MEDICAL BENEFIT EXCLUSIONS
For Medical benefits, this Insurance does not cover:
1. Pre-existing Conditions which are excluded under this policy. This means that any claims for Pre-existing Conditions will not be covered for the duration of this policy.
a) If You are a United States citizen, this exclusion is waived for the first $25,000 in eligible medical expenses incurred outside the United States and Canada (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. Any exclusion specifically listed in Medical Benefits exclusions, 2 through 40, will not receive benefits from this waiver.
b) If you are a non-U.S. citizen 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 the Lifetime Maximum Limit as provided in the Acute Onset of a Pre-existing Condition(s) section of the Schedule of Benefits 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. Any exclusion specifically listed in Medical Benefits exclusions, 2 through 40, will not receive benefits from this waiver.
2. Charges for treatment which exceed 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 there of, 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 a $50,000 lifetime maximum benefit 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, sponsored and/or organized Amateur or Interscholastic Athletics; 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.
12. 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;
13. Diagnosis or Treatment of the Temporomandibular joint;
14. Chiropractic care or acupuncture;
15. 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.
16. 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;
17. 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;
18. Mental and Nervous Disorder or rest cures;
19. Learning disabilities, attitudinal disorders, or disciplinary problems;
20. Congenital abnormalities and conditions arising out of or resulting therefrom;
21. Expenses incurred during a Hospital emergency room visit which is not of an Emergency nature;
22. Injury sustained while taking part in Mountaineering, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle, snowmobiling, motorcycle/motor scooter riding (whether as a passenger or driver), scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, wakeboard riding, jet skiing, windsurfing, snow skiing and snow boarding and any other sport, recreational, athletic, or adventure activity which is undertaken for thrill seeking and exposes the insured to abnormal or extreme risk of injury and/or is in violation of applicable laws, rules, or regulations. (Certain named activities may be covered by purchasing the Hazardous Sports Rider, please refer to the Hazardous Sports Coverage Section). 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 4500 meters or above.
23. Treatment paid for or furnished under any other individual, government, or group policy or charges provided at no cost to the Insured Person;
24. Diagnosis and or Treatment of venereal disease, including all sexually transmitted diseases and conditions and any and all consequences thereof;
25. 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;
26. 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;
27. 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);
28. 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.
29. 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.
30. Treatment for human organ or tissue transplants and their related treatment;
31. 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.
32. 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;
33. Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV).
34. Exercise programs, whether or not prescribed or recommended by a Physician;
35. Treatment required as a result of complications or consequences of a treatment or condition not covered hereunder.
36. Charges for travel accommodations, except as provided for in the Local Ambulance, Emergency Medical or Political Evacuation, Return of Mortal Remains, Return of Minor Children, Emergency Reunion, Natural Disaster, and Interruption of Trip sections of this insurance.
37. Diagnosis or treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive materials.
38. Diagnosis or treatment for acne, moles, skin tags, disease of sebaceous glands, seborrhea, sebaceous cyst, unspecified disase of the sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.
39. 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.
40. Treatment of sleep apnea or other sleep disorders.
EXCLUSIONS FOR ACCIDENTAL DEATH AND DISMEMBERMENT, EMERGENCY MEDICAL EVACUATION/REPATRIATION, RETURN OF MORTAL REMAINS, EMERGENCY MEDICAL REUNION, RETURN OF MINOR CHILD
With regards to Accidental Death and Dismemberment, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Emergency Medical Reunion, and Return of Minor Child, 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. c) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by 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 Policy 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, fire fighting, 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, Political Evacuation, Return of Minor Child, Emergency Reunion, and Interruption of Trip 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.
For Lost of Checked Luggage, 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.