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Plan Exclusions


Student Health Advantage Group Platinum

IMPORTANT NOTICE REGARDING PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA): This insurance is not subject to, and does not provide benefits required by, PPACA. On January 1, 2014, PPACA requires U.S. citizens, U.S. nationals and resident-aliens to obtain PPACA compliant insurance coverage unless they are exempt from PPACA. Penalties may be imposed on persons who are required to maintain PPACA compliant coverage but do not do so. Eligibility to purchase or renew this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including PPACA. Please note that it is solely your responsibility to determine if PPACA is applicable to you and the Company and IMG shall have no liability whatsoever, including for any penalties that you may incur, for your failure to obtain required PPACA compliant coverage.


EXCLUSIONS:

Except as expressly provided for in the Schedule of Benefits/Limits, all charges, costs, expenses and/or claims (collectively “Charges”) incurred by the Insured Person, and any claim for death or dismemberment benefits directly or indirectly relating to or arising or resulting from or in connection with any of the following acts, omissions, events, conditions, charges, consequences, claims, Treatment (including diagnoses, 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 or obligation for any coverage thereof or therefor:

(1) War; Military Action
The Company shall not be liable for and will not provide coverage or benefits for any claim or charges incurred with respect to any Illness, Injury, death or 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 events (collectively, “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, 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; and
(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, Illness, 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 the Master Policy or this Certificate, except to the extent that the Insured Person shall prove that such claim, Charges, Illness, Injury or other consequence happened independently of the existence of such abnormal conditions and/or Occurrences.

(2) Terrorism
The Company shall not be liable for and will not provide coverage or benefits in excess of the amount shown in the Schedule of Benefits/Limits for any claim or charges, Illness, 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.
However, the Company shall not under any circumstances be liable for and will not provide any coverage or benefits for any claim, charges, Illness, 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 Insured Person’s active and voluntary planning or coordination of or participation in any act of Terrorism; and/or 2015 Student Health Advantage Group Platinum 17 SHA-GP2015
(b) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning was issued or in effect on or within six (6) months prior to the Insured Person’s date of arrival in said location, post, area, territory or country; and/or
(c) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning becomes effective or is in effect on or after the Insured Person’s date of arrival in said location, post, area, territory or country, and the Insured Person unreasonably fails or refuses to heed such warning and thereafter remains in said location, post, area, territory or country.
 

(3) Pre-existing Conditions
Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance until the Insured Person has maintained coverage under this insurance plan continuously for at least six (6) months; and

(4) for Congenital disorders and conditions arising out of or resulting therefrom; and

(5) Maternity and Newborn Care
Charges for pre-natal care, delivery, post-natal care, and care of Newborns, are excluded from this insurance when conception occurred prior to the Effective Date of Coverage and/or the Pregnancy is a result of Invitro Fertilization; and

(6) Charges for any Treatment or supplies that are:
(a) not incurred, obtained or received by an Insured Person during the Period of Coverage; and/or
(b) not presented to the Company for payment by way of a complete Proof of Claim within ninety (90) days of the date such Charges are incurred; and/or
(c) not administered or ordered by a Physician; and/or
(d) not Medically Necessary; and/or
(e) provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable; and/or
(f) in excess of Usual, Reasonable, and Customary; and/or
(g) incurred by an Insured Person who was HIV + on or before the Effective Date of this insurance relating to or arising or resulting directly or indirectly from HIV, AIDS virus, AIDS related Illness, ARC Syndrome, AIDS and/or any other Illness arising or resulting from any complications or consequences of any of the foregoing conditions; whether or not the Insured Person had knowledge of his/her 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; and/or
(h) provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician; and/or
(i) performed or provided by a Relative of the Insured Person; and/or
(j) not expressly included as Eligible Medical Expenses; and/or
(k) provided by a person who resides or has resided with the Insured Person or in the Insured Person's home; and/or
(l) required or recommended as a result of complications or consequences arising from or related to any Treatment, Illness, Injury, or supply excluded from coverage or which is otherwise not covered under this insurance; and

(7) Charges incurred for telephone consultations except Telemedicine consultations through an established Telemedicine protocol system will be considered individually based on medical necessity and appropriateness as determined by the Company under the plan; and

(8) Charges incurred due to a failure to keep a scheduled appointment; and

(9) Charges incurred for Surgeries or Treatment or supplies which are:

(a) Investigational, Experimental, or for research purposes, and/or
(b) related to genetic medicine, genetic testing, surveillance testing and/or wellness screening procedures for genetically predisposed conditions indicated by genetic medicine or genetic testing, including, but not limited to amniocentesis, genetic screening, risk assessment, preventive and prophylactic surgeries recommended by genetic testing, and/or any procedures used to determine genetic pre-disposition, provide genetic counseling, or administration of gene therapy; and

(10) Charges incurred while confined primarily to receive Custodial Care, Educational or Rehabilitative Care; and

(11) Charges incurred for any Surgery, Treatment or supplies relating to, arising from or in connection with, for, or as a result of:

(a) weight modification or any Inpatient, Outpatient, Surgical or other Treatment of obesity (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms or procedures of bariatric Surgery by whatever name called, or reversal thereof, including without limitation intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling; and/or
(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 Insured Person (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof); and/or
(c) 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; and/or
(d) any Illness or Injury sustained while taking part in: Professional Athletics, or other athletic activity that is sponsored or sanctioned by the International Olympic Committee, and adventure sports and activities, including, without limitation the following (including any combination or derivative of the following): abseiling; mountaineering activities where specialized climbing equipment, ropes or guides are normally or reasonably should have been used; athletic or sporting activities (except for activities that are non-contact, non-collision and engaged in by the Insured Person solely for recreational, entertainment or fitness purposes); aviation (except when travelling solely as a passenger in a commercial aircraft); BMX; BASE jumping; bobsledding; bungee jumping; canyoning; caving; hang gliding; heli-skiing; high diving; hot air ballooning; inline skating; jet skiing; jungle zip lining; kiteboarding; kayaking; luge; motocross (MOTO-X); mountain biking; parachuting; paragliding; parascending; rappelling; racing of any kind including without limitation by horse, motor, motorcycle, automobile, or any other motorized or non-motorized vehicle of any type or other means; rock climbing; any rodeo activity; ski jumping; sky diving; snow skiing except for recreational downhill and/or cross country snow skiing (provided that there is no coverage for any Illness of Injury sustained while skiing in violation of applicable laws, rules or regulations; away from prepared and marked in-bound territories; and/or against the advice of the local ski school or local authoritative body); snowboarding; snowmobiling; spelunking; surfing; trekking; whitewater rafting; windsurfing; wildlife safaris; and sub-aqua pursuits involving underwater breathing apparatus below a depth of 30 meters. Practice or training in preparation for any excluded activity which results in Illness or Injury will be considered as activity while taking part in such activity; and/or
(e) any Illness or Injury sustained while participating in 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; and/or
(f) any Illness 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; and/or
(g) any Injury or Illness 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 but not for the Treatment of Substance Abuse; and/or
(h) any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician. For purposes of this exclusion, “vehicle” shall include motorized devices regardless of whether or not a driver or operator license is required (including watercraft and aircraft) and non-motorized bicycles and scooters for which no permit or license is required; and/or
(i) any willfully Self-inflicted Injury or Illness; and/or
(j) any sexually transmitted or venereal disease; and/or
(k) any testing for the following: HIV, seropositivity to the AIDS virus, AIDS related Illnesses, ARC Syndrome, AIDS; and/or
(l) any Illness or Injury resulting from or occurring during the commission of a violation of law by the Insured Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations; and/or
(m) any Substance Abuse except as otherwise expressly set forth; and/or
(n) speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy; and/or
(o) orthoptics, visual therapy or visual eye training; and/or
(p) any Illness 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; provided, however, that claims for Treatment or supplies for the feet may be eligible for coverage under this insurance at the sole option of the Company and subject to all other Terms of this insurance when related to:
(i) an Injury to the foot arising from an Accident covered hereunder; and/or
(ii) an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment; and/or
(q) hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician; and/or
(r) any sleep disorder, including without limitation sleep apnea; and/or
(s) any exercise program, whether or not prescribed or recommended by a Physician; and/or
(t) any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s); and/or
(u) any organ or tissue or other transplant or related services, Treatment or supplies; and/or
(v) any artificial or mechanical devices designed to replace human organs temporarily or permanently after termination of Inpatient status; and/or
(w) any efforts to keep a donor alive for a transplant procedure; and/or
(x) any Illness or Injury resulting from or sustained after entering the Host Country and as a result of epidemics, pandemics, public health emergencies, natural disasters, or other disease outbreak conditions that may affect a person’s health and about which the World Health Organization has issued an Emergency Travel Advisory, US Centers for Disease Control & Prevention has issued a Warning Level 3 (avoid nonessential travel), or similar governmental agency of the Insured Person’s Country of Residence had published, communicated or issued a Travel Warning restriction or official declaration informing the public about such health issues before the Insured Person traveled to the Host Country; and

(12) Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception or birth; including but not limited to: artificial insemination; oral contraceptives, Treatment for infertility or impotency; vasectomy or reversal of vasectomy; sterilization or reversal of sterilization; surrogacy or abortion; and

(13) Charges incurred for any Treatment or supply that either promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction; and

(14) Charges incurred for Dental Treatment, except as otherwise expressly set forth; and

(15) Charges incurred for eyeglasses, contact lenses, hearing aids, hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason; and

(16) Charges incurred for eye Surgery, such as but not limited to radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness, or astigmatism; and

(17) Charges incurred for Treatment of the temporomandibular joint; and

(18) Charges incurred for any immunizations and/or routine physical exams; and

(19) Charges incurred while in the Insured Person’s Home Country, except as otherwise expressly provided for hereunder; and

(20) Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and

(21) Any taxes, involuntary or forced contributions, assessments, charges, fees or surcharges imposed by any governmental agency or authority:
(a) arising out of or as a result of any Treatment or supplies received by the Insured Person; and/or
(b) based upon the Company’s election hereunder, if any, to pay benefits directly to providers as an accommodation to the Insured Person; and/or
(c) for any other reason; and

(22) Charges or expenses incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the U.S. Food and Drug Administration or which are considered “off-label” drug use; and for drugs or medicines not prescribed by a Physician; and

(23) Charges for Treatment or supplies for temporomandibular joint syndrome and/or craniomandibular syndrome; and

(24) Charges and all costs related to or arising from or in connection with all trips to the Host Country undertaken for the purpose of securing medical Treatment or supplies; and

(25) Charges incurred for hospice care; and

(26) Accidental Death or Dismemberment when the Insured Person’s death or dismemberment is caused directly or indirectly by, results from, or where there is a contribution from, any of the following:
(a) bodily or mental infirmity, illness or disease, or
(b) infection, other than infection occurring simultaneously with, and as a direct result of, the accidental injury.