To cover scholastic, collegiate, and other amateur organized sporting activities.
There is no Amateur Sports coverage with this plan.
Accident or Accidental shall mean an event, independent of Illness or self inflicted means, which is the direct cause of bodily Injury to an Insured Person.
Acute Onset of a Pre-existing Condition(s) shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the Certificate. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a Congenital condition or that gradually becomes worse over time will not be considered Acute Onset. A Pre-existing Condition will not be considered an Acute Onset if during the 30 days prior to the acute event You had a change in prescription or treatment for a diagnosis related to the acute event. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to arrival in the United States and prior to the Effective Date of coverage.
Administrator shall mean Seven Corners, Inc.
Airworthiness Certificate or Airworthy Certificate shall mean the “Standard” Airworthiness Certificate issued by the Federal Aviation Agency of the United States or its foreign equivalent issued by the government authority having jurisdiction over civil aviation in the country of its registry.
Benefit Period shall mean the one hundred and eighty (180) days following the onset of an Eligible Accident, Injury or Illness in which to receive Medically Necessary Covered Expenses. If Your plan terminates during Your Benefit Period, You will still be eligible to receive Treatment so long as the Treatment is within Your Benefit Period and outside Your Home Country (except as provided under the Home Country Coverage).
Child(ren) means the Plan Participant’s natural Child, adopted Child (or Child placed in the Plan Participant’s home for purposes of adoption), foster Child, stepchild, or other Child for whom the Plan Participant has legal guardianship (proof will be required). A Child must reside with the Plan Participant in a parent-Child relationship. NOTE: In the event the Plan Participant shares physical custody of the Child with another parent, the requirement that the Child reside with the Plan Participant will be waived.
Coinsurance shall mean the percentage amount of eligible Covered Expenses, after the Deductible, which are the responsibilities of the Insured Person and must be paid by the Insured Person. The Coinsurance amount is stated in the SCHEDULE OF BENEFITS, under each stated benefit.
Coma/Comatose shall mean a profound state of unconsciousness from which the Insured cannot be aroused to consciousness, even by powerful stimulation, as determined by a Physician.
Common Carrier shall mean any public air conveyance operating under a valid license providing for the transportation of passengers for hire.
Company or Underwriter shall mean Certain Underwriters at Lloyd’s, London.
Congenital shall mean a physical abnormality or condition that is present at birth, whether inherited or caused by the environment.
Covered Expense(s) shall mean “Eligible Benefit”.
Custodial Care shall mean that type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist an Insured in performing the activities of daily living. Custodial Care also includes non-acute care for the comatose, semi-comatose, paralyzed or mentally incompetent patients. Such services shall be considered Custodial Care without regard to the provider by whom or by which they are prescribed, recommended or performed.
Deductible shall mean the amount of eligible Covered Expenses which are the responsibility of each Insured Person and must be paid by each Insured Person before benefits under the Certificate are payable by the Company.
Disablement as used with respect to medical expenses shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician as defined in this Certificate.
Displaced shall mean that You are required to depart a destination due to an evacuation ordered by prevailing authorities.
Educational or Rehabilitative Care shall mean care for restoration (by education or training) of one’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.
Eligible Benefit(s) shall mean benefits payable by the Company to reimburse expenses which are for Medically Necessary services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed or ordered by a Physician; Usual, Reasonable and Customary charges; incurred while insured under this program and which do not exceed the Maximum Benefit.
Eligible Dependent Child shall mean the Insured Person’s unmarried Children over fourteen (14) days and under nineteen (19) years of age.
Eligible Spouse shall mean the Insured Person’s legal spouse or legal domestic partner or civil union partner.
Experimental / Investigational means all services or supplies associated with: 1) Treatment or diagnostic evaluation which is not generally and widely accepted in the practice of medicine in the United States of America or which does not have evidence of effectiveness documented in peer reviewed articles in medical journals published in the United States. For the Treatment or diagnostic evaluation to be considered effective such articles should indicate that it is more effective than others available: or if less effective than other available treatments or diagnostic evaluations, is safer or less costly; 2) A drug which does not have FDA marketing approval; 3) A medical device which does not have FDA marketing approval; or has FDA approval under 21 CFR 807.81, but does not have evidence of effectiveness for the proposed use documented in peer reviewed articles in medical journals published in the United States. For the device to be considered effective, such articles should indicate that it is more effective than other available devices for the proposed use; or if less effective than other available devises, or is safer or less costly. The Company will make the final determination as to whether a service or supply is Experimental/Investigational.
