Exclusions and Limitations

Exclusions and Limitations:  
This Plan does not cover nor provide benefits for:
1. Expense incurred as the result of dental treatment, except for treatment resulting from Injury to sound, natural teeth.
2. Services normally provided without charge by the Policyholder’s health service, Infirmary, or Hospital, or by Health Care Providers employed by the Policyholder.
3. Eyeglasses, contact lenses, hearing aids, or prescriptions or examinations for them.
4. Injury due to participation in a riot.
5. Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare paying passenger in an aircraft operated by a scheduled airline maintaining regular published schedules on a regularly established route.
6. A loss resulting from war or any act of war, whether declared or not.
7. Injury or sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation.
8. Injury sustained or Sickness contracted while in the service of the Armed Forces of any country.  We will return a pro-rata premium for any period not covered upon request.  
9. Treatment provided in a governmental Hospital unless there is a legal obligation to pay such charges in the absence of insurance.
10. Elective treatment or elective surgery, except as specifically provided.
11. Cosmetic or plastic surgery, except as a result of Injury.
12. Treatment of mental or nervous disorders except as specifically provided.
13. Treatment of substance abuse except as specifically provided.
14. For foreign students, expenses incurred within the Covered Person’s Home Country or Country of regular domicile.
15. Routine physicals, preventive medicines, serums, or vaccines as prescribed, except as specifically provided.
16. Voluntary or elective abortions except as specifically provided.
17. Expense incurred after the date of insurance terminates for an Insured Person except as may be specifically provided in the Extension of Benefits Provision.
18. For services, supplies or treatment; including any period of hospital confinement, which were not recommended, approved and certified as necessary and reasonable by a Doctor; or expenses non-medical in nature.
19. Participation in a riot or civil disorder, commission of or attempt to commit a felony or illegal act.
20. Suicide, attempted suicide, or intentionally self-inflicted injury.
21. For expenses that occur while the Covered Person is under the influence of any drug unless administered under the advice and consent of a Doctor..
22. Injury resulting from the play or practice of interscholastic, club, intercollegiate or professional sports.
23. Expense incurred for: topical acne treatments; fertility medication; legend vitamins or food supplements; smoking deterrents; immunization agents; biological sera; blood plasma; drugs to promote or stimulate hair growth; experimental drugs; drugs dispensed in a hospital or rest home.

Pre-Existing Conditions Limitation:
No benefits will be paid for expenses incurred for a Pre-existing Condition as defined herein. Pre-existing Conditions as used herein means  an illness, disease or other condition of the Covered Person, that in the six month period before the Covered Person’s coverage became effective under the Policy: a) first manifested itself, worsened, became acute or exhibited symptoms that would have caused a person to seek diagnosis, care or treatment; or b) required taking prescribed drugs or medicines, unless the condition for which the prescribed drug or medicine is taken remains controlled without any change in the required prescription; or c) was treated by a Doctor or treatment had been recommended by a Doctor.  This limitation does not apply after the Covered Person has been insured under the policy for six consecutive months.  Credit will be allowed toward satisfying the six (6) month period if the Insured Person was covered under a Qualifying Previous Health coverage within sixty-three (63) days immediately prior to the effective date of this coverage exclusive of any applicable waiting period.  If a Covered Person is continuously insured under a qualified student health insurance program from one policy year to the next, an Injury, Sickness or condition that manifests itself during a prior year’s coverage will not be considered a pre-existing Injury, Sickness or condition.  Qualifying Previous Health Coverage means any (a) blanket or general policy of medical, surgical or hospital insurance, (b) policy of accident or sickness insurance,
(c) non-group medical, surgical or hospital insurance, (d) non-group or group hospital or medical plan issued by a nonprofit hospital or medical service corporation, (e) non-group health maintenance issued by a Health Maintenance Organization, (f) self-funded or self-insured employer group plan, (g) health coverage provided to persons serving in the armed forces of the United States, or (h) Medicare or Medicaid which was in effect within 63 days prior to the Covered Person’s effective date of coverage.

Subrogation

If claims for an Injury or Sickness are incurred by a Covered Person, and it appears that the Injury or Sickness was due to the fault of someone else, this Plan will not pay for such claims until it has obtained documentation from the Covered Person establishing its reimbursement rights in accordance with this provision.