Benefits are not payable for any loss caused by, or resulting from, a Pre-existing Condition, unless the loss is incurred at least 6 months after the covered person’s effective date. This provision applies only to the Hospitalization and Surgery benefits of the plan.
“Pre-existing Condition” means a medical condition, injury or sickness for which a covered person has been diagnosed or treated within the 6 months prior to their effective date under the plan.
The Pre-existing Condition Limitation will be waived for groups with 10 or more eligible employees. For groups with less than 10 eligible employees, the Pre-existing Condition Limitation can be waived – for initial enrollees only - if the employer previously provided similar coverage under another policy and there is no lapse in coverage between plans. In this case, any employees enrolled after the group’s initial effective date will be subject to the Pre-existing Condition Limitation.
The Limited Medical Indemnity Plan will not pay benefits for any loss, injury or sickness that is caused by, or results from:
- Suicide or any intentionally self-inflicted injury
- commission, or attempt to commit, a felony
- participation in a riot, or insurrection
- any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any controlled substance unless administered on the advice of a physician
- declared or undeclared war or act of war
- surgery to correct vision or hearing; eyeglasses, contact lenses and hearing aids, braces, appliances, or examinations or prescriptions therefore
- dental care, x-rays or treatment other than injury to sound, natural teeth and gums resulting from an accidental injury and rendered within 6 months of the injury
- weight loss or modification and complications arising therefrom, including surgery and any other form of treatment for the purpose of weight loss or modification
- treatment, services or supplies received travel or activity outside of the U.nited S.tates, except for acute sickness or injury sustained during the first 30 days of travel outside the U.S.
- any drug, treatment, or procedure that either promotes or prevents conception or childbirth regardless of what the drug, treatment, or procedure was originally prescribed or intended for
- treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy
- cosmetic surgery. Cosmetic surgery means surgery that is performed to alter or reshape normal structures of the body in order to improve the patient’s appearance. This Exclusion does not apply to , except for reconstructive surgery. Reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
- (1) to improve function.
- (2) to create a normal appearance, to the extent possible.
- The repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices; dentures, partial dentures, braces or fixed or removable bridges
- Prescription medicines
- For AD&D benefits only, any injury that is caused by flight or travel in, or upon:
(a) an aircraft or other craft designed for navigation above or beyond the earth’s atmosphere except as a fare-paying passenger (b) an ultra light, hang-gliding, parachuting or bungi-cord jumping (c) a snowmobile (d) any two or three wheeled motor vehicle (e) any off-road motorized vehicle not requiring licensing as a motor vehicle (f) any watercraft or other craft designed for water use above or beneath the water, except as a fare-paying passenger
- Any accidental injury where the covered person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator’s license
- Services, treatment or loss:
(a) rendered in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay (b) payable by any automobile insurance policy without regard to fault (does not apply in any state where prohibited) (c) which a covered person would not have to pay if he did not have insurance (d) provided by a doctor, nurse or any other person who is employed or retained by the employer or who is a member of the covered person’s immediate family (e) covered by state or federal workers’ compensation, employer’s liability, occupational disease law, or similar laws (f) injury or sickness sustained while on active duty in the armed forces of any country. This does not include Reserve or National Guard duty for training. Upon receipt of proof of service, we will refund any unearned premium paid on a pro rata basis
- Treatment, procedures, products or services that are experimental or investigative. “Experimental or Investigative” means a drug, device or medical treatment or procedure that:
(a) cannot lawfully be marketed without approval of the United States Food and Drug Administration and approval for marketing has not been given at the time of being furnished (b) has Reliable Evidence indicating it is the subject of ongoing clinical trials or is under study to determine its maximum tolerated dose, toxicity, safety, efficacy, or its efficacy as compared with the standard means of treatments or diagnosis; or (c) has Reliable Evidence indicating that the consensus of opinion among experts is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.
“Reliable Evidence” means (i) published reports and articles in authoritative medical and scientific literature; (ii) the written protocol(s) of the treating facility or the protocols of another facility studying substantially the same drug, device, medical treatment or procedure; or (iii) the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.
- for any procedure begun before the covered person was covered under the policy, except for Comprehensive Orthodontic Treatment or as provided in the Description Benefits or as provided under the Takeover Benefits
- for any procedure begun after the covered person’s coverage under the policy ends, except as provided by the Extension of Benefits
- to replace lost, missing, stolen or duplicate appliances
- for any procedure which is not shown on the Description of Benefits
- for education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control
- for the completion of claim forms or missed or broken appointments, for the review of a proposed treatment plan or case presentation by a dentist or any charges in connection with a covered person’s transfer to another dentist
- to a covered person because of a dental condition or injury for which he is eligible for benefits under any Worker’s Compensation act or similar laws
- for charges for which the covered person is not liable or which would not have been made had no insurance been in force
- for services which are not recommended by a dentist or which are not dentally necessary
- because of war or any act of war, declared or not
- for any dental condition or injury that is intentionally self-inflicted
- for prescribed drugs, medications or for prescription take-home fluoride
- for devices such as, but not limited to, night guards, mouth guards; TMJ splilnts, and inhibiting appliances for thumbsucking or devices and supplies of the type normally intended for sport or home
- for replacement of serviceable dental work for any reason except as a result of injury
- for any procedure or service a covered person requests to treat, modify, correct or change an existing dental condition which at the time the initial procedure was performed was then considered acceptable according to the standards of medicine or dentistry