Extended Care Facility shall mean an institution, or a distinct part of an institution, which is licensed as a Hospital, Extended Care Facility or rehabilitation facility by the state in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a Physician; and 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 Treatment, Custodial Care, nursing care or for care of Mental Illness or the mentally incompetent.
Felonious Assault shall mean any willful or unlawful use of force upon the Insured: (1) with the intent to cause bodily injury to the Insured; and (2) that results in bodily harm to the Insured; and (3) that is a felony or a misdemeanor in the jurisdiction in which it occurs.
Home Country shall mean the country where the Insured Person(s) has his or her true, fixed and permanent residence. For United States Citizens, the Home Country is always the United States.
Home Health Care shall mean services or supplies needed as the result of a medical condition which is eligible under the Certificate. The Insured must be physically unable to obtain needed medical services on an Outpatient basis, and it must be in lieu of hospitalization or confinement in an Extended Care Facility. The treatment plan must be prescribed by a licensed Physician who is required to provide updates to the insurer at the appropriate intervals. Home Health Care is Medically Necessary health care provided in the patient’s home by health care professionals at the direction of a licensed Physician. Health care professionals may include part-time or intermittent nursing care provided under the supervision of a Registered Nurse, physical therapy, occupational therapy, medications and laboratory services as well as a home health aide. Expenses for Home Health Care do not include food, housing, homemaker services, or Physician charges which are covered elsewhere in the Certificate, Therapy services which are covered elsewhere in the Certificate and environmental supplies such as: hand rails, ramps, special telephones, air conditioners, home delivered meals, etc. The caregiver cannot be a Relative of the Insured Person, and the care must be provided primarily for therapeutic value and not to assist in activities of daily living or Custodial Care;
Hospital as used in this Certificate shall mean except as may otherwise be provided, a Hospital (other than an institution for the aged, chronically ill or convalescent, resting or nursing homes) operated pursuant to law for the care and Treatment of sick or Injured persons with organized facilities for diagnosis and Surgery and having 24-hour nursing service and medical supervision.
Host Country shall mean any country other than the country where an Insured Person has his or her true, fixed and permanent home and principal establishment.
Illness(es) wherever used in this Certificate shall mean a Sickness, disorder, Illness, pathology, abnormality, malady, morbidity, affliction, disability, defect, handicap, deformity, birth defect, congenital defect, symptomatology, syndrome, malaise, infection, infirmity, ailment, disease of any kind, or any other medical, physical or health condition. Provided, however, that Illness does not include learning disabilities, or attitudinal or disciplinary problems. All Illnesses that exist simultaneously or which arise subsequent to a prior Illness and which directly or indirectly relate to or result or arise from the same or related causes or as a consequence thereof or from one another are considered to be one Illness. Further, if a subsequent Illness results or arises from causes or consequences that are the same as or related to the causes or consequences of a prior Illness, the subsequent Illness will be deemed to be a continuation of the prior Illness and not a separate Illness.
Immediate Family Member means a Plan Participant’s Spouse, domestic partner, civil union partner, parent (includes Step-parent), Child(ren) (includes legally adopted or step Child(ren), brother, sister, step-Child(ren), grandchild(ren), or in-laws). A Member of the Immediate Family includes an individual who normally lives in the Plan Participant’s household.
Injury wherever used in this Certificate shall mean bodily Injury caused solely and directly by violent, Accidental, external, and visible means occurring while this Certificate is in force and resulting directly and independently of all other causes in Disablement covered by this Certificate.
Inpatient shall mean if You are confined in an institution and are charged for room and board.
Insurance means the coverage that is provided under the Certificate.
Insured or Insured Person(s) shall mean a person eligible for benefits under the Certificate who has applied for coverage and is named on the application and for whom the Company has accepted premium.
