|
• |
Treatment, services or supplies incurred for:
|
|
• |
Hospital room and board and general nursing care up to
the semi-private room rate limited to 30 days.
|
|
• |
Intensive Care. |
|
• |
Hospital miscellaneous expense |
|
• |
Operating room expense |
|
• |
Doctor’s fees for surgery. No more than one surgical
procedure will be covered when multiple procedures are
performed through the same incision or in immediate
succession. However, benefits will be payable up to 1.57
times the surgical procedure charge when more than one
surgical procedure through different operating fields
are performed during the same surgical session.
|
|
• |
Assistant surgeon expense. |
|
• |
Anesthesia services |
|
• |
Doctors visits, inpatient and outpatient.
|
|
• |
Hospital Emergency care or care in other Emergency
facility. |
|
• |
Outpatient services |
|
• |
X-ray and laboratory services |
|
• |
Ambulance expense |
|
• |
Durable Medical Equipment |
|
• |
Registered Nurse expense |
|
EXCLUSIONS |
|
|
This Certificate does not provide benefits for: |
|
|
Treatment services or supplies which: |
|
• |
Are not Medically Necessary; |
|
• |
Are not prescribed by a Doctor as necessary to treat an
Injury; |
|
• |
Are determined to be Experimental/Investigational in
nature; |
|
• |
Are received without charge or legal obligation to pay;
|
|
• |
Are received from persons employed or retained by the
Policyholder or any Family Member, unless otherwise
specified; or |
|
• |
Are not specifically listed as Covered Charges in this
Certificate. |
|
• |
Intentionally self-inflicted Injury, violating or
attempting to violate any duly enacted law. |
|
• |
Injury by acts of war, whether declared or not.
|
|
• |
Injury received while traveling or flying by air, except
as a fare-paying passenger on a regularly scheduled
commercial airline. |
|
• |
Injury or Sickness arising out of or in the course of
employment and which is paid or received under any
Workers’ Compensation or Occupational Disease Act or
Law. |
|
• |
Treatment of illness, disease or infections, except
pyogenic infections or bacterial infections which result
from the accidental ingestion of contaminated substances |
|
• |
Heat exhaustion. |
|
• |
Treatment of Osgood-Schlatter’s disease; appendicitis;
osteomyelitis; pathological fractures; congenital
weakness; hernia; TMJ; fainting; headaches; boils;
spondylolysis; osteochondritis dissecans; detached
retina unless directly caused by Injury; or Mental or
Nervous Disorders whether or not caused by Injury. |
|
• |
Injury contributed to by the use of alcohol or drugs not
prescribed by a Doctor. |
|
• |
Suicide or attempted suicide while sane; or
self-destruction or an attempt to self-destroy while
insane. CAXXEX102 |
|
• |
Dental treatment, except as specifically stated.
CAFLEX300 |
|
• |
Loss resulting from being legally intoxicated or under
the influence of alcohol as defined by the laws of the
state in which the Injury occurs. |
|
• |
Loss resulting from being under the influence of any
drugs or narcotic unless administered on the advice of a
Doctor. |
|
• |
Injury sustained while operating, riding in or upon,
mounting or alighting from, any two- or three- wheeled
recreational motor/engine driven vehicle or snowmobile
or all terrain vehicle (ATV). CAXXEX400 |
|
• |
Injury which occurs while the Insured is on active duty
service in any armed forces. Reserve or National Guard
active duty for training is not excluded unless it
extends beyond 31 days. |
|
• |
Injury sustained flying in an ultra light, hang gliding,
parachuting or bungi-cord jumping, byflight in a space
craft or any craft designed for navigation above or
beyond the earth’s atmosphere. |
|
• |
Treatment in any Veteran’s Administration or federal
Hospital, except if there is a legal obligation to pay. |
|
• |
Cosmetic surgery, except for reconstructive surgery on
an injured part of the body. CAXXEX600 |
|
v |
Covered Charges incurred outside of the United States or
its possessions, unless such Covered Charges are
incurred while the Covered Person is on a trip of not
more than 30 days. CAXXEX700 |
|
• |
Injury resulting from participation in organized sports
for Covered Persons over the age of 18. |
|
• |
Physical Therapy or Physiotherapy, spinal manipulation,
and manual manipulative treatment or therapy, where
allowed. |
Max
