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What Is Not Covered (Diplomat America Policy Exclusions)

The Plan Document does not cover any loss resulting from any of the following unless otherwise covered under the Plan Document by Additional Benefits:

(1) Suicide, attempted suicide (including drug overdose) self-destruction, attempted self-destruction or intentional self-inflicted Injury while sane or insane;

(2) War or any act of war, declared or undeclared;

(3) Any Covered Loss which occurs while the Plan Participant is on Active Duty Service in any Armed Forces, National Guard, military, naval or air service or organized reserve corps;

(4) Any Covered Loss sustained while in the service of the armed forces of any country. When the Plan Participant enters the armed forces of any country, We will refund the unearned pro rata premium upon request;

(5) Voluntary, active participation in a riot or insurrection;

(6) Medical expenses resulting from a motor vehicle accident in excess of that which is payable under any other valid and collectible insurance;

(7) Medical Treatment related to organ transplants, whether as donor or recipient; this includes expenses incurred for the evaluation process, the transplant surgery, post operative treatment, and expenses incurred in obtaining, storing or transporting a donor organ. In relation to a bone marrow or stem cell transplant this exclusion would include harvesting & mobilization charges;

(8) For any Covered Losses resulting from the Plan Participant's intoxication or use of illegal drugs or any drugs or medication that is intentionally not taken in the dosage recommended by the manufacturer or for the purpose prescribed by the Plan Participant's Physician;

(9) Commission or attempt to commit an assault or felony, or that occurs while being engaged in an illegal occupation;

(10) Eligible Expenses for which the Plan Participant would not be responsible in the absence of the Policy;

(11) Treatment of acne;

(12) Charges which are in excess of Usual, Reasonable and Customary charges;

(13) Charges that are not Medically Necessary;

(14) Charges provided at no cost to the Plan Participant;

(15) Expenses incurred for treatment while in Your Home Country;

(16) Expenses incurred for an Accident or Injury or Sickness after the Benefit Period shown in the Schedule of Benefits or incurred after the termination date of coverage;

(17) Regular health checkups; routine physical, immunizations or other examination where there are no objective indications or impairment in normal health;

(18) Services or treatment rendered by a Physician, Registered Nurse or any other person who is employed or retained by the Policyholder; or an Immediate Family member of the Plan Participant;

(19) Duplicate services actually provided by both a certified nurse midwife and Physician;

(20) Any Covered Loss paid under Workers Compensation, Employers liability laws or similar occupational benefits or while engaging in an occupation for monetary gain from sources other than the Policyholder;

(21) Benefits for enrolling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a Physician;

(22) Aggravation or re-injury of a prior Injury that the Plan Participant suffered prior to his or her coverage Effective Date, unless We receive a written medical release from the Plan Participants Physician;

(23) Pre-existing conditions; (This exclusion does not apply to Emergency Evacuation/Repatriation or Return of Mortal Remains);

(24) Treatment of a hernia, including sports hernia, whether or not caused by a Covered Accident;

(25) Pregnancy or childbirth, elective abortion; elective cesarean section; or any complications of any of these conditions; pregnancy or childbirth of a dependent when dependent child of a Plan Participant

(26) 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, or abortion;

(27) Charges incurred for Surgery or treatments which are, Experimental/Investigational, or for research purposes;

(28) Expense incurred for treatment of temporomandibular joint (TMJ) disorders or craniomandibular joint dysfunction and associated myofacial pain;

(29) Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury resulting from an Accident or emergency pain relief treatment to natural teeth while the Plan Participant is covered under the Policy, and rendered within 6 months of the Accident;

(30) Eyeglasses, contact lenses, hearing aids braces, appliances, or examinations or prescriptions therefore;

(31) Weak, strained or flat feet, corns, calluses, or toenails;

(32) Private-duty nursing services;

(33) The cost of the Plan Participants unused airline ticket for the transportation back to the Plan Participants Home Country, where an Emergency Medical Evacuation or Repatriation and/or Return of Mortal Remains benefit is provided;

(34) Expenses payable under any prior policy which was in force for the person making the claim;

(35) For the cost of a one way airplane ticket used in the transportation back to the Insured's country where an air ambulance benefit is provided and medically necessary;

(36) Treatment paid for or furnished under any other individual or group policy, or other service or medical prepayment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for the treatment without cost to any individual;

(37) Travel in or upon:

  • (a) A snowmobile;
  • (b) A water jet ski;
  • (c) Any two or three wheeled motor vehicle, other than a motorcycle registered for on-road travel;
  • (d) Any off-road motorized vehicle not requiring licensing as a motor vehicle; when used for recreation or competition. Unless the Hazardous Activity Benefit is purchased.

