Included in Emergency Medical
$60,000 per person
Emergency Evacuation arranges to medically transport a patient to an appropriate medical facility. Medical Repatriation arranges for a patient to return home to receive care. Repatriation of Remains arranges for return of deceased remains back to the place of residence.
32.1 Emergency Medical Evacuation — The Scheme Administrator will arrange Emergency Medical Evacuation only to the nearest Hospital that is qualified to provide the Medically Necessary Treatment to prevent the Participating Member’s loss of life. The Scheme Administrator will use its best efforts to arrange with independent, third-party contractors any Emergency Medical Evacuation within the least amount of time reasonably possible. The Participating Member understands and agrees that the timeliness, duration and outcome of an Emergency Medical Evacuation can be affected by events and/or circumstances that are not within the direct control of the Scheme Administrator, which would include, but not limited to, availability and performance of competent transportation equipment and staff; delays or restrictions on flights or other modes of transportation caused by mechanical problems, government officials, telecommunications problems, and/or geographical and weather conditions. The Participating Member agrees to hold the Scheme Administrator, its agents and representatives harmless from, and agrees that the Scheme Administrator, its agents and representatives shall not be held liable for, any delays, losses, damages or other claims that arise from or are caused by the acts or omissions of such independent third-party contractors, or that arise from or are caused by any acts, omissions, events or circumstances that are not within the direct and immediate control of the Scheme Administrator and/or its authorized agents and representatives, which would include, without limitation, the events and circumstances set forth above. The Scheme Administrator will reimburse the Participating Member for the following Expenses Incurred by the Participating Member arising out of or in connection with an Emergency Medical Evacuation occurring while the Evidence of Insurance is in effect. Subject to the Maximum Limit set forth in the Schedule of Benefits/Limits and the other Terms of this insurance, which would include the Conditions and Restrictions set forth below:
32.1.1 Emergency air transportation to a suitable airport nearest to the Hospital where the
32.1.2 Emergency ground transportation necessarily preceding Emergency air transportation Participating Member will receive treatment; and and from the destination airport to the Hospital where the Participating Member will receive treatment; and
32.1.3 The Participating Member must be in compliance with all Terms of this insurance; and
32.1.4 The Scheme Administrator will provide Emergency Medical Evacuation Benefits only
32.1.5 Medically Necessary Treatment cannot be provided locally to prevent Participating
32.1.6 Transportation by any other method would result in loss of the Participating Member’s
32.1.7 Emergency Medical Evacuation is recommended by the attending Physician who
32.1.8 Emergency Medical Evacuation is agreed to by the Participating Member or
32.1.9 Emergency Medical Evacuation is approved in advance and all arrangements are
32.1.10 The Illness or Injury giving rise to the Emergency Medical Evacuation occurred suddenly when the Illness or Injury giving rise to the Emergency Medical Evacuation is covered under the Terms of this insurance, except when provided under the Sudden Onset of Pre-existing condition; and Member(s) loss of life; and life; and certifies to the matters in subsections 32.1.5 and 32.1.6 above; and a Relative of the Participating Member; and coordinated by the Scheme Administrator; and and/or spontaneously, and without: (i) advance warning, (ii) advance treatment, diagnosis or recommendation for treatment by a Physician, or (iii) prior manifestation of symptoms or conditions that would have caused a prudent person to seek medical attention prior to the onset of the Emergency; and
32.3 Emergency Reunion — Subject to the Terms of this insurance, Eligible Medical Expenses will be reimbursed up to $50,000 to the Participating Member as outlined in the Schedule of Benefits/Limits in cases where there has been an Emergency Medical Evacuation covered under the Terms of this insurance. Subject to the Deductible and Coinsurance and other limits as specified in the Schedule of Benefits/Limits, and subject to the Conditions and Restrictions set forth below the following Expenses Incurred in respect of travel by a Relative or friend of the Participating Member will be reimbursable to the Participating Member upon the recommendation and prior approval of the Scheme Administrator:
32.3.1 The cost of an economy air ticket for one Relative or friend to the airport serving the area where the Participating Member is Hospitalized as a result of the Emergency Evacuation or is to be Hospitalized as a result of the Emergency Medical Evacuation, and return from either of such locations to the point of their original departure; and
32.3.2 Reasonable and necessary travel, meals (Maximum of $25 per day), transportation, and accommodation Expenses Incurred in relation to the Emergency Reunion (but excluding entertainment).
