$250 per person
The Medical Deductible is a co-pay amount which is the responsibility of the insured. Options vary by plan and can range from $0 to $2500. Deductibles can be charged 1) per policy; or 2) per person; or 3) per occurrence, injury or illness; or 4) combination of the above. Most Long Term Plans require you to select a deductible option while most Vacation plans offer a zero deductible benefit.
Deductible means the dollar amount of Eligible Expenses which must be incurred and paid by the Plan Participant before benefits are payable under the Policy or Plan Document. It applies separately to each Plan Participant.
The male pronoun includes the female whenever used.
For the purposes of the Policy the capitalized terms used herein are defined as follows:
Additional terms may be defined within the provision to which they apply.
Accident or Accidental means a sudden, unforeseeable, external event that result in Injury to the Plan Participant and occurs while the coverage is in effect.
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 policy. 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 means 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 the Plan Participant’s plan terminates during the Plan Participant’s Benefit Period, the Plan Participant will still be eligible to receive Treatment so long as the Treatment is within the Benefit Period and outside the Home Country (except as provided under the Home Country Coverage).
Child 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 Covered Expenses, after the Deductible, which is Plan Participant’s responsibility to pay.
Common Carrier means any motorized land, sea, and/or air conveyance operating under a valid license for the transportation of passenger for hire.
Company means Advent, Lloyd’s Syndicate 780. Also hereinafter referred to as Underwriter, We, Us and Our(s).
Complications of Pregnancy means a condition which:
When pregnancy is not terminated, requires Medical Treatment and whose diagnosis is distinct from pregnancy but is adversely affected by or are caused by pregnancy, such as: (a) acute nephritis; (b) nephrosis; © cardiac decompensation; (d) missed abortion; (e) eclampsia; (f) puerperal infection; (g) R.H. Factor problems; (h) severe loss of blood requiring transfusion; and (i) other similar medical and surgical conditions of comparable severity related to pregnancy.
When pregnancy is terminated: (a) non-elective cesarean section; (b) ectopic pregnancy that is terminated; and ©spontaneous termination of pregnancy during a period of gestation in which a viable birth is not possible;
Complications of Pregnancy will not include:
Physician prescribed rest during the period of pregnancy;
Similar conditions associated with the management of a difficult pregnancy but which are not a separate Complication of Pregnancy.
Delivery by cesarean section is considered a complication of pregnancy if the cesarean section is non-elective. A cesarean section will be considered non-elective if the fetus or mother is determined to be in distress and is in immediate danger of death, Sickness or Injury if a cesarean section is not performed. A cesarean section beyond one performed in any previous pregnancy will also be considered non-elective if vaginal delivery is medically inappropriate, or a vaginal delivery is attempted but discontinued due to immediate danger of death, Sickness or Injury to the Child or mother.
Congenital means a physical abnormality or condition that is present at birth, whether inherited or caused by the environment.
Covered Expense shall mean “Eligible Benefit”.
Deductible means the dollar amount of Eligible Expenses which must be incurred and paid by the Plan Participant before benefits are payable under the Policy or Plan Document. It applies separately to each Plan Participant.
Disablement (as used with respect to medical expenses) shall mean an Illness or an Accidental bodily Injury necessitating Medical Treatment by a Physician.
Dependent means a Plan Participant’s:
1) lawful spouse, if not legally separated or divorced, or Domestic Partner or Civil Union Partner.
2) unmarried Children over 14 days and under 19 years of age.
The age limitations will not apply to a Plan Participant’s unmarried Child who is dependent on the Plan Participant or other care providers for lifetime care and supervision, and incapable of self-sustaining employment by reason of mental or physical handicap that occurred before age 19. Proof of such dependence and incapacity must be furnished to the Company immediately upon enrollment or within 31 days of the Child reaching the age limitation. Thereafter proof will be required whenever reasonably necessary, but not more often than once a year after the 2-year period following the age limitation.
Eligible Benefit(s) shall mean benefits payable by the Underwriter 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; Reasonable and Customary charges; incurred while Plan Participant under this program and which do not exceed the maximum benefit.
Eligible Expenses means the Reasonable and Customary charges for services or supplies which are incurred by the Plan Participant for the Medically Necessary treatment of an Injury or Sickness. Eligible Expenses must be incurred while the Policy is in force.
