Coverage is not provided for loss due to a pre-existing condition for 12 months from the effective date of the Covered Person’s insurance. Pre-existing condition means: (a) the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a one year period preceding the effective date of the Covered Person’s insurance; or (b) a condition for which medical advice or treatment was recommended by a Doctor or received from a Doctor within a one year period preceding the effective date of the Covered Person’s insurance.
No benefits will be paid by this policy for any loss or Injury that is caused by, results from, or is contributed to by:
1. Intentionally self-inflicted Injury, suicide or attempted suicide, while sane.
2. War or any act of war, whether declared or not.
3. Active participation in a riot or insurrection.
4. Service in the military, naval or air service of any country, or international organization.
5. Piloting or serving as a crewmember or riding in any aircraft except as a fare-paying passenger on a regularly scheduled or charter airline.
6. Work related injuries covered under Worker’s Compensation, Employer’s Liability Laws, or similar occupational benefits
7. Medical mishap or negligence, including malpractice
8. While traveling outside the United States, Canada, Mexico, or any United States possessions, except for a Medical Emergency or a covered Accidental Death or Accidental Dismemberment..
9. Treatment provided in a governmental hospital, benefits provided under a government program (except Medicaid or Medicare), and any other services for which no charge is normally made in the absence of insurance.
10. Treatment by an Immediate Family member or a member of the Covered Person’s household.
11. Alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a Doctor.
12. Cosmetic care, except for Medically Necessary reconstructive plastic surgery. Reconstructive plastic surgery is defined as:
a. Surgery to restore normal bodily functions; or
b. Surgery to improve functional impairment by anatomic alteration made necessary as a result of a congenital birth defect; or
c. Breast reconstruction following a mastectomy.
13. Dental treatment, except for Injury to sound, natural teeth.
14. Hernia, adenoids, tonsils, varicose veins, appendix, disorder of the reproductive organs, voluntary abortion, or elective sterilization with 6 months after the Covered Person’s effective date of insurance.
15. Rest care, convalescent care, or rehabilitative care.
16. Treatment of Mental or Nervous Disorders.
In addition to the General Exclusions, no benefits will be paid by this policy for Injury or death to which a contributing cause is:
1 The Covered Person’s violation or attempt to violate any duly enacted law, or the commission or attempt to commit an assault or a felony, or that occurs while the Insured is engaged in an illegal activity or occupation.
2 Injury or death from an Accident where the Covered Person’s intoxication would be considered a contributing cause to the Accident. Intoxication is determined according to the laws and/or regulations of the jurisdiction in which the Accident occurred. It will be considered a contributing cause if:
a. An investigation into the cause of the Accident by a police department or other government body makes such determination; or
b. It meets a “prudent and reasonable” test. “Prudent and reasonable” means that a review of the circumstances of the Accident by an ordinarily prudent person would find that the most reasonable interpretation of the facts indicate that intoxication was a causal factor.
3 Loss for which the Covered Person would not be responsible in the absence of this Coverage.
In addition to the General Exclusions, Accident Medical/Dental Expense Benefits will not be paid for:
1. Treatment of hernia, Osgood-Schlatter’s Disease, osteochronditis, appendicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, or detached retina unless caused by Injury, whether or not caused by a Covered Accident.
2. Pregnancy, childbirth, miscarriage, abortion or any complications of any of these conditions.
3. Mental and Nervous Disorders (except as provided in the Group Policy).
4. Damage to or loss of dentures or bridges, or damage to existing orthodontic equipment (except as specifically covered by the Group Policy).
5. Expense incurred for treatment of Temporomandibular or Craniomandibular joint dysfunction and associated myofacial pain (except as provided by the Group Policy).
6. Covered medical expenses for which the Covered Person would not be responsible in the absence of this Coverage.
7. Any expense paid or payable by any other valid and collectible group insurance plan.
8. Conditions that are not caused by a Covered Accident.
9. Any treatment, service or supply not specifically covered by the Group Policy.
This package of benefits is not a substitute for comprehensive health insurance.