative of the applicant/Participating Member and is not an agent or representative for or on behalf of the Scheme Administrator, Underwriters, and/or the Master Policyholder.
ARC Syndrome: AIDS related complex, as that term defined by the United States Centers for Disease Control and Prevention.
Beneficiary: The person(s), executers, or administrators entitled to receive payment of Benefits.
Canada: A federated country in North America made up of ten (10) provinces and three (3) territories.
Coinsurance: The payment by or obligations of the Participating Member for payment of Eligible Medical Expenses at the percentage specified in the Schedule of Benefits/Limits contained herein and exclusive of the Deductible.
Coverage Period: The period beginning on the Effective Date of Coverage of the Evidence of Insurance and ending on the earliest of the following dates: (i) the termination date specified in the Declaration, or (ii) the termination date as determined in accordance with Section 15 above. The Coverage Period of Insurance can be no less than five (5) days and no more than three-hundred-sixty-four (364) days.
Covered Transplant: A transplant involving the heart, heart/lung, lung, kidney, kidney/pancreas, liver, and allogenic or autologous bone marrow.
Custodial Care: Those types of care or services, wherever furnished and by whatever name called, that are designed primarily to assist an individual.
Death: Complete and irreversible cessation of life.
Deductible: The dollar amount of Eligible Medical Expenses specified on the Proof of Insurance, that the Participating Member must pay per Period of Insurance prior to receiving Benefits under this insurance, and exclusive of Coinsurance.
Dental Treatment: Treatment or supplies relating to the care, maintenance, or repair of teeth, gums, or bones supporting the teeth, which would include dentures and preparation for dentures.
Dependent Child; Children: A Participating Member who is less than eighteen (18) years of age at the time of Application and shares the Participating Members r home for at least half the year (if divorced, the Dependent Child may live with former spouse); and must not provide more than one-half of his/her own support (scholarships excluded); or must be less than twenty-four (24) years of age at the time of Application, and a full-time student and claim the Participating Members r residence as his/her official residence while away at school; and must not provide more than one-half of his/her own support (scholarships excluded); and must be the Participating Members r biological, step or legally adopted.
Disabled: A person who has a congenital or acquired mental or physical defect that interferes with normal functioning of the body, system or the ability to be self-sufficient. Durable Medical Equipment (DME): Durable Medical Equipment consists of a standard basic Hospital bed and/or a standard basic wheelchair.
Educational Care: Care for restoration (by education or training) of a person’s ability to function in a normal or near-normal manner following an Illness or Injury. This type of care includes, but is not limited to, vocational or occupational therapy, and speech therapy.
Effective Date or Effective Date of Coverage: The date coverage for the Participating Member begins under the Terms of the Master Policy and the Evidence of Insurance, as indicated on the Proof of Insurance Letter.
Eligible Medical Expenses: Expenses for Injuries, Illnesses and cost incurred by a Participating Member in which all Terms, Conditions and Limits of the Evidence of Insurance have been met in full. Eligible Medical Expenses will not be determined until the Scheme Administrator has received and reviewed the Complete Proof of Claim. Eligible Medical Expenses are subject the Limits, Deductibles and Coinsurance set forth on the Participating Members Declaration, Schedule of Benefits and Evidence of Insurance.
Emergency: A medical condition manifesting itself by acute signs or symptoms that could reasonably result in placing the Participating Member’s life or limb in danger if medical attention is not provided within twenty-four (24-) hours.
EST: US Eastern Standard Time.
Evidence of Insurance: The document issued by the Master Policyholder to the Participating Member, which describes and provides an outline and evidence of eligible coverages and Benefits payable to or for the benefit of the Participating Member under the Master Policy, and which includes the Participating Member’s Application and any Riders attached thereto. Expenses Incurred: Expenses rendered by a Participating Member that have or may not yet have been paid by the responsible parties.
Experimental: Any Treatment that includes completely new, untested drugs, procedures or services, or the use of which is for a purpose other than the use for which they have previously been approved; new drug procedure or service combinations; and alternative therapies that are not generally accepted standards of current medical practice.