Intensive Care shall mean a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
Loss in reference to quadriplegia, paraplegia, hemiplegia, and uniplegia, shall mean the complete and irreversible paralysis of such limbs and with regard to hands and feet, actual severance through and above the wrist or ankle joints, and with regard to eyes, entire irrecoverable Loss of sight.
Master Application means the Application for the Master Policy.
Master Policy means that certain group insurance policy, No. NA16SC01 issued to World Commercial Trust by Certain Underwriters at Lloyd’s, London, which is available upon request from Seven Corners.
Maximum Benefit means the largest total amount of Eligible Expenses that the Company will pay for the Plan Participant as found on the ID card.
Medical Emergency means the occurrence of a Sickness, Injury or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain that an individual could reasonably expect the absence of immediate medical attention to result in A) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy, or B) serious impairment to such person’s bodily functions; C) serious dysfunction of any bodily organ or part of such person; or D) serious disfigurement of such person.
Medical Treatment means examination, Treatment, and/or consultation by a Physician for a condition which first manifested itself, worsened or became acute or had symptoms which would have prompted a reasonable person to seek diagnosis, care or Treatment.
Medically Necessary shall mean services and supplies received while insured that are determined by the Company to be: (1) appropriate and necessary for the symptoms, diagnosis, or direct care and Treatment of the Insured Person’s medical conditions; (2) within the standards the organized medical community deems good medical practice for the Insured Person’s condition; (3) not primarily for the convenience of the Insured Person, the Insured Person’s Physician or another Service Provider or person; (4) not Experimental/Investigational or unproven, as recognized by the organized medical community, or which are used for any type of research program or protocol; and (5) not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate Treatment. For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services the Insured Person is receiving or the severity of the Insured Person’s condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician may prescribe, order, recommend, or approve a service, supply, or level of care does not, of itself, make such Treatment Medically Necessary or make the charge of a Covered Expense under this Certificate.
Mental Illness and Mental and Nervous Disorder shall mean any 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; any disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of the International Classification of Diseases as published by the U.S. Department of Health and Human Services; and those psychiatric and other Mental Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders published by the American Psychiatric Association. Mental Illness and Mental and Nervous Disorder does not mean or include learning disabilities, attitudinal disorders or disciplinary problems. For purposes of this Insurance, Mental Illness and Mental and Nervous Disorder do not include Substance Abuse.
Mountaineering shall mean the sport, hobby or profession of walking, hiking, and climbing up mountains either: 1) utilizing harnesses, ropes, crampons or ice axes; or 2) ascending 4,500 meters or above.
Natural Disaster shall mean any event or force of nature caused by environmental factors that has catastrophic consequences. Covered Natural Disasters are: avalanche, earthquake, flood, hurricane, impact event, landslides, mudslides, tornado, tsunami, tropical cyclone, typhoon, volcanic eruption, and wildfire.
Occupational Disease means an Illness or Injury resulting from or in the course of any employment for wage or profit by the Plan Participant. Occupational Disease is not a contagious disease resulting from exposure to fellow employees or from a hazard to which the workman would have been equally exposed outside of his employment. An Occupational Disease is also not an ordinary disease of life to which the general public is equally exposed, unless such disease follows as a complication and a natural incident of an Occupational Disease or unless there is a constant exposure peculiar to the occupation itself that makes such disease a hazard inherent in such occupation.
Outpatient shall mean an Insured Person who receives care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for an Illness or Injury, but who is not confined and is not charged for room and board.
Parachuting shall mean an activity involving the breaking of a free fall from an airplane using a parachute.
Physician(s) or Surgeon shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery(ies) in accordance with the laws of the jurisdiction where such professional services are performed.
Plan Participant means a person and dependent eligible for coverage as identified in the enrollment/application, for whom proper premium payment has been made when due, and who is therefore a Plan Participant under the Certificate.
Plan means this document, the Master Application of the Policyholder and any end endorsements, riders or amendments that will attach during the Period of Coverage.
Period of Coverage shall mean the Period of Coverage issued by the Company to the Insured Person, typically beginning with the Effective Date and ending with the Termination Date or the date coverage is renewed by the Company.
Policyholder means the entity shown as the Policyholder in the SCHEDULE OF BENEFITS.
