The Accident Plan does not provide benefits for the following:
Claims for benefits received after the timely filing period of 12 months after initial treatment.
Injuries incurred prior to the effective date of coverage.
Treatment, services or supplies which:
Are not Medically Necessary;
Are not prescribed by a Physician as necessary to treat an injury;
Are determined to be experimental/investigational in nature;
Are received without charge or legal obligation to pay;
Are received from persons employed or retained by any family member, unless otherwise specified; or
Are not specifically listed as benefits in the plan.
Injury by acts of war, whether declared or not.
Injury received while traveling or flying by air, except as a fare-paying passenger and not as a pilot or crew member, on a regularly scheduled commercial airline.
Injury covered by Worker’s Compensation, Employer Liability law or Occupational Disease Act or Law.
Injury sustained while committing or attempting to commit an illegal act.
Any bacterial infection (except pyogenic infections which shall occur with and through an accidental cut or wound).
Suicide or attempted suicide while sane or insane.
Intentionally self-inflicted injury.
Loss resulting from being legally intoxicated or under the influence of alcohol as defined by the laws of the state of jurisdiction in which the injury occurs.
Loss resulting from being under the influence of drugs or narcotics unless Notesadministered on the advice of a Physician.
Injury sustained while participating in or practicing for any professional or sports activity, in which there is some form of remuneration.
Injury which occurs while a Covered Person is on active duty service in any armed forces. Reserve or National Guard active duty for training is not excluded unless it extends beyond 31 days.
Injury sustained flying in an ultra-light, hang gliding, parachuting or bungee-cord jumping, by flight in a any flying craft.
Content source: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control
Cosmetic surgery, except for reconstructive surgery on an injured part of the body.
Covered Charges incurred outside of the United States or its possessions.
Driving in any organized or scheduled race or speed test or while testing an automobile or any vehicle on any racetrack or speedway or waterway.
Handling, storing or transporting explosives.
Scaling up clifs or mountain walls.
Scuba Diving or Spelunking (exploring caves).
Participation in martial arts or mixed martial arts if over the age of 18
Reinjury or complications on an injury caused or contributed to by a condition that existed before the Accident.
Repetitive motion injuries, strains, hernia, tendonitis, bursitis and heat exhaustion not related to a specific injury.
The Critical Illness Plan does not provide benefits for the following
Claims for benefits received after the timely filing period of 12 months after first diagnosis.
There is a 12/12 pre-existing exclusion. This means anything which was diagnosed within 12 months prior to the effective date of coverage is not covered for the first 12 months of coverage.
Any disease first diagnosed within the waiting period as showing in the schedule, immediately following the effective date. If tissue is extracted during the waiting period or prior to the efective date and results in a positive diagnosis of cancer, this will not be a covered condition. The date of a positive diagnosis of cancer will be considered to be the earlier of the date of clinical diagnosis or the date the specimen used to diagnose cancer is taken. If a positive diagnosis of cancer is made and/or cancer is treated within the waiting period or if medical advice is given within the waiting period which leads to the subsequent positive diagnosis of cancer after the waiting period, the member has the option to cancel their plan and receive a refund of all contributions paid.
Any amount in excess of any maximum benefit for covered conditions.
Diseases or conditions that do not meet the definition of a covered condition in the plan
Suicide or attempted suicide while sane or insane.
Intentionally self-inflicted injury.
Loss resulting from being legally intoxicated or under the influence of alcohol as defined by the laws of the state of jurisdiction in which the injury occurs.
Loss resulting from being under the influence of drugs or narcotics unless administered on the advice of a Physician.
Any act of war or participation in a riot, insurrection or rebellion.
The Hospital Indemnity Plan does not provide benefits for the following
Claims for benefits received after the timely filing period of 12 months after initial treatment.
Suicide or attempted suicide while sane or insane.
Intentionally self-inflicted injury.
Loss resulting from being legally intoxicated or under the influence of alcohol as defined by the laws of the state of jurisdiction in which the injury occurs.
Loss resulting from being under the influence of drugs or narcotics unless administered on the advice of a Physician.
Any act of war or participation in a riot, insurrection or rebellion.
Elective surgery.
Surgery to correct vision or hearing, unless a result of a covered Injury, medically necessary surgery for glaucoma, cataracts or other sickness or injury.
Dental care, dental x-rays, or dental treatment.
Gastric or intestinal bypass services, including lap banding, gastric stapling, and other
similar procedures to facilitate weight loss; the reversal, or revision of such procedures; or
services required for the treatment of complications from such procedures.
Rest cures or custodial care, or treatment of sleep disorders.
Cosmetic surgery. This exclusion does not apply to reconstructive surgery:
on an injured part of the body following infection or disease of the involved part, of a congenital disease
or anomaly of a covered dependent newborn or adopted infant;
or on a non-diseased breast to restore and achieve symmetry between two breasts following a Mastectomy.
Care or treatment for mental, nervous or substance abuse-related disorders (unless otherwise stated).
Surgery and treatment, procedures, products or services that are experimental or investigative.
Driving in any organized or scheduled race or speed test or while testing an automobile or any vehicle on any racetrack or speedway or waterway.
Hospital Confinement and/or Hospital Admission due to any covered person’s giving birth or complications of pregnancy within the first 9 months after the Covered Person’s effective date under this plan as a result of a normal pregnancy, including cesarean section.
Any covered dependent child giving birth or complications of pregnancy.
Treatment of a covered dependent child’s children.
Sickness or Injury sustained while on active duty in the armed forces of any country. This does not include Reserve or National Guard duty for training.
Injury or illness covered by Worker’s Compensation, Employer Liability law, or Occupational Disease Act or Law.