32.4 Conditions and Restrictions:
32.4.1 The period of coverage for the Emergency Reunion shall not exceed fifteen (15) days, which would include travel days; and
32.4.2 The Emergency Reunion must be due to an Emergency Medical Evacuation covered under the Terms of this insurance; and
32.4.3 The attending Physician must deem the illness or injury as a threat to the Participating Members life and recommends the presence of a Relative or friend to either the location where the Participating Member is being evacuated from or the destination of the evacuation, whichever is considered by the attending Physician and the Scheme Administrator to be the more reasonable; and
32.4.4 All Emergency Reunion travel, transportation and accommodation arrangements, and Benefits must be coordinated and approved in advance by the Scheme Administrator in order to be eligible for coverage under this insurance.
32.5 Return Of Mortal Remains — In the event of the Death of the Participating Member as a result of an Illness or Injury covered under this insurance while the Participating Member is outside of his/her Home Country, the Scheme Administrator will reimburse the estate of the Participating Member up to $50,000 for the return of the Participating Member’s Mortal Remains to his/her Home Country (but not which would include any costs of burial); provided, however, that the Scheme Administrator must coordinate and approve all costs related to the return of the Participating Member’s Mortal Remains in advance as a condition to this benefit. The Scheme Administrator will use their best efforts to arrange the timely return of the Participating Member’s Mortal Remains. The Participating Member and his/her heirs understand that the timeliness of the Return of Mortal Remains can be affected by circumstances which are not within the control of the Scheme Administrator such as, but not limited to the availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems or weather. The Participating Member, and his/her heirs, agree to hold the Scheme Administrator and Underwriters harmless and shall not be held liable for any delays, which are not within their direct and immediate control. The Scheme Administrator and Underwriters are held harmless and shall not be held liable for loss of or any damage or other impairment to bodily remains incurred during the transport process or otherwise.
Accident: A sudden, unintentional, and unexpected occurrence caused by external, visible means and resulting in physical Injury to the Participating Member.
Affidavit of Eligibility: The properly completed form provided to the Scheme Administrator that certifies that an applicant is eligible to be covered under this insurance plan because they do not meet the citizenship and/or residency requirements of other insurance companies in the area where they reside.
AIDS: Acquired Immune Deficiency Syndrome, as that term is defined by the United States Centers for Disease Control.
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, renewal 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/the 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: AIDS related complex, as that term is defined by the United States Centers for Disease Control.
Beneficiary: The person(s), executers or administrators entitled to receive payment of Benefits.
Benefit: The amount of Principal Sum payable for Death.
Canada: A federated country in North America made up of ten provinces and three territories, (Canada).
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.
Complicated Delivery: A delivery in which some condition puts the mother, the developing fetus, or both at higher-‐than-‐normal risk for complications during or after the delivery.
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 more than three hundred sixty five (365) 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.
Declaration: The Declaration of Insurance issued by the Scheme Administrator to the Participating Member contemporaneously with the Evidence of Insurance (and/or upon renewal or Reinstatement hereof) evidencing the Participating Member’s insurance coverage under the Master Policy as evidenced by the Evidence of Insurance, which Declaration shall be incorporated in and become a part of the Master Policy. The Declaration serves as a descriptive document highlighting the coverage limits, deductible(s), coverage dates, amendments and/ or riders, and names of Participating Members for all Evidence of Insurance issued by the Scheme Administrator on behalf of the Master Policyholder and Underwriters.
Deductible: The dollar amount of Eligible Medical Expenses specified in the Declaration, 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, including dentures and preparation for dentures.
Dependent Child; Children: A Participating Member who is less than eighteen (18) years of age at time of Application and shares your home for at least half the year (if divorced, the child may live with former spouse); and must not provide over one-‐half of his/her own support (scholarships excluded); or must be less than twenty four (24) years of age at time of Application and a full-‐time student and claim your residence as his/her official residence while away at school; and must not provide over one-‐half of his/her own support (scholarships excluded); and must be your biological, step, or legally adopted child/children.