Extended Care Facility: An institution, or a distinct part of an institution, that is licensed as a Hospital, Extended Care Facility or rehabilitation facility by the state or country in which it operates; is regularly engaged in providing twenty-four (24-) hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; maintains a daily record on each patient; provides each patient with a planned program of observation prescribed by a Physician; provides each patient with active Treatment of an Illness or Injury. Extended Care Facility does not include a facility primarily for rest, the aged, Substance Abuse, Custodial Care, nursing care, or for care of Mental or Nervous Disorders or the mentally incompetent.
Family: A Participating Member and his/her Spouse (see definition of Spouse) who is covered as a Participating Member under this insurance plan and his/her Dependent Child(ren) (see definition of Dependent Child; Children) who are under the age of eighteen (18) and covered as Participating Members under this insurance plan.
HIV Positive: Laboratory evidence defined by the United States Centers for Disease Control and Prevention as being positive for Human Immunodeficiency Virus infection.
Home Country: The country of which the Participating Member is a citizen, national or maintains his/her residence or usual place of abode; or the country of which the Participating Member is the possessor of a validly issued passport. US citizens always have the US as their Home Country regardless of where they are.
Home Health Care Agency: A public or private agency or one of its subdivisions, which operates pursuant to law; and is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation and Treatment prescribed by a Physician.
Home Nursing Care: Services, provided by a Home Health Care Agency and supervised by a Registered Nurse, that are directed toward the personal care of a patient, provided always that such care is in lieu of Medically Necessary Inpatient care.
Hospice: An institution that operates as a Hospice; is licensed by the state or country in which it operates; and operates primarily for the reception, care and palliative control of pain for terminally ill persons who have, as certified by a Physician, a life expectancy of not more than one-hundred-eighty (180) days.
Hospital: An institution that operates as a Hospital pursuant to law; is licensed by the state or country in which it operates; operates primarily for the reception, care, and Treatment of sick or injured persons as Inpatients; provides twenty-four(24)hour nursing service by Registered Nurses on duty or call; has a staff of one or more Physicians available at all times; provides organized facilities and equipment for diagnosis and Treatment of acute medical, surgical or mental/nervous conditions on its premises; and is not primarily a long-term care facility, Extended Care Facility, Nursing, rest, Custodial Care, or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment. Hospitalization or Hospitalized: Confined and/or treated in a Hospital as an Inpatient.
Illness: A sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. Illness does not include learning disabilities, or attitudinal or disciplinary problems.
Initial Effective Date: The date the Participating Member first obtains coverage under the Beacon/Axis Series Family of Insurance plans and maintains continuous unbroken coverage thereafter.
Injury: Bodily Injury resulting from an Accident.
Inpatient: A person who is an overnight resident patient of a Hospital, using and being charged for room and board.
Intensive Care Unit: A Cardiac Care Unit or other unit or area of a Hospital that meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations for Special Care Units.
Investigational: Treatment that includes drugs, procedures or services that are still in the clinical stages of evaluation and not yet released for distribution by the US Food and Drug Administration.
Loss of Limb: Definite diagnosis of the complete severance of one or more limbs at or above the wrist or ankle joint as the result of an accident.
Loss of Sight: Loss means entire and irrecoverable loss of sight in one or both eyes as the result of an accident.
Master Policyholder: The Beacon/Axis Series Group Insurance Trust (Anguilla).
Maximum Limit: The cumulative total dollar amount of benefit payments and/or reimbursements available to a Participating Member under this insurance during the Participating Member’s period of coverage. When the Maximum Limit is reached, no further Benefits, reimbursements or payments will be available under this insurance.
