Terms &
Conditions
Exclusions
Benefits
otherwise provided by the Policy will not be payable for
services or expenses or any Loss resulting from or in
connection with the following:
- Dental treatment except (a) dental treatment
required by Covered Injury to sound, natural teeth, or
(b) benefits described in the Dental Benefits
provision of the Policy or provided by optional rider,
if any;
- War or any act of war;
- Service in the armed forces or units auxiliary
thereto. Premiums will be refunded on a pro-rata basis
for any Insured Person who enters military services
and all coverage for that Insured Person will be
suspended until military service is over;
- Any intentional self-inflicted injury, suicide or
attempted suicide;
- Addiction to, overdose of or sickness or injury
resulting from use of drugs, narcotics, hallucinogens,
controlled or uncontrolled substances unless
administered on and according to the advice of a
Physician, except as stated in the Hospital and
Intensive Care Confinement Indemnity Benefits
provision;
- Hospitalization for which the principal purpose is
physical examination or diagnosis;
- Routine well-baby care;
- Elective abortion or any elective procedure or
treatment;
- Services or supplies provided solely for cosmetic
purposes, unless necessitated as a result of
accidental injury sustained while covered by the
Policy;
- Alcoholism or any sickness or injury to which a
contributing cause was the Insured Person’s being
under the influence of or resulting from the use of
intoxicants, except as stated in the Hospital and
Intensive Care Confinement Indemnity Benefits
provision;
- Aviation of any type, except as a fare-paying
passenger on a regularly scheduled flight on a
commercial airline;
- Services performed by the Insured Person or a
member of the Insured Person’s immediate family as
defined under Physician;
- Mental or Nervous Disorders without demonstrable
organic disease, except as stated in the Hospital and
Intensive Care Confinement Indemnity Benefits
provision;
- Care or treatment for which no charges are made
which an Insured Person is required to pay, except in
cases of Medicaid;
- Confinement or treatment in any convalescent home,
sanitarium, convalescent rest or nursing facilities,
facilities for the aged, or facilities for drug
addiction or alcoholism, except as stated in the
Hospital and Intensive Care Confinement Indemnity
Benefits provision;
- An Insured Person’s commission of or attempt to
commit a felony or any Loss to which a contributing
cause was the Insured Person’s being engaged in an
illegal occupation;
- Charges incurred outside the United States, if an
Insured Person traveled to the location for the
purpose of receiving medical services, drugs or
supplies; and
- Participation in a riot, rebellion or
insurrection.
Limitations
- When an Insured Person attains age 65 or becomes
eligible for Medicare, whichever occurs first, the
benefits of the Policy and its Attachments, if any,
are payable only to the extent that Covered Expenses
are not paid by Medicare and would otherwise be
payable under the Policy. The benefits will also be
subject to any other EXCLUSIONS AND LIMITATIONS set
forth in the Policy.
- The Policy does not provide benefits for Covered
Injury or Covered Sickness occurring or first
Manifesting itself prior to the Certificate Effective
Date, subject to the Pre-Existing Conditions
Limitation. The Policy does not provide any benefits
for any expense incurred prior to the Certificate
Effective Date.
Pre-Existing Conditions
Limitation
The Policy does not provide
benefits for Loss or Losses due to Pre-Existing
Conditions which are incurred during the twelve-month
period following the Certificate Effective Date. Losses
due to Pre-Existing Conditions, not excluded by name or
specific description, which are incurred on and after
the first anniversary date of the Certificate Effective
Date for an Insured will be paid as a Covered Sickness
or Covered Injury. This Pre-Existing Conditions
limitation does not apply to the Annual Physical
Examination benefit provided by the
Policy.
Renewability /
Termination
The Group Policy/Certificate will
automatically terminate at the end of a grace period if
the premium is not paid. The Group Policy under which
the Certificate is issued may be amended or cancelled at
any time as stated in its provisions. Coverage for you
and/or your dependents will end automatically on the
first day of the month that (a) you cease to be eligible
for coverage, (b) you are no longer an employee of the
participating employer, (c) the employer’s group falls
below the required participation levels stated in the
Group Policy, or (d) the last day of the month in which
your dependent(s) no longer meets the definition of a
dependent as defined in the Certificate. If you request
termination of insurance and wish to re-enroll at a
later date, we reserve the right to require a waiting
period.
Benefit exclusions and limitations may
apply to the policy and riders. For costs or complete
details of coverage, contact your agent or the
Company.
Underwritten By:
ABC Insurance Company
10700 Any street ,
Houston, TX 77092
U.S.A.
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