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 the following items: a standard basic hospital bed; and/or a standard basic wheel chair.
Educational or 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.
Effective Date; 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 Declaration.
Eligible Medical Expenses: As defined in Section 30 above.
Emergency: A medical condition manifesting itself by acute signs or symptoms which 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: U.S. 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 coverage’s 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 which are not generally accepted standards of current medical practice.
Extended Care Facility: An institution, or a distinct part of an institution, which 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 who is covered as a Participating Member under this insurance plan and his/her natural Child or Children (see definition of Dependent Child; Children) who are under the age of eighteen (18) and covered as Participating Members under this insurance plan.
HIV +: Laboratory evidence defined by the United States Centers for Disease Control as being positive for Human Immunodeficiency Virus infection.
Home Country: The country of which the Participating Member is a citizen or 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, which 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 which operates as a hospice; and 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 days (180).
Hospital: An institution which 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; 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 (most recent, if more than one) 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 which are still in the clinical stages of evaluation and not yet released for distribution by the US Food and Drug Administration.
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 which 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 which is needed to provide safe, adequate, and appropriate diagnosis or Treatment.
Mental or Nervous Disorders: A mental, nervous, or emotional Illness which 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.
Normal Delivery: A Vaginal delivery with no unexpected complications before or after delivery.
Other Insurance: As defined in Section 14 above.
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 Declaration.
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 five (365) 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, only, 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, or verification of coverage, a verification of benefits, or a 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, including 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 (“Due Dates”) 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 fetus develops to birth.
Primary Beneficiary: The Beneficiary(ies) named by the Participating Member as the first party entitled to Benefits.
Principal Sum: The Benefit based upon the attained age of the Participating Member.
Professional Athletics: A sport activity, including 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.
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.
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, LLC, 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, LLC, 1 North Pennsylvania Street Suite 600 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: email@example.com.
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 down by an Authoritative Diving Body.
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, which occurs unexpectedly and without advance warning, either in the form of Physician recommendation or symptoms which would 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 or Surgical Procedure: An invasive diagnostic or surgical procedure; or the Treatment of 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, including 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 including the intention to influence any government and/or to put the public, or any section of the public, in fear. All other Terms, clauses and conditions remain unchanged.
Third party Liability: Third party liability insurance coverage is the portion of an insurance policy that covers loss to others, caused by the policyholder, whether it is personal injury or property damage. Subject to the Benefits and Limits set forth in the SCHEDULE OF BENEFITS AND LIMITS in Section 21.
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, including 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.
U.S.: 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 and/or (collectively “Charges”) incurred by the Participating Member and directly or indirectly relating to or arising 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 Scheme Administrator shall provide no benefits and shall have no liability therefor:
31.1 War; Military Action; 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”):
31.1.1 war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war;
31.1.2 mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power;
31.1.3 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; martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege; or
31.1.4 Terrorism -‐ For the purpose of this insurance, an “Act of Terrorism” means an act, including 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 including the intention to influence any government and/or to put the public, or any section of the public, in fear. All other Terms, clauses and conditions remain unchanged.
31.1.5 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 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 abnormal conditions and/or Occurrences; and
31.2 Pre-‐existing Conditions-‐ Charges resulting directly or indirectly from or relating to any Pre-‐existing Condition are excluded from coverage under this insurance unless the Participating Member’s charges are a result of a Sudden Onset of a Pre-‐Existing Condition, thereafter such Charges are limited in coverage as provided in Section 21, Schedule of Benefits/Limits, above; and
31.3 Maternity – Charges related 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, including Newborn Care.
31.4 Charges incurred for Surgeries or Treatment or supplies which are:
31.4.1 Investigational, Experimental, or for Research Purposes, and/or
31.4.2 Charges for any Child under the age fourteen (14) days, and
31.4.3 Any Treatment for or related to any congenital condition, and
31.4.4 any charges which are not incurred by a Participating Member during his/her Coverage Period
31.4.5 Charges which are not submitted within the timely filing limits
31.4.6 Treatment, services or supplies which are not medically necessary related to genetic medicine or genetic testing, including 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 and routine physical exams.