Medically Necessary; Medical Necessity: A Treatment or supply that is necessary and appropriate for the diagnosis or Treatment of an Illness or Injury based on generally accepted standards of current medical practice as determined by the Scheme Administrator. By way of example but not limitation, a Treatment or supply will not be considered Medically Necessary or a Medical Necessity if it is provided or obtained only as a convenience to the Participating Member or his/her provider; and/or if it is not necessary or appropriate for the Participating Member’s Treatment, diagnosis or symptoms; and/or if it exceeds (in scope, duration or intensity) that level of care that is needed to provide safe, adequate, and appropriate diagnosis or Treatment.
Medical Research: Research conducted to aid and supports the body of knowledge in the field of medicine. Medical research can be divided into two general categories: the evaluation of new treatments for both safety and efficacy in what are termed clinical trials, and all other research that contributes to the development of new treatments. The latter is termed preclinical research if its goal is specifically to elaborate knowledge for the development of new therapeutic strategies.
Mental or Nervous Disorders: A mental, nervous or emotional Illness that generally denotes an Illness of the brain with predominant behavioral symptoms; or an Illness of the mind or personality, evidenced by abnormal behavior; or an Illness or disorder of conduct evidenced by socially deviant behavior. Mental or Nervous Disorders include, without limitation, psychosis; depression; schizophrenia; bipolar affective disorder; and those psychiatric Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association. Mental or Nervous Disorder does not include learning disabilities, or attitudinal or disciplinary problems. For purposes of this insurance, Mental or Nervous Disorder does not include Substance Abuse.
Mortal Remains: The bodily remains or ashes of a Participating Member.
Newborn: An infant from the moment of birth through the first thirty-one (31) days.
Outpatient: A person who receives Medically Necessary Treatment by a Physician or other healthcare provider that does not require an overnight stay in a Hospital.
Participating Member: The person(s) named as the Participating Member(s) on the Proof of Insurance.
Participating Organization: A business, society or association that has purchased medical coverage for a group of individuals.
Period of Insurance: The period beginning on the Effective Date of Coverage of the Evidence of Insurance and ending on the earliest of the following dates: (i) the termination date specified in the Declaration, or (ii) the termination date as determined in accordance with Section 15 above. The Period of Insurance can be no more than three-hundred-sixty-four (364) days.
Physician: A duly licensed practitioner of the medical arts. A Physician must be currently licensed by the state or country in which the services are provided, and the services must be within the scope of that license.
Pre-Certification; Pre-Certify: A general determination of Medical Necessity, made in reliance and based upon the completeness and accuracy of the information provided at the time thereof. Pre-Certification is not an assurance, authorization, verification of coverage, verification of Benefits or guarantee of payment. See Section 24 above, for further details.
Pre-existing Condition: Any Illness, Injury or Mental or Nervous Disorder that, with reasonable medical certainty, existed on or at any time prior to the Initial Effective Date of this insurance, whether or not previously manifested or symptomatic, diagnosed, treated or disclosed on the Application or on any Claim Form or otherwise, which would include any chronic, subsequent or recurring complications, or consequences associated therewith or arising or resulting therefrom.
Premium: The Premium payments required to effectuate and maintain the Participating Member’s insurance coverage and Benefits under this insurance, in the amounts and at the times established by the Scheme Administrator in its sole discretion from time to time.
Pregnancy; Pregnant: The process of growth and development within a woman’s reproductive organs of a new individual from the time of conception through the phases where the embryo grows and the fetus develops to birth.
Principal Sum: The benefit based upon the attained age of the Participating Member and is a Sub-Limit (see Sub-Limit definition) of the policy maximum.
Professional Athletics: A sport activity, which would include practice, preparation and actual sporting events, for any individual or organized team that is a member of a recognized professional sports organization, is directly supported or sponsored by a professional team or professional sports organization, is a member of a playing league that is directly supported or sponsored by a professional team or professional sports organization; or has any athlete receiving for his or her participation, any kind of payment or compensation, directly or indirectly, from a professional team or professional sports organization.
