Except as expressly provided for in Benefit Summary, all Charges, Cost, expenses and/or claims incurred by the Covered Person, and directly or indirectly relating to or arising or resulting from or in connection with any of the following acts, omissions, events, conditions, expenses, consequences, Treatment (including diagnosis, consultations, tests, examinations and evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Company shall provide no benefits or reimbursements and shall have no liability obligation for any coverage thereof or thereafter:
1. Pre-Existing Conditions: Expenses incurred resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance except and unless the Charges resulted directly from a sudden and unplanned recurrence or Acute Exacerbation of a Stable Pre-Existing Condition, in which case the charges will be covered only according to the Terms of PRE-EXISTING CONDITION Benefit provision.
2. Any condition that requires immediate medical attention within five (5) days following the Effective Date unless the Charges resulted directly from a sudden and unplanned recurrence or Acute Exacerbation of a Stable Pre-Existing Condition, in which case the charges will be covered only according to the Terms of PRE-EXISTING CONDITION Benefit provision.
3. Expenses incurred a) for any potentially fatal condition diagnosed before the Effective Date; b) any condition for which the Covered Person is traveling to seek medical Treatment; c) traveling against the advice of a Physician, while on a waiting list for Inpatient Hospital or clinic treatment.
4. Expenses incurred for any condition directly or indirectly related to or caused by cancer, dialysis, or any ongoing or preventative care associated therewith. This exclusion applies notwithstanding the PRE-EXISTING CONDITION BENEFIT provision.
5. Expenses incurred for Chronic, Congenital, congenital anomalies, or recurrent Sicknesses and conditions arising out of or resulting therefrom, except to the extent expressly covered under the PRE-EXISTING CONDITION BENEFIT provision.
6. Expenses incurred for complications, consequences, or Treatment arising from or related to a) any Treatment, Sickness, Injury, or supply received prior to the effective date of coverage under this insurance; b) any condition, Treatment, Injury, Sickness, or supply excluded from coverage or otherwise not covered under this insurance; or c) complications due to any Sickness or Injury not covered under this insurance.
7. Expenses incurred for any sexually transmitted or venereal disease; and/or any testing for the following: HIV, Vaccine induced seropositivity to the AIDS virus, AIDS related Sicknesses, ARC Syndrome, AIDS. This exclusion includes Charges for any Treatment or supplies for a Covered Person who was HIV + on or before the Initial Effective Date of this insurance, whether or not the Covered Person had knowledge of their HIV status prior to the Effective Date, and whether or not the Charges are incurred in relation to or as a result of said status. As well as conditions arising or resulting directly or indirectly from HIV, AIDS virus, AIDS related Sickness, ARC Syndrome, AIDS and/or any other Sickness arising or resulting from any complications or consequences of any of the foregoing conditions.
8. Expenses incurred for the Treatment of hernia; Dengue Fever; Osgood-Schlatter’s Disease; osteochondritis; osteomyelitis.
9. Expenses incurred related to any medical examination, treatment and surgical intervention which are not administered in a licensed healthcare institution.
10. Expenses incurred at a Hospital or Facility when the Covered Person checks themself out Against Medical Advice (AMA) of their Physician and leaves before reaching a Medically Necessary specified endpoint of Treatment or when the Sickness or Injury worsens after the Covered Person Left or discharged from the Facility Against Medical Advice.
11. Expenses incurred related to medical examination where no Sickness has been diagnosed or Accident has been ascertained; for any visit to a medical provider that does not result in a covered Diagnosis code after medical review or testing and for non-specified pain.
12. Expenses incurred services, supplies, or treatment expenses which are non-medical in nature.
13. Expenses incurred for Elective Surgery or Treatment of any kind
14. Expenses incurred for Surgeries, Treatment or supplies which are Investigational, Experimental and for research purposes.
15. Expenses incurred Treatment not administered or ordered by a Physician.
16. Expenses incurred Treatment not Medically Necessary for the Diagnosis, care or Treatment of the physical condition involved. This also applies when and if they are prescribed, recommended, or approved by the attending Physician.
17. Expenses incurred for: a) nonprescription drugs, medicines, vitamins, food extracts, nutritional supplements, IV vitamin therapy, or herbal therapy; b) drugs or medicines not prescribed by a Physician; c) drugs, medications, biological products, Durable Medical Equipment (DME), devices, supplies, services, surgeries, or procedures not approved by the United States Food and Drug Administration (FDA); or d) drugs or medicines considered "off-label" use.