Pre-existing Condition(s) shall mean 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 during the 36* months prior to the Effective Date of Coverage under this Certificate, 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 during the 36 month period immediately preceding the Effective Date of Coverage under this Certificate. *For Insured Persons traveling outside the United States, the period is 12 months instead of 36 months.
Pregnancy means the physical condition of being pregnant, including complication of Pregnancy.
Registered Nurse shall mean a graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and one who is legally entitled to place the letters “RN” after his or her name.
Relative shall mean spouse, parent, sibling, Child, grandparent, grandchild, step-parent, step-Child, step-sibling, in-laws (parent, son, daughter, brother and sister), aunt, uncle, niece, nephew, legal guardian, ward, or cousin of the Insured Person.
Rest Cures shall mean a treatment, as for nervous disorders, consisting of complete rest, often with special diet, massage, etc., especially at a spa or sanitorium.
Scheduled Departure Date means the date on which the Plan Participant is originally scheduled to leave on the Plan Participant’s trip.
Service Provider(s) shall mean a Hospital, convalescent/skilled nursing facility, ambulatory surgical center, psychiatric Hospital, community mental health center, residential treatment facility, psychiatric treatment facility, alcohol or drug dependency treatment center, birthing center, Physician, dentist, chiropractor, licensed medical practitioner, nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Company approves.
Sickness means Illness, malady or disease which requires treatment by a Physician while covered by this Certificate. All related conditions and recurrent symptoms of the same or a similar condition will be considered the same Sickness.
Sound Natural Tooth or Sound Natural Teeth is a tooth that is whole or properly restored; is without impairment, periodontal or other conditions; is not more susceptible to Injury than a virgin tooth, and is not in need of the Treatment provided for any reason other than Accidental Injury. A tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not a Sound Natural Tooth.
Spouse means lawful spouse, if not legally separated or divorced, or domestic partner or civil partner.
Substance Abuse shall mean a condition brought about when an individual uses alcohol, chemicals or any other drug(s) in such a manner that his/her health and/or judgement is impaired and/or ability to control actions is lost.
Surgery(ies) or Surgical Procedure shall mean an invasive diagnostic 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.
Terrorist Activity shall mean an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or government(s).
Traveling Companion shall mean spouse, parent, sibling, Child, grandparent, grandchild, step-parent, step-Child, step-sibling, in-laws (parent son, daughter, brother, or sister), aunt, uncle, niece, nephew, legal guardian, ward, or business partner of the Insured Person.
Treatment(s) means a specific in-office or Hospital physical examination of or care rendered to You, consultation, diagnostic procedures and services, Surgery, medical services and supplies including medication prescribed or provided by a Service Provider.
Trip means a scheduled trip for which coverage for travel arrangements is requested and the premium is paid prior to the Plan Participant’s actual or Scheduled Departure Date of the Plan Participant’s Trip.
Usual, Reasonable and Customary shall mean the maximum amount that the Company determines is Usual, Reasonable and Customary for Covered Expenses the Insured Person receives, up to but not to exceed charges actually billed. The Company’s determination considers: (1) amounts charged by other Service Providers for the same or similar service in the locality where received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; (2) any usual medical circumstances requiring additional time, skill or experience; and (3) other factors the Company determines are relevant, including but not limited to, a resource based relative value scale. For a Service Provider who has a reimbursement agreement, the Usual, Reasonable and Customary charge is equal to the amount that constitutes payment in full under any reimbursement agreement with the Company.
You or Your shall mean the Primary Insured Person and the Primary Insured’s Spouse or Dependent.
For Medical Benefits, this Insurance does not cover:
1. Pre-existing Conditions which are excluded under this Certificate. This means that any claims for Pre-existing Conditions will not be covered for the duration of this Certificate.
a) If You are a United States resident under age 70, this exclusion is waived for the first $25,000 in eligible medical expenses incurred outside the United States (for persons age 70 and over, the amount is $5,000), minus Your Deductible and selected Coinsurance option (Plan E or F). This waiver does not include coverage for known, scheduled, required, or expected medical care, drugs, or Treatments existent or necessary prior to the effective date of this program.
b) If you are a non-U.S. resident under age 70, this exclusion is waived for eligible medical expenses for an Acute Onset of a Pre-existing Condition(s) (as defined herein) up to $45,000 (Ages 65-69 limited to $2,000) for eligible medical expenses incurred in the United States, minus Your Deductible and selected Coinsurance option (Plan A or B). For persons age 70 and over, there is no benefit. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs, or Treatments existent or necessary prior to arrival in the United States and prior to the effective date of this program.