Proof of Insurance: The Proof of Insurance issued by the Scheme Administrator to the Participating Member contemporaneously with the Evidence of Insurance (and/or upon extension hereof) evidencing the Participating Member’s insurance coverage under the Master Policy as evidenced by the Evidence of Insurance, which Proof of Insurance shall be incorporated in and become a part of the Master Policy. The Proof of Insurance serves as a descriptive document highlighting the coverage limits, Deductible(s), coverage dates, optional Riders, and the name of Participating Member for all Evidence of Insurance issued by the Scheme Administrator on behalf of the Master Policyholder and Underwriters.
Rare Conditions/Defect: Conditions/defects which affect a small number of people compared to the general population and, because they are rare, can present challenges with regards to diagnosis, Treatment, and prevention. A condition/defect is considered to be rare when it affects 1 person in 2,000 or fewer.
Registered Nurse: A graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters “R.N.” after his or her name.
Rehabilitative Care: Care for restoration (by education or training) of a person’s ability to function in a normal or near normal manner following an Illness or Injury. This type of care includes, but is not limited to, vocational or occupational therapy, and speech therapy.
Relative: A parent, guardian, spouse, son, daughter or immediate Family member of the Participating Member.
Rider: Any exhibit, schedule, attachment, amendment, endorsement or other document attached to, issued in connection with, or otherwise expressly made a part of or applicable to, the Master Policy, the Evidence of Insurance, or the Application, as the case may be.
Routine Physical Exam: Examination of the physical body by a Physician for preventative or informative purposes only, and not for the Treatment of any Illness or Injury.
Scheme Administrator: The Scheme Administrator, as referred to herein; Azimuth Risk Solutions, acts solely as the disclosed and authorized agent and representative for and on behalf of the Master Policyholder and Underwriters, and has and shall have no direct, indirect, joint, several, separate, individual, or independent liability or obligation of any kind under the Master Policy or the Evidence of Insurance to the Participating Member or to any other person or entity. Azimuth Risk Solutions, is located at 1 North Pennsylvania Street Suite 200 Indianapolis, Indiana 46204, USA. Telephone Number: 317-644- 6291 or 888-201-8050, Fax Number: 317-423-9620 or 888-201-8851, Website: www.azimuthrisk.com, Email: firstname.lastname@example.org.
Sports Diving: Recreational underwater diving activities requiring the use of underwater or artificial breathing apparatus, and carried out in strict accordance with the guidelines, codes of good practice and recommendations for safe diving practices as laid out by an Authoritative Diving Body.
Spouse: Wife/husband or domestic partner living at the same address and sharing financial responsibilities but not including business partners or associates.
Sub-Limits: Extra limitations in an insurance policy’s coverage of certain losses. They are part of the Maximum Limit (see Maximum Limit definition). That is, they do not provide extra coverage, but set a maximum to cover a specific loss. Sub-Limits may be expressed as a dollar amount or a percentage of the coverage available.
Substance Abuse: Alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency. Sudden Onset of a Pre-existing Condition: An Unexpected outbreak or recurrence of a Pre-existing Condition, that occurs Unexpectedly and without advance warning, either in the form of Physician recommendation or symptoms that have caused a prudent person to seek medical attention prior to the outbreak or recurrence. Treatment must be obtained within twenty-four (24) hours of the sudden and Unexpected occurrence of pain.
Surgery/Surgical Procedure: An invasive diagnostic or Treatment for Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
Terms: Terms, provisions, conditions, definitions, limits, Sub-Limits, limitations, wordings, restrictions, qualifications and/or exclusions.
Terrorism: An act, which would include, but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes, which would include the intention to influence any government and/or to put the public, or any section of the public, in fear.
Third-party Liability: Third-party liability insurance coverage is the portion of an insurance policy that covers loss to others caused by the Participating Member during the Coverage Period, whether it is personal Injury or property damage. Subject to the Terms, Conditions and Limits set for in Section 34.
Treatment: Any and all services and procedures rendered in the management and/or care of a patient for the purpose of identifying, diagnosing, treating, curing, preventing, controlling and/or combating any Illness or Injury, which would include, without limitation, verbal or written advice, consultation, examination, discussion, diagnostic testing or evaluation of any kind, pharmacotherapy or other medication, and/or Surgery.
