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 and the United States is your Home Country, this exclusion is waived for Eligible Benefits incurred outside the United States and Canada as defined below:
1) For persons less than age 65 with a Primary Health Plan as defined in the policy, Pre-Existing Conditions are waived up to the medical maximum selected.
2) For persons less than age 65 without a Primary Health Plan as defined in the policy, Pre-Existing Conditions are waived up to the first $20,000.
3) For persons age 65 and over, Pre-Existing Conditions are waived up to the first $2,500 regardless of whether there is a Primary Health Plan.
This waiver does not include coverage for known, scheduled, required, 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-United States citizen and suffer a Myocardial Infarction or Stroke and are admitted to a Hospital, this exclusion is waived only in order to pay a $200 per night benefit for each night spent in the Hospital, up to a maximum benefit of $3,000. The term “Myocardial Infarction” shall require an acute and emergent onset of the condition. The term “Stroke” shall require an acute and emergent onset of the condition.
2. Charges for Treatment(s) of the following Illness(es) or Surgery(ies), which Manifest(ed) themselves or are recommended, or symptoms occur during the first one hundred and eighty (180) days of Coverage hereunder beginning on the initial Effective Date: any condition of the breast; any treatment of all forms of cancer/neoplasm; any condition of the prostate; disorders of the reproductive system; hysterectomy; gall stones or urologic stones (kidney, ureteral, bladder or urethral stones) and any associated complications; any acne diagnosis or acne related condition; asthma; allergies; tonsillectomy; back conditions; adenoidectomy; hemorrhoids; hemorrhoidectomy; hernia, or any Surgery(ies) that is(are) not Emergency in nature, as Emergency is defined hereunder. (Does not apply to United States citizens traveling outside of the United States and Canada)
3. Claims not received by Seven Corners within ninety (90) days of the date of service;
4. 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 nonmedical in nature;
5. Expenses for Vocational, Speech, Recreational or Music Therapy;
6. Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
7. Suicide or any attempt thereof; 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 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; ii) 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). iii) 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). iv) 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;
12. Routine physicals, innoculations, 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. Treatment of the Temporomandibular joint;
14. Services or supplies performed or provided by a Relative of the Insured Person, or anyone who lives with the Insured Person;
15. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids, cosmetic or plastic Surgery (including deviated nasal septum), routine dental expenses, 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;
16. 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;
17. Any Mental and Nervous disorders or Rest Cures;
18. Congenital abnormalities and conditions arising out of or resulting therefrom;
19. Learning disabilities, attitudinal disorders, or disciplinary problems;
20. Weight reduction programs or the surgical treatment of obesity;
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, zip lining, racing by any animal or motor vehicle or motorcycle, snowmobiling, motorcycle/motor scooter riding (whether as passenger or driver), scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing and snow boarding, luge, motocross, Moto X, skateboarding, and any other sport or athletic 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. Mountaineering shall mean the sport, hobby or profession of walking, hiking, and climbing either: 1) utilizing harnesses, ropes, crampons, or ice axes; or 2) ascending 4,500 meters or above. Parachuting shall mean an activity involving the breaking of a free fall using a parachute. (UNLESS HAZARDOUS SPORTS RIDER IS PURCHASED, see section labeled Hazardous Sports Coverage);
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. Treatment of venereal or sexually transmitted disease;
25. Sex change operations, or for treatment of sexual dysfunction or sexual inadequacy;
26. Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV).
27. Pregnancy expenses or Illness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from an Accident;
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 treatment is a follow-up to a covered disablement during coverage (see Home Country Coverage Benefit) or if the expenses pertain to 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. Expenses incurred as a result of the Insured’s failure to accept or follow a Physician’s advice, treatment, or recommended treatment.
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 the following: war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war.
a) mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power.
b) 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 du jure or de facto or to the influencing of it by terrorism or violence.
c) 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 plan 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;
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 (3) months prior to the effective date of coverage.
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 Loss 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.