Emergency means a Sickness or Injury for which the Plan Participant seeks immediate Medical Treatment at the nearest available facility. The condition must be one which manifests itself by acute symptoms which are sufficiently severe (including severe pain) that without immediate medical care a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would cause:
His life or health would be in serious jeopardy, or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn Child;
His bodily functions would be seriously impaired; or
A body organ or part would be seriously damaged.
Experimental/Investigational means that a drug, device or medical care or treatment will be considered experimental/investigational if:
The drug or device cannot be lawfully marketed without approval of the Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished; 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.
The informed consent document utilized with the drug, device, medical care or treatment states or indicates that the drug, device, medical care or treatment is part of a clinical trial, experimental phase or investigational phase or if such a consent document is required by law;
The drug, device, medical care or treatment or the patient informed consent document utilized with the drug, device or medical care or treatment was reviewed and approved by the treating facility’s Institutional Review Board or other body serving a similar function, or if federal or state law requires such review and approval;
Reliable Evidence show that the drug, device or medical care or treatment is the subject of ongoing Phase I or Phase II clinical trials, is the research, experimental study or investigational arm of ongoing Phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis; or
Reliable Evidence show that the prevailing opinion among experts regarding the drug, device or medical care or treatment is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis.
Reliable evidence means only: published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility studying substantially the same drug, device or medical care or treatment or the written informed consent used by the treating facility or other facility studying substantially the same drug, device or medical care or treatment. Eligible Expenses will be considered in accordance with the drug, device or medical care at the time the expense is incurred. Management staff in Our Claims Department or a claims payor acting on Our behalf will make the determination if the drug, device or medical care is Experimental/Investigational based on the above criteria.The Company will make the final determination as to whether a service or supply is Experimental/Investigational
Expatriate means (1) a person working or living outside their country of citizenship; (2) a person working outside their country of citizenship and outside the employer’s country of domicile; or (3) non-U.S. citizens working in the United States.
He, His and Him includes “she”, “her” and “hers.”
Home Country means the country where a Plan Participant has his or her true, fixed and permanent home and principal establishment.
Hospital means an institution licensed, accredited or certified by the State that:
1) Operates as a Hospital pursuant to law for the care, treatment and providing in-patient services for sick or injured persons;
2) Is accredited by the Joint Commission on Accreditation of Healthcare Organizations;
3) Provides 24-hour nursing service by registered nurses (R.N.) on duty or call;
4) Has a staff of one or more licensed Physicians available at all times;
5) Provides organized facilities for diagnosis, treatment and surgery, either
a) on its premises; or
b) in facilities available to it, on a pre-arranged basis;
6) Is not primarily a nursing care facility, rest home, convalescent home or similar establishment, or any separate ward, wing or
section of a Hospital used as such; and
7) Is not a place for drug addicts, alcoholics or the aged.
Hospital also includes tax-supported institutions, which are not required to maintain surgical facilities.We will not deny a claim for services solely because the Hospital lacks major surgical facilities and is primarily of a rehabilitative nature, if such rehabilitation is specifically for the treatment of a physical disability, and the Hospital is accredited by any one of the following:
1) the Joint Commission of Accreditation of Hospitals; or
2) the American Osteopathic Association; or
3) the Commission on the Accreditation of Rehabilitative Facilities.
Hospital does not include a place, special ward, floor or other accommodation used for: custodial or educational care; rest, the aged; a nursing home or an institution mainly rendering treatment or services for mental illness or substance abuse, except as specifically stated.
Hospital Stay means a Medically Necessary overnight confinement in a Hospital when room and board and general nursing care are provided for which a per diem charge is made by the Hospital.
Host Country shall mean any country other than the country where an Plan Participant has his or her true, fixed and permanent home and principal establishment.
Illness 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. Any complication or any condition arising out of an Illness for which the Plan Participant is being treated or has received Treatment will be considered as part of the original Illness.
Immediate Family 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 means bodily harm resulting, directly and independently of disease or bodily infirmity, from an Accident. All injuries to the same person sustained in one Accident, including all related conditions and recurring symptoms of injuries will be considered on Injury.
Inpatient shall mean if You are confined in an institution and are charged for room and board.
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
Insurance means the coverage that is provided under the Policy.
Master Application means the Application for the Master Policy.
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.
Medically Necessary means a treatment, drug, device, service, procedure or supply that is:
1) Required, necessary and appropriate for the diagnosis or treatment of a Sickness or Injury; and
2) Prescribed or ordered by a Physician or furnished by a Hospital; and
3) Performed in the least costly setting required by the condition; and
4) Consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered;
5) Not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate Treatment.