Unexpected: Sudden, unintentional, not expected and unforeseen.
US: The United States of America and or any of its territories.
Usual, Reasonable and Customary: The most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. The Scheme Administrator reserves the right to determine, in the reasonable exercise of its discretion, whether charges are Usual, Reasonable and Customary. In determining whether a charge is Usual, Reasonable and Customary, the Scheme Administrator may consider one or more of the following factors, without limitation: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or service as compared to the length of time required to perform other similar services; the severity or nature of the Illness or Injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; and such other factors as the Scheme Administrator, in the reasonable exercise of its discretion, determines are appropriate.
31 EXCLUSIONS — All charges, costs Expenses 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:
31.1 War; Military Action — The Scheme Administrator shall not be liable for and will not provide
31.1.1 War, invasion, act of foreign enemy hostilities, warlike operations (whether war be
31.1.2 Mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution,
31.1.3 Any act of any person acting on behalf of or in connection with any organization with
31.2 Pre-Existing Conditions — Any Illness, Injury, Mental or Nervous Disorder, sickness, disease, 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”): declared or not) or civil war; or military or usurped power; or 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; or 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 the Evidence of Insurance or Effective Date of the insurance; 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, existed at the time of Application or within the 730 days immediately preceding the Effective Date of the Evidence of Insurance or Effective Date of Insurance. For the purposes of the Complications of Pregnancy coverage offered herein, Pregnancy will not be included within the definition of a Pre-existing Condition; and
31.3 Maternity — Charges related to or incurred for Pregnancy; and
31.3.1 Routine pre-natal care, child birth, and post-natal care; and
31.3.2 False labor, edema, prolonged labor, prescribed rest during the period of Pregnancy,
31.4 Charges Incurred For Surgeries, Treatment Or Supplies That Are:
31.4.1 Investigational, Experimental, or for Medical Research purposes; and
31.4.2 Charges for any Participating Member under the age of fourteen (14) days; and
31.4.3 Any treatment for or related to any congenital condition; and
31.4.4 Any charges that are not incurred by a Participating Member during his/her Coverage
31.4.5 Charges that are not submitted within the timely filing limits; and
31.4.6 Treatment, services or supplies that are not Medically Necessary related to genetic which would include Newborn Care; and Period; and medicine or genetic testing, which would include, without limitation, amniocentesis, genetic screening, risk assessment, prevention and/or to determine pre-disposition, genetic counseling, and/or gene therapy; and
31.4.7 Any immunizations/vaccinations, Routine Physical or gynecology exams; and
31.5 Charges Incurred While Confined While Confined Primarily To Custodial Care, Educational, Or Rehabilitative Care; and
31.6 Charges Incurred For Any Surgery, Treatment, Or Supplies Relating To, Arising From Or In Connection With, For, Or As A Result Of:
31.6.1 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
31.6.2 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
31.6.3 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
31.6.4 Medical Expenses Incurred 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.
31.6.5 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
31.6.6 Any Illness or Injury sustained while participating in any activity where such activity is undertaken against medical advice; and/or
31.6.7 Any Injury or Illness sustained after the consumption of intoxicating liquor or drugs. Which 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 and scooters for which no permit or license is required; and/or
31.6.8 Any willfully self-inflicted Injury or Illness; and/or
31.6.9 Any venereal disease; and/or
31.6.10 Treatment by a chiropractor; and/or
31.6.11 Treatment of a Mental Health Disorder; and/or
31.6.12 Treatment for acne, other acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, and hypertrophic and atrophic conditions of skin; and/or
31.6.13 Telephone consultations or failure to keep a scheduled appointment; and/or
31.6.14 Any testing for the for: HIV, seropositivity to the AIDS virus, AIDS-related Illnesses, ARC
31.6.15 Any Illness or Injury resulting from or occurring during the commission of a violation of Syndrome and AIDS; and/or law by the Participating Member, which would include, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations; and/or 31.6.16 Any Substance Abuse; and/or
31.6.17 Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or
31.6.18 Orthoptics, visual therapy or visual eye training; and
31.6.19 Psychometric, behavioral and Educational testing; and
31.6.20 The Zika Virus or complications there of; and music therapy; and/or
31.7 The Feet, Which Would Include, Without Limitation:
31.7.1 Orthopedic shoes, prescribed orthopedic devices to be attached to or placed in shoes; and/or
31.7.2 Treatment of weak, strained, flat, unstable or unbalanced feet; and/or
31.7.3 Metatarsalgia, bone spurs, hammertoes or bunions; and
31.7.4 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:
126.96.36.199 An Injury to the foot arising from an Accident covered hereunder; or
188.8.131.52 An Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of treatment; and
31.8 Hair Loss, Which Would Include, Without Limitation:
31.8.1 Which would include without limitation, wigs; and/or
31.8.2 Hair transplants; and/or
31.8.3 Any drug that promises to promote hair growth, whether or not prescribed by a Physician; and
31.9 Any Sleep Disorders; and
31.10 Any Exercise Programs — Whether or not prescribed or recommended by a Physician; and
31.11 Nuclear or Atomic Radiation — Any exposure to any medical or non-medical radioactive
31.12 Any Artificial or Mechanical Devices — designed to replace human organs temporarily or
31.13 Fertility/Infertility — Charges incurred for any treatment or supply that either promotes,
prevents or attempts to promote or prevent conception; which would include, but not limited,
31.13.1 Artificial insemination; and
31.13.2 Oral contraceptives; and
31.13.3 Treatment for infertility or impotency; and
31.13.4 Vasectomy or reversal of vasectomy; and
31.13.5 Sterilization or reversal of sterilization; and
31.14 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
31.15 Dental Treatment — Except for Emergency Dental Treatment necessary to repair or replace
sound natural teeth lost or damaged in an Accident covered hereunder or as necessary
treatment of sudden, Unexpected pain to sound natural teeth, and subject to the limits set forth
in the Schedule of Benefits/Limits;
31.15.1 Routine or general dental care; and
31.15.2 Charges incurred for treatment of the temporomandibular joint; and
31.16 Vision — Charges incurred but not limited to;
31.16.1 For eyeglasses or contact lenses; and/or
31.16.2 Charges for any treatment, supply, examination or fitting related to these devices; and
31.16.3 Eye refraction for any reason; and
31.16.4 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
31.16.5 Charges for Treatment of cataracts or glaucoma
31.17 Hearing — Hearing aids, hearing implants and charges for any Treatment, supply, examination or fitting related to these devices; and
31.18 Newborn Care — Charges incurred by the Participating Member for the treatment of his/her Newborns (or for supplies related thereto); and
31.19 Accommodations — Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and
31.20 Taxes and Other Miscellaneous Fees — Any taxes, assessments, charges, fees or surcharges imposed by any governmental agency or authority:
31.20.1 Arising out of or as a result of any treatment or supplies received by the Participating Member; or
31.20.2 Based upon the Company’s election hereunder, if any, to pay Benefits directly to providers; or
31.20.3 For any other reason; and
31.21 Non-Prescription/Over-The-Counter Medication — Charges or Expenses Incurred for non- prescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; 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; and
31.22.1 Any organ, 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
31.22.2 Any artificial, non-human organs, or mechanical devices designed to replace human organs temporarily or permanently; and/or
31.22.3 Any efforts to keep a donor alive for a transplant procedure, whether or not the transplant procedure is a Covered Transplant; and
31.23 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;
31.23.1 The warning has been in effect within one-hundred and eighty (180) days immediately prior to the Participating Member(s) date of arrival; and
31.23.2 Within ten (10) days following the date the warning is issued the Participating Member(s) has failed to depart the country or location; and
31.24 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).
31.25 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.