  • (38) Injury sustained while taking part in: mountaineering; hang gliding; parachuting; bungee jumping; racing by horse, motor vehicle or motorcycle; snowmobiling; motorcycle/motor scooter riding; scuba diving, involving underwater breathing apparatus, water skiing; snow skiing; spelunking parasailing; white water rafting; surfing, unless part of a school credit course; and snowboarding. Unless the Hazardous Activity Benefit is purchased.

    (39) Practice or play in any amateur, club, intramural, interscholastic, intercollegiate, sports contest or competition. Unless Athletic Sports Rider is purchased.

    (40) Practice or play in any professional or semiprofessional sports contest or competition;

    (41) Rest cures or custodial care;

    (42) Treatment of Mental and Nervous Disorders;

    (43) Weight reduction programs or surgical treatment of obesity;

    (44) Treatment of venereal disease;

    (45) Elective or Cosmetic surgery and Elective Treatment or treatment for congenital anomalies (except as specifically provided), except for reconstructive surgery on a diseased or injured part of the body (Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness);

    (46) Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from:

  • (a) While riding as a passenger in any Aircraft not intended or licensed for the transportation of passengers; or
  • (b) While being used for any test or experimental purpose; or
  • (c) While piloting, operating, learning to operate or serving as a member of the crew thereof; or
  • (d) while traveling in any such Aircraft or device which is owned or leased by or on behalf of the Policyholder of any subsidiary or affiliate of the Policyholder, or by the Plan Participant or any member of his household.
  • (e) A space craft or any craft designed for navigation above or beyond the earth's atmosphere; or
  • (f) An ultra light, hang-gliding, parachuting or bungi-cord jumping; Unless the Hazardous Activity Benefit is purchased. Except as a fare paying passenger on a regularly scheduled commercial airline or as a passenger in a non-scheduled, private aircraft used for business or pleasure purposes.

  • (47) Ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste, from combustion of nuclear fuel, the radioactive, toxic, explosive or other hazardous properties of any nuclear assembly or nuclear component of such assembly.

    (48) Plan Participant being exposed to the Utilisation of nuclear, chemical or biological weapons of mass destruction.

    (49) Treatment of HIV infection, HIV related illness and AIDS (acquired immune deficiency syndrome) in excess of a lifetime maximum of $7,500;

    (50) Expenses incurred for services, testing and treatment of Sleep Apnea. In addition to any of the exclusions listed above, for Eligible Expenses under Trip Interruption, this Insurance also does not cover the following:

  • (1) The Plan Participant or Traveling Companion or Traveling Companions 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);
  • (2) Prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which the Plan Participant purchased their trip arrangements;
  • (3) A Pre-Existing Condition existing prior to the Plan Participants departure from their Home Country.

    In addition to any of the exclusions listed above, for Eligible Expenses under Baggage Loss, this Insurance also does not cover the following:

  • (1) Animals;
  • (2) Artificial teeth or limbs, hearing aids;
  • (3) Sunglasses, contact lenses or eyeglasses;
  • (4) Professional or occupational equipment or property, whether or not electronic business equipment or;
  • (5) Telephones or PDA devices, computer hardware or software. No Benefit will be payable for Home Alteration and Vehicle Modification, as the result of: Any condition for which the Plan Participant Person is entitled to benefits under any Workers Compensation Act or similar law.
  • Disclaimer

    Plan features listed here are high level, provided for your convenience and information purpose only. Please review the Evidence of Coverage and Plan Contract (Policy) for a detailed description of Coverage Benefits, Limitations and Exclusions. Must read the Policy Brochure and Plan Details for complete and accurate details. Only the Terms and Conditions of Coverage Benefits listed in the policy are binding.