18. Expenses incurred for: a) immunizations, vaccinations, routine or preventive examinations, wellness screenings, laboratory testing, or diagnostic imaging where there is no objective indication of disease, illness, Injury, or impairment of health; or b) Genetic Medicine, genetic testing, surveillance testing, genetic counseling, wellness screening procedures, gene therapy, prophylactic surgery, risk assessment, or treatment associated with genetic testing or genetically predisposed conditions.
19. Expenses incurred for: a) eye refractions, eye examinations for corrective lenses, or fitting of corrective lenses unless required as a result of a covered accidental bodily Injury; b) refractive eye surgery performed primarily to correct nearsightedness, farsightedness, or astigmatism; or c) contact lenses, hearing aids, wheelchairs, braces, appliances, artificial limbs, orthopedic braces, orthotic devices, orthoptics, visual therapy, visual training, artificial eyes, larynx devices, examinations, prescriptions, repairs, or replacements relating thereto.
20. Expenses incurred any non-surgical Sickness or Treatment of the feet, including without limitation: orthopedic shoes; orthopedic prescription devices to be attached to or placed in shoes; Treatment of weak, strained, flat, unstable, or unbalanced feet; metatarsalgia, bone spurs, hammer toes or bunions; and any Treatment or supplies for corns, calluses, or toenails.
21. Expenses incurred for childbirth, pre-natal care, delivery, post-natal care, and care of Newborns, including complications of delivery and/or of newborns, birth control, artificial insemination, treatment for fertility or impotency, sterilization or reversal thereof, or abortion.
22. Expenses incurred or Treatment for a) cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and follows a Surgery which was covered under this insurance; b) modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Covered Person; c) weight modification or any Inpatient, Outpatient, Surgical or other Treatment of obesity; d) hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician.
23. Expenses incurred for suicide or attempted suicide, intentional self-injury, while under the effect of intoxicating liquors or drugs.
24. Expenses incurred for any mental or nervous disorders or rest cures.
25. Expenses incurred any Substance Abuse Disorder or any Injury or Sickness sustained as a result of being under the influence of or due wholly or partly to the effects of alcohol, liquor, intoxicating substance, narcotics or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician.
26. Expenses incurred for a) organ, tissue, or marrow transplants; or b) any efforts to keep a donor alive or donor-related expenses associated with a transplant procedure.
27. Expenses incurred for Treatment or supplies for a) wear and tear of teeth due to cavities and chewing or biting down on hard objects, such as but not limited to pencils, ice cubes, nuts, popcorn, and hard candies. b) for Dental Injury without associated face, skull, neck and/or jaws c) Dental Injury or that can be evaluated and Treated in a dental office. d) or Dental services which provide oral care maintenance including tooth repair by fillings, root canals, tooth removal and x-rays; e) temporomandibular joint (TMJ), craniomandibular syndrome, chronic TMJ pain, orthognathic surgery, Le-Fort Surgery, or splints, or f) any dental treatment, except as specifically provided for hereunder.
28. Expenses incurred for: a) private duty nursing; b) custodial care; c) educational, rehabilitative, skilled nursing, or nursing care; or d) hospice care.
29. Expenses incurred for: a) massage therapy, biofeedback, acupuncture, music therapy, occupational therapy, recreational therapy, sleep therapy, speech therapy, or vocational therapy; b) treatment of sleep disorders, including sleep apnea; c) exercise or fitness programs or equipment; or d) Treatment provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician.
30. Expenses incurred for any Sickness or Injury sustained while participating in any activity where such activity is undertaken in disregard of or against the recommendations, Treatment programs, or medical advice of a Physician or other healthcare provider.
31. Expenses incurred for any Sickness or Injury sustained while taking part in, practicing or training for, participating in: a) a Professional or Semi-Professional Sport; b) an amateur, club, intramural, interscholastic or intercollegiate sport or athletic activities that are sponsored by any governing body or authority; c) activities designated as Adventure Sports, which include, but are not limited to the following: abseiling; BMX; bobsledding; bungee jumping; canyoning; caving; hot air ballooning; jungle zip lining; parachuting; paragliding; parascending; rappelling; skydiving; spelunking; and windsurfing. d) Extreme Sports, which include but are in no way limited to the following (and include any combination or derivative of the following): BASE jumping; big game hunting; cave diving; cliff diving; downhill mountain biking and racing; extreme skiing; freediving; free flying; free running; free skiing; freestyle scootering; gliding; heli-skiing; ice canoeing; ice climbing; kitesurfing; mixed martial arts; motocross; motorcycle racing; motor rally; mountaineering or trekking above elevation of 3500 meters; parkour; piloting a commercial or non-commercial aircraft; powerbocking; scuba diving; sub aqua pursuits; snowmobile racing; truck racing; whitewater kayaking or whitewater rafting Class VI and higher difficulty; and wingsuit flying; e) while taking part in snow skiing, snowboarding, or snowmobiling where the Covered Person is in violation of applicable laws, rules, or regulations of a ski resort, out of bounds or in unmarked or unpatrolled areas; backcountry skiing, skiing off-piste; f) Collision Sports; g) athletic or recreational activities where the Covered Person is not physically or medically fit or does not hold the necessary qualifications to engage in said activities; g) any sporting, recreational or adventure activity where such activity is undertaken against the advice or direction of any local authority or any qualified instructor or contrary to the rules, recommendations, and procedures of a recognized Governing Body for the sport or activity.