If the Pre-existing Conditions exclusion is waived, all of the remaining exclusions still apply.
2. Charges for Treatment which exceed Usual, Reasonable and Customary charges; or charges incurred for Surgeries or Treatments which are Investigational, Experimental, or for research purposes; expenses which are non-medical in nature;
3. Claims not received by Seven Corners within ninety (90) days of the date of service;
4. Expenses for vocational, occupational, sleep, speech, recreational or music therapy;
5. Durable medical equipment;
6. Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
7. Suicide or any attempt thereof, or self-destruction or any attempt thereof; intentionally self-inflicted Injury or Illness;
8. Expenses as a result of, or in connection with, the commission of a felony offense or any other criminal or illegal activity as defined by the local governing body;
9. War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the Insured Person or the country in, or over, which the act occurs, Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the Insured Person whether war be declared with that state or not. For the purpose of this Exclusion; i) Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals (including in connection with Terrorist Activity). ii) Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals (including in connection with Terrorist Activity). iii) Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals (including in connection with Terrorist Activity). Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;
10. Terrorist Activity. For the purpose of this Exclusion, Terrorist Activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist Activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s). The Company shall not be liable for and will not provide coverage or benefits in excess of the maximum stated in the SCHEDULE OF 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 act of Terrorism; and provided, 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 direct or indirect involvement in the Terrorist Activity.
b) The Terrorist Activity takes place in a country or location where the United States government has issued a travel warning that has been in effect within the six (6) months prior to the Insured Person’s date of arrival.
c) The Insured Person unreasonably fails or refuses to depart a country or location following the date a warning to leave that country or location is issued by the United States government.
11. Injury sustained while participating in professional athletics, including but not limited to the event, games, practice, conditioning and any other activity related to professional athletics.
12. Injury sustained while participating in amateur or interscholastic athletics, including but not limited to the event, games, practice, conditioning and any other activity related to amateur or interscholastic athletics; this exclusion does not apply to non-competitive, recreational or intramural activities. Note: A sponsored and/or organized Amateur or Interscholastic Athletic event includes training camps, team sports, or any formal grouping of people participating in one or multiple events that may/may not require a fee for participation.
13. Occupational Diseases, including but not limited to disease(s) related to asbestos exposure, and the complications thereof, including asbestosis and mesothelioma related to asbestos exposure;
14. Routine physicals, inoculations, or other examinations including but not limited to laboratory, diagnostic, or x-ray examinations where there are no objective indications or impairment in normal health;
15. Diagnosis or Treatment of the temporomandibular joint;
16. Chiropractic care or acupuncture;
17. Services, supplies, or Treatment prescribed, performed or provided by a Relative of the Insured Person or any family member of the Insured Person or anyone who lives with the Insured Person. This includes but is not limited to prescription medication and any diagnostic testing;
18. Treatment and the provision of false teeth or dentures or dental appliances, normal ear tests and the provision of hearing aids, hearing implants, cosmetic or plastic Surgery (including deviated nasal septum), dental expenses except as specifically provided in the Dental Emergency Treatment benefit , eye refractions or eye examinations for the purpose of prescribing corrective lenses for eye-glasses or for the fitting thereof, unless caused by Accidental bodily Injury incurred while insured hereunder; eyeglasses, contact lenses; eye surgery when the primary purpose is to correct nearsightedness, farsightedness or astigmatism;
19. Treatment in connection with alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency or use of any drug or narcotic agent; Injury sustained while under the influence of or Disablement due wholly or partly to the effects of intoxicating liquor, chemicals, or drugs or narcotic agent, unless administered under the advice of a Physician and said narcotic agent was taken in accordance with the proper dosing as directed by the physician;
20. Mental and Nervous Disorder or Rest Cures;
21. Learning disabilities, attitudinal disorders, or disciplinary problems;
22. Congenital abnormalities and conditions arising out of or resulting therefrom;
23. Expenses incurred during a Hospital emergency room visit which is not a Medical Emergency;
24. Injury sustained while taking part in Mountaineering, hang gliding, paragliding, Parachuting, paragliding, zip lining, parasailing, bungee jumping, racing by any animal or motor vehicle or motorcycle, snowmobiling, motorcycle/motor scooter riding (whether as a passenger or driver), scuba diving involving underwater breathing apparatus (unless SSI, PADI or NAUI certified), water skiing, wakeboard riding, jet skiing, windsurfing, snow skiing and snowboarding (except for recreational downhill and/or cross country snow skiing or snowboarding. No cover provided while skiing/boarding in any violation of applicable laws, rules or regulations, away from prepared and market in-bound territories; and/or against the advice of the local ski school or local authoritative body); and any sport or athletic activity which is undertaken for thrill seeking and exposes the Plan Participant to abnormal or extreme risk of injury; Hazardous Sports Coverage: the following are covered if the required premium has been paid: motorcycle/motor scooter riding (whether as a passenger or a driver), hang gliding, Parachuting, zip lining, parasailing, bungee jumping, water skiing, wakeboard riding, jet skiing, windsurfing, snowmobiling, and spelunking.