31.5 Charges incurred while confined primarily to receive 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 (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms 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; 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 which was covered under this insurance; and/or
31.6.4 any Injury or Illness sustained while taking part in mountaineering activities where specialized climbing equipment, ropes or guides are normally or reasonably should have been used, Amateur Athletics, Professional Athletics, aviation (except when traveling solely as a passenger in a commercial aircraft), hang gliding and parachuting, snow skiing except for recreational downhill and/or cross country snow skiing (no cover provided whilst skiing in violation of applicable laws, rules or regulations; away from prepared and marked inbound territories; and/or against the advice of the local ski school or local authoritative body), racing of any kind including by horse, motor vehicle (of any type) or motorcycle, spelunking, and sub aqua pursuits involving underwater breathing apparatus (except as otherwise expressly set forth in Section 32.7 Recreational Underwater Activities). Practice or training in preparation for any excluded activity which results in Injury will be considered as activity while taking part in such activity; and/or
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 as a result of being under the influence of or due wholly or partly to the effects of intoxicating liquor or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician but not for the Treatment of Substance Abuse; and/or
31.6.8 any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs other than 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 (including watercraft and aircraft) and non-‐motorized bicycles and scooters for which no permit or license is required; and/or
31.6.9 any willfully self-‐inflicted Injury or Illness; and/or
31.6.10 any venereal disease; and/or
31.6.11 Treatment by a chiropractor
31.6.12 Treatment of a mental health disorder
31.6.13 Treatment for acne, other acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin.
31.6.14 Telephone consultations or failure to keep a scheduled appointment
31.6.15 any testing for the following: HIV, seropositivity to the AIDS virus, AIDS related Illnesses, ARC Syndrome, AIDS; and/or
31.6.16 any Illness or Injury resulting from or occurring during the commission of a violation of law by the Participating Member, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations; and/or
31.6.18 speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy; and/or
31.6.19 orthoptics,visual therapy or visual eye training
31.7 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, hammertoes or bunions; and 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:
31.7.1 an Injury to the foot arising from an Accident covered hereunder; or
31.7.2 an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment; and/or
31.8 hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician; and/or
31.9 any sleep disorder; and/or
31.10 any exercise program, whether or not prescribed or recommended by a Physician; and/or
31.11 any exposure to any non-‐medical nuclear or atomic radiation, and/or radioactive material(s); and/or
31.12 any artificial or mechanical devices designed to replace human organs temporarily or permanently; and/or
31.13 Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception; including but not limited to: artificial insemination; oral contraceptives, Treatment for infertility or impotency; vasectomy or reversal of vasectomy; sterilization or reversal of sterilization; and
31.14 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
31.15 Charges incurred for 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 For policies purchased more than ninety (90) days.
31.15.2 $250 Maximum Limit per Policy Period.
31.16 Charges incurred for eyeglasses, contact lenses, hearing Aids, hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason; and
31.17 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; and
31.18 Charges incurred for Treatment of the temporomandibular joint; and
31.19 Charges incurred by the Participating Member for the Treatment of his/her Newborns (or for supplies related thereto); and
31.20 Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and
31.21 Any taxes, assessments, charges, fees or surcharges imposed by any governmental agency or authority:
31.21.1 arising out of or as a result of any Treatment or supplies received by the Participating Member, or
31.21.2 Based upon the Company’s election hereunder, if any, to pay benefits directly to providers, or
31.21.3 For any other reason; and
31.22 Complementary Medicine, charges or expenses incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the U.S. Food and Drug Administration or which are considered “off-‐label” drug use; and for drugs or medicines not prescribed by a Physician.
31.23.1 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
31.23.2 any artificial, non-‐human organs, or mechanical devices designed to replace human organs temporarily or permanently; and/or
31.23.3 any efforts to keep a donor alive for a transplant procedure, whether or not the transplant procedure is a Covered Transplant;