32. Expenses incurred for any artificial or mechanical devices designed to replace human organs temporarily or permanently after termination of Inpatient status except as covered under MECHANICAL EQUIPMENT RENTAL FOR TREATMENT OF RESPIRATORY PARALYSIS.
33. Expenses incurred for Treatment paid for or furnished under a) any other individual or group insurance policy, employer-sponsored medical plan, medical prepayment plan, or mandatory government program; or b) any workers' compensation law or similar benefit program.
34. Expenses incurred for care or Treatment in the Covered Person’s Country of Residence.
35. Expenses incurred not presented to the Company for payment by way of a completed Proof of Claim within ninety (90) days from the date such Charges are incurred.
36. Expenses incurred in excess of Usual and Customary Charges.
37. Expenses or fees incurred or for a) the completion of Medical Claim Forms b) failure to keep a scheduled appointment. c) due to fluctuations in exchange rates or for any bank charges the Covered Person incurs when a check, bank transfer, or payment is received from the Company.
38. Expenses incurred any Treatment, service or supply not specifically covered by this insurance.
39. Expenses incurred for which the Covered Person would not be responsible for in the absence of this insurance.
40. Expenses incurred for Treatment or supplies that are not incurred, obtained, or received by a Covered Person during the Period of Insurance.
41. Expenses incurred Treatment performed or provided by a Relative of the Covered Person or provided by a person who resides or has resided with the Covered Person or in the Covered Person's home.
42. Expenses incurred for any Sickness or Injury resulting from or occurring during the commission of a violation of law by the Covered Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
43. Expenses incurred for Sickness or Injury incurred in the Destination Country, Affected Area, or Country of Residence as a result of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, which may affect a Covered Person’s health, unless coverage is expressly provided under the PUBLIC HEALTH EMERGENCY provision of this insurance.
44. Expenses incurred for the ordinary cost of a one-way airplane ticket used in the transportation back to the Covered Person’s country where an air ambulance benefit is provided.
45. Expenses incurred for any travel, transportation and/or accommodations, except as otherwise expressly provided for under RETURN OF MINOR CHILDREN OR GRAND-CHILDREN OR TRAVELING COMPANION.
46. The Company shall not be liable for and will not provide coverage or benefits for any claim or Charges incurred with respect to any Sickness, Injury, death and dismemberment, or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising or incurred in connection with or as a result of any of the following acts or occurrences: (a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war (b) mutiny, riot, strike, military or popular uprising, insurrection, insurgency, rebellion, revolution, military or usurped power (c) 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 de jure or de facto or to the influencing of it by violence of any type (d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (e) any use of radiological, chemical, nuclear or biological weapons or any other radiological, chemical, nuclear or biological events of any type (including in connection with an act of Terrorism). Any claim, Charges, Sickness, Injury or other consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether or not 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 and considered to be consequences for which the Company shall not be liable under this this insurance, except to the extent that the Covered Person shall prove that such claim, Charges, Sickness, Injury or other consequence happened independently of the existence of such abnormal conditions and/or occurrences.
47. The Company shall not be liable for any claim or Charges, Sickness, 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. Further, the Company shall not be liable for and will not provide any coverage or benefits for any claim, Charges, Sickness, 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 Covered Person’s active and voluntary planning or coordination of or participation in any act of Terrorism (b) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning or Emergency Travel Advisory was issued or in effect on or within six (6) months prior to the Covered Person’s date of arrival in said location, post, area, territory or country (c) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning or Emergency Travel Advisory becomes effective or is in effect on or after the Covered Person’s date of arrival in said location, post, area, territory or country, and the Covered Person unreasonably fails or refuses to heed such warning and thereafter remains in said location, post, area, territory or country.
48. The Company will not cover any person as under this insurance, if such cover would result in the Company being exposed to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws, or regulations of the European Union, United Kingdom, or the United States of America.