25. Treatment paid for or furnished under any other individual, government, or group policy or charges provided at no cost to the Insured Person;
26. Diagnosis and or Treatment of venereal disease, including all sexually transmitted diseases and conditions and any and all consequences thereof;
27. Pregnancy expenses or Illness resulting from Pregnancy, childbirth, or miscarriage; or for miscarriage resulting from an Accident or complications of Pregnancy; or for postnatal care;
28. Drug, Treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, Treatment for infertility or impotency, sterilization or reversal thereof;
29. Expenses incurred while the Insured Person is in their Home Country (except after approved Emergency Medical Evacuation/Repatriation or if covered under the Home Country Coverage Benefit);
30. Expenses incurred for which travel was undertaken to seek Medical Treatment for a condition; or incurred after the Insured Person’s physician has limited or restricted travel;
31. All charges incurred while confined primarily to receive Custodial Care, Educational or Rehabilitative Care, or any Medical Treatment in any establishment for the care of the aged;
32. Treatment for human organ or tissue transplants and their related Treatment;
33. Weight reduction programs or the surgical Treatment of obesity, including but not limited to wiring of the teeth and all forms of intestinal bypass Surgery;
34. Modifications of the physical body intended to improve the psychological, mental or emotional well-being of the Insured, including but not limited to sex-change Surgery; any drug, Treatment, or procedure that promotes, enhances or corrects impotency or sexual dysfunction;
35. Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV);
36. Exercise programs, whether or not prescribed or recommended by a Physician;
37. Treatment required as a result of complications or consequences of a Treatment or condition not covered hereunder;
38. Charges for travel accommodations, except as provided for in the Local Ambulance, Emergency Medical or Political Evacuation, Return of Mortal Remains, Return of Minor Child(ren), Emergency Medical Reunion, Natural Disaster, and Interruption of Trip sections of this Insurance;
39. Diagnosis or Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive materials;
40. Diagnosis or Treatment for acne, moles, skin tags, disease of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of the sebaceous glands, hypertrophic and atrophic conditions of skin, nevus;
41. Treatment, services or supplies that are not administered by or under the supervision of a Physician and products that can be purchased without a doctor’s prescription;