When specifically applied to Hospital confinement, it means that the diagnosis or Treatment of symptoms or a condition cannot be safely provided on an outpatient basis.
The purchasing or renting air conditioners, air purifiers, motorized transportation equipment, escalators or elevators in private homes, swimming pools or supplies for them, and general exercise equipment are not considered Medically Necessary. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may consider the cost of the alternative to be the Eligible Expense.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 Policy
A Treatment, drug, device, procedure, supply or service shall not be considered as Medically Necessary if it:
Is Experimental/Investigational or for research purposes;
Is provided for education purposes or the convenience of the Plan Partic ipant, the Plan Participant’s Immediate Family, Physician, Hospital or any other provider;
Exceeds in scope, duration, or intensity that level of care that is needed to provide safe, adequate and appropriate diagnosis or Treatment and where ongoing treatment is merely for maintenance or preventive care;
Could have been omitted without adversely affecting the person’s condition or the quality of medical care;
Involves the use of a medical device, drug or substance not formally approved by the United States Food and Drug Administration;
Involves a service, supply or drug not considered Reasonable and Customary by the Healthcare Financing Administration Medicare Coverage Issues Manual; or
It can be safely provided to the patient on a less cost effective basis such as out-patient, by a different medical professional, or pursuant to a more conservative form of treatment.
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.
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.
Mountaineering means 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 means a flood, hurricane, tornado, earthquake, mudslide, tsunami, avalanche, landslide, volcanic eruption, fire, wildfire or blizzard that is due to natural causes.
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 means a Plan Participant who receives care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for a Sickness or Injury, but who is not confined and is not charged for room and board.
Outpatient Surgical Facility means a surgical or medical center which has (1) permanent facilities for surgery; (2) organized medical staff of Physicians and registered graduate Registered Nurses; (3) is authorized by law in the jurisdiction in which it is located to perform surgical services and is licensed (if no license is required, officially approved) under law.
Out-of-Pocket Maximum means the maximum dollar amount the Plan Participant is responsible to pay during a Benefit Period. After the Plan Participant has reached the Out-of-Pocket Maximum, the Policy pays 100% of Eligible Expenses for the remainder of the Benefit Period. The Out-of-Pocket Maximum is met by accumulated Deductible, Coinsurance . Penalties and amounts above the Reasonable and Customary expenses do not count toward the Out-of-Pocket Maximum. The Out-of-Pocket Maximum is shown on the Schedule of Benefits.
Parachuting means an activity involving the breaking of a free fall from an airplane using a parachute.
Participation/Subscription Agreement means the agreement completed by a Plan Participant for insurance under the Master Policy.
Period of Coverage shall mean the Period of Coverage issued by the Underwriter to the Plan Participant Person, typically beginning with the effective date and ending with the expiration Date or the date coverage is renewed by the Underwriter.
Physician or Legally Qualified Physician or Surgeon means a person who is a qualified practitioner of medicine. As such, He or She must be acting within the scope of his/her license under the laws in the jurisdiction in which He or She practices and providing only those medical services which are within the scope of his/her license or certificate. It does not include a Plan Participant, a Plan Participant’s Spouse, son, daughter, father, mother, brother or sister or other relative.
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 Policy.
Policy means this document, the Master Application of the Policyholder and any end endorsements, riders or amendments that will attach during the Period of Coverage.
Policy Period means the period of time following the Policy’s Effective Date, as shown on the Schedule of Benefits.
Policyholder means the entity shown as the Policyholder in the Schedule of Benefits.
Pre-Existing Condition means 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 thirty-six (36) months prior to the effective date of coverage under this policy, 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 thirty-six (36) month period immediately preceding the effective date of coverage under this policy.
*For U.S. and Canadian residents traveling outside the United States and Canada, the Pre-existing Condition period is twelve (12) months instead of thirty-six (36) months.
Pregnancy means the physical condition of being pregnant, including Complication of Pregnancy.
Reasonable and Customary means the most common charge for similar professional services, drugs, procedures, devices, supplies or Treatment within the area in which the charge is incurred. The most common charge means the lesser of:
The actual amount charged by the provider;
The negotiated rate; or
The charge which would have been made by the provider (Physician, Hospital, etc) for a comparable service or supply made by other providers in the same Geographic Area, as reasonable determined by Us for the same service or supply.
Reasonable and Customary Charges, Fees or Expenses as used in the Policy to describe expense will be considered to mean the percentile of the payment system in effect at Policy issue as shown on the Schedule of Benefits.
Registered Nurse means a licensed registered professional Registered Nurse (R.N.).
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 Plan Participant.
Scheduled Departure Date means the date on which the Plan Participant is originally scheduled to leave on the Plan Participant’s trip.
Scheduled Return Date means the date on which the Plan Participant is originally scheduled to return to the point of origin or the original final destination of the Plan Participant’s trip.
Service Provider means 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, Registered 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 Policy. All related conditions and recurrent symptoms of the same or a similar condition will be considered the same Sickness.
Skilled Nursing Facility means a facility that provides skilled nursing 24 hours a day, seven days a week, under the supervision of a Registered Nurse, and/or skilled rehabilitative services at least five days per week. The emphasis is on skilled nursing care, with restorative, physical, occupational, and other therapies available. A Skilled Nursing Facility provides services that cannot be efficiently or effectively rendered at home or in an intermediate care facility. The service provided must be directed towards the patient achieving independence in activities of daily living, improving the patient’s condition, and facilitating discharge.
Sound Natural Tooth 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, 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 means alcohol, drug or chemical abuse, overuse or dependency.
Surgery or Surgical Procedure means an invasive or diagnostic procedure; or the treatment of Sickness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
Terrorism or 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. Terrorism 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 terrorism can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s).
Third Party means a person or entity other than the Plan Participant, the Policyholder or the Company.
Transportation Expense means the cost of Medically Necessary conveyance, personnel, and services or supplies.
Traveling Companion means a person or persons whose names appear with the Plan Participant’s on the same Travel Arrangements and who, during the Trip, will share accommodations with the Plan Participant in the same room, cabin, condominium unit, apartment unit or other lodging
Treatment 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.
Underwriter or We, Our, Us means Advent, Lloyd’s Syndicate 780 underwriting this insurance.
You, Your, Yours, He or She means the Plan Participant and the Plan Participant’s Spouse or Dependents who meets the eligibility requirements of the Policy and whose insurance under the Policy is in force.
No Benefit shall be payable for Medical, In-Hospital Indemnity, Dental, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Return of Minor Child(ren), Emergency Medical Reunion, as the result of:
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. This exclusion does not apply to Emergency Evacuation/Repatriation.
a. If the Plan Participant is a United States resident, this exclusion is waived up the amount stated in the Schedule of Benefits for eligible medical expenses incurred outside the United States and Canada, minus the Deductible and selected Coinsurance option.
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 49, will not receive benefits from this waiver.If the Plan Participant is a non-U.S. resident under age 70, this exclusion is waived up to the amount stated in the
Schedule of Benefits for eligible medical expenses for an Acute Onset of a Pre-existing Condition(s) (as defined herein) incurred in the United States, minus the Deductible and selected Coinsurance option. 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 49, will not receive benefits from this waiver.
2. Injury or Illness which is not presented to the Underwriter for payment within ninety (90) days of receiving Treatment;
3. Charges for Treatment which is not Medically Necessary;
4. Charges provided at no cost to the Plan Participant;
5. Charges for Treatment which exceed Reasonable and Customary charges;
6. Charges incurred for Surgery or Treatments which are, Experimental/Investigational, or for research purposes;
7. Services, supplies or Treatment, including any period of Hospital confinement, which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
8. Suicide, or any attempt thereof, while sane or self-destruction or any attempt thereof, while sane;
9. War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the Plan Participant 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 Plan Participant 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.
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.
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.
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. 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;
11. 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.