42. Treatment of sleep apnea or other sleep disorders.
With regards to Accidental Death and Dismemberment, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Emergency Medical Reunion, and Return of Minor Child(ren), this Insurance does not cover:
1. Suicide or attempt thereof by the Insured Person while sane, or self-destruction or any attempt thereof by the Insured Person while insane;
2. Disease or Sickness of any kind; (only applicable to AD&D)
3. Bacterial infections except pyogenic infection which shall occur through an Accidental cut or wound; (only applicable to AD&D)
4. Hernia of any kind; (only applicable to AD&D)
5. Injury sustained while the Insured Person is riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting, from any type of aircraft;
6. Injury sustained while the Insured Person is riding as a passenger in any aircraft (a) not having a current and valid Airworthy Certificate and (b) not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft;
7. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with: (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. © 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 terrorism or violence; (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 (hereinafter for the purposes of this Exclusion called the “Occurrences”). Any consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether 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 to be consequences for which the Company shall not be liable under this Certificate except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such abnormal conditions;
8. Service in the military, naval or air service of any country and while on duty as a member of a police force or unit;
9. Flying in any aircraft being used for or in connection with acrobatic or stunt flying, racing, endurance tests, rocket-propelled aircraft, crop dusting or seeding or spraying, firefighting, exploration, pipe or power line inspection, any form of hunting or herding, aerial photography, banner towing or any experimental purpose;
10. Being under the influence of alcohol or having taken drugs or narcotics unless prescribed by a legally qualified Physician or Surgeon;
11. Injury occasioned or occurring while the Insured Person is committing or attempting to commit a felony or to which a contributing cause was the Insured Person being engaged in an illegal occupation;
12. Riding or driving in any kind of competition;
13. Pregnancy, childbirth, miscarriage or abortion;
14. Covered Expenses incurred after the Insured Person’s Physician has limited or restricted travel; or Covered Expenses incurred as a result of a change in prescribed Treatment during, or within the three months prior to the Effective Date of Coverage.
15. All Emergency Medical Evacuation, Return of Mortal Remains, Return of Minor Child(ren), and Emergency Medical Reunion costs not
arranged by Seven Corners Assist.
For Interruption of Trip, this Insurance does not cover: (1) war or any act of war, whether declared or not; participation in a felony, riot or insurrection; participation in contests of speed; a Pre-existing Condition existing prior to the Insured’s departure from their Home Country that has the likelihood of causing death; the Insured Person or Traveling Companion or Traveling Companion’s family making changes to personal plans; having business or contractual obligations; being unable to obtain necessary travel documents (passports, visas, etc.); being detained or having property confiscated by customs authorities; carrier caused delays (including bad weather); prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which the Insured Person purchased their trip arrangements. All costs not arranged by Seven Corners Assist.
For Loss of Checked Baggage, this Insurance does not cover: animals; automobiles or automobile equipment; boats; motors; motorcycles; other conveyances or their appurtenances (except bicycles while checked as baggage with a Common Carrier); household furniture; eye-glasses or contact lenses; artificial teeth or dental bridges; hearing aids; prosthetic limbs; musical instruments; money or securities; tickets or documents; or sporting equipment if loss or damage results from the use thereof.
For Political Evacuation and Repatriation, this Insurance does not cover: 1) Losses recoverable under any other Insurance or through an employer; 2) Losses arising from or attributable to a) dishonest or criminal acts committed or attempted by the Insured, b) alleged violation of the laws of the Host Country, unless the company determines such allegations to be fraudulent, or c) failure to maintain required documents or visas; 3) Losses attributable to a ) debt, insolvency, commercial failure, or the repossession of any property, b) Insured’s non-compliance with a contract or license or c) implementation of illegally contributed exchange rates; 4) Losses due to liability assured by the Insured under any contract. 5) All costs not arranged by Seven Corners Assist.
Exclusions Related to Natural Disaster Evacuation/Repatriation Benefits
1. The Natural Disaster Evacuation/Repatriation of You while in the United States;
2. Any medical expenses incurred by You;
3. The Kidnap and/or ransom of You;
4. Any expenses not related to Natural Disaster Evacuation/Repatriation, including expenses for transportation from the Host Country by normal commercial mans;
5. Natural Disaster Evacuation/Repatriation when the Natural Disaster situation directly giving rise to it precedes Your arrival;
6. The evacuation of You from a Host Country when the evacuation notice issued by the United States or Host Country Government has been posted for a period of more than sixty (60) days.
7. You elect not to depart in a timely manner with evacuation arrangements coordinated by Seven Corners. In this circumstance, coverage for Natural Disaster Evacuation/Repatriation is immediately terminated;
8. Services rendered without the coordination and approval of Seven Corners.
9. Any country subject to the administration and enforcement of U.S. economic embargoes and trade sanctions by the OFFICE OF FOREIGN ASSETS CONTROL (OFAC)
10. Any services other than those indicated and described within this document will not be provided
11. While traveling within 50 miles of Your primary place of residence