12. Routine physicals, immunizations or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or x-ray examinations, except in the course of a Disablement established by a prior call or attendance of a Physician;
13. Diagnosis or Treatment of the temporomandibular joint;
14. Expenses for vocational, occupational, sleep, speech, recreational or music therapy;
15. Services, supplies, or treatment prescribed, performed or provided by a Relative of the Plan Participant or any Immediate Family member of the Plan Participant or anyone who lives with the Plan Participant. 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, dental expenses except as specifically provided in the Dental (Accident Coverage) benefit;
17. Cosmetic or plastic Surgery (including deviated nasal septum)
18. 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 Plan Participant hereunder; eyeglasses, contact lenses; eye surgery when the primary purpose is to correct nearsightedness, farsightedness or astigmatism;
19. Elective Surgery which can be postponed until the Plan Participant’s return to their Home Country, where the objective of the trip is to seek medical advice, Treatment or Surgery;
20. 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;
21. Any Mental and Nervous disorders or rest cures;
22. Learning disabilities, attitudinal disorders, or disciplinary problems;
23. Congenital abnormalities and conditions arising out of or resulting there from;
24. Expenses which are non-medical in nature;
25. Expenses as a result of or in connection with intentionally self-inflicted Injury or Illness;
26. Expenses as a result of or in connection with the commission of a felony offense;
27. Injury sustained while taking part in Mountaineering, hang gliding, paragliding, Parachuting, 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 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, bungee jumping, water skiing, snow skiing, snowmobiling, snowboarding, and spelunking.
28. Treatment paid for or furnished under any other individual or group policy or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government plan or facility set up for Treatment without any cost to You;
29. 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;
30. Diagnosis and or Treatment of venereal disease, including all sexually transmitted diseases and conditions and any and all consequences thereof;
31. Pregnancy or Illness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from an Accident or Complications of Pregnancy; or for postnatal care;
32. 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;
33. Treatment for human organ tissue transplants and their related treatment;
34. Expenses incurred while in the Plan Participant’s Home Country, except as provided under the Home Country Coverage;
35. Expenses incurred during a Hospital emergency visit which is not of an emergency nature;
36. Covered Expenses incurred for which the Trip to the Host Country was undertaken to seek Medical Treatment for a condition;
37. Covered Expenses incurred during a Trip after the Plan Participant’s Physician has limited or restricted travel;
38. This plan does not insure against loss or damage (including death or Injury) and any associated cost or expense resulting directly from the discharge, explosion or use of any device, weapon or material employing or involving nuclear fission, nuclear fusion or radioactive force, or chemical, biological, radiological or similar agents, whether in time of peace or war, and regardless of who commits the act.
39. Sex change operations, or for Treatment of sexual dysfunction or sexual inadequacy;
40. 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;
41. Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), Aids-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV).
42. Expenses incurred in the United States unless the expenses pertain to the Home Country Coverage Benefit, or unless the option has been selected and applicable premium has been paid in full.
43. Exercise programs, whether or not prescribed or recommended by a Physician;
44. Treatment required as a result of complications or consequences of a Treatment or condition not covered hereunder;
45. 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 the Insurance;
46. Diagnosis or Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive materials;
47. 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;
48. 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;
49. Treatment of sleep apnea or other sleep disorders.
No Benefit shall be payable for Accidental Death and Dismemberment as the result of:
1. Suicide or attempt thereof while sane or self-destruction or any attempt thereof while insane;
2. Disease of any kind; Bacterial infections except pyogenic infection which shall occur through an Accidental cut or wound;
3. Hernia of any kind;
4. Injury sustained while riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting from, any type of aircraft;
5. Injury sustained while 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;
6. 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 Underwriter shall not be liable under this Policy except to the extent that the Plan Participant shall prove that such consequence happened independently of the existence of such abnormal conditions;
7. Service in the military, naval or air service of any country;
8. Flying in any aircraft being used for or in connection with acrobatic or stunt flying, racing or endurance tests;
9. Flying in any rocket-propelled aircraft;
10. Flying in any aircraft being used for or in connection with 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;
11. Flying in any aircraft which is engaged in any flight which requires a special permit or waiver from the authority having jurisdiction over civil aviation, even though granted;
12. Sickness of any kind;
13. Being under the influence of alcohol or having taken drugs or narcotics unless prescribed by a legally qualified Physician or Surgeon;
14. Injury occasioned or occurring while the Plan Participant is committing or attempting to commit a felony or to which a contributing cause was the Plan Participant being engaged in an illegal occupation;
15. While riding or driving in any kind of competition;
16. Pregnancy, childbirth, miscarriage or abortion;
17. This plan does not insure against loss or damage (including death or Injury) and any associated cost or expense resulting directly from the discharge, explosion or use of any device, weapon or material employing or involving nuclear fission, nuclear fusion or radioactive force, or chemical, biological, radiological or similar agents, whether in time of peace or war, and regardless of who commits the act.
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 Plan Participant’s departure from their Home Country that has the likelihood of causing death; the Plan Participant Person or Traveling Companion or Traveling Companion’s Immediate 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 Plan Participant Person purchased their trip arrangements.