Limited Accident and Sickness Plan Exclusions
What's Not Covered?
SecureCare Limited Accident and Sickness Insurance Plans underwritten by ACE American Insurance Co. will not pay for any loss, injury or sickness that is caused by, or results from:
- Intentionally self-inflicted injury.
- Suicide or attempted suicide.
- War or any act of war, whether declared or not.
- Service in the military, naval or air service of any country.
- Commission of, or attempt to commit, a felony, an assault or other illegal activity.
- Commission of or active participation in a riot, or insurrection.
- An accident if the covered person is the operator of a motor vehicle and does not possess a valid motor vehicle operator's licenses, except while participating in a Driver's Education Program.
- Medical or surgical treatment, diagnostic procedure, administration of anesthesia related to medical mishap or negligence, including malpractice.
- Travel or activity outside the United States, except for a Medical Emergency.
- Alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a Doctor unless specifically provided herein.
- Repair or replacement of existing dentures, partial dentures, braces fixed or removable bridges, or other artificial dental restoration.
- Repair, replacement, examinations for prescriptions or the fitting of eyeglasses or contact lenses.
- While the covered person is legally intoxicated (as determined by that state's laws) or while under the influence of any drug unless administered under the advice and consent of a Physician.
- Medical expenses and disability for which the covered person is entitled to benefits under any Worker's Compensation Act.
- Medical expenses paid or parable under any mandatory no fault automobile insurance contract or mandatory basic reparations benefit if no fault.
- Injury to a covered person resulting from that covered person's willful violation of the Policyholder's rules or regulations. Willful violations includes, but is not limited to: a) competing without protective clothing, helmets, gloves, etc. required by the Policyholder's rules or regulations; or b) competing in a racing vehicle that is in violation of the Policyholder's rules or regulations.
- Pre-Existing Conditions* occurring in the first six months of coverage (applies to Hospital & Surgery benefits only).
- Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed.
- Mental and Nervous Disorders (except as provided in the Policy).
- Covered medical expenses for which the covered person would not be responsible for in the absence of this Policy.
- Cosmetic surgery, except for reconstructive surgery needed as the result of an injury or sickness.
- Experimental or Investigational drugs, services, supplies or any procedure held to be experimental or investigatory by Us at the time the procedure is done.
* A Pre-Existing Condition is an illness or disease or other condition, that in the 6 month period before the person's coverage is effective:
- first manifested itself, worsened, became acute or exhibited the symptoms that would have caused an ordinarily prudent person to seek diagnosis, care or treatment; or
- 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
- was treated by a doctor or treatment had been recommended by a doctor.
What's not covered by the Insured Generic Drug Plan?
No Prescription Drug Benefits (Optional Insured Generic Drug Co-Pay Plan) will be paid for:
- Brand Name Prescription Drugs.
- All over-the-counter products and medications unless shown in the definition of Prescription Drug. This includes, but is not limited to, electrolyte replacement, infant formulas, miscellaneous nutritional supplements, and all other over-the counter products and medications.
- Blood glucose meters and insulin injecting devices.
- Depo-Provera; condoms, contraceptive sponges, and spermicides; sexual dysfunction drugs.
- Biologicals (including allergy tests); blood products; growth hormones; hemophiliac factors; MS injectables; immunizations; and all other injectables unless shown in the definition of Prescription Drug.
- Medical supplies and durable medical equipment.
- Liquid nutritional supplements; pediatric Legend Drug vitamins; prescribed versions of Vitamins A, D, K, B12, Folic Acid and Niacin - used in treatment versus as a dietary supplement; and all other Legend Drug vitamins and nutritional supplements.
- Anorexiants; any cosmetic drugs including, but not limited to, Renova and skin pigmentation preps; any drugs or products used for the treatment of baldness; and topical dental fluorides.
- Refills in excess of that specified by the prescribing Doctor, or refills dispensed after one year from the original date of the prescription.
- Any drug labeled "Caution - limited by Federal Law for Investigational Use" or experimental drugs.
- Any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment.
- Drugs needed due to conditions caused, directly or indirectly, by a covered person taking part in a riot or other civil disorder; or the covered person taking part in the commission of a felony.
- Drugs needed due to conditions caused, directly or indirectly, by declared or undeclared war or any act of war; or drugs dispensed to a covered person while on active duty service in any armed forces.
- Any expenses related to the administration of any drug.
- Drugs or medicines taken while in or administered by a Hospital or any other health care facility or office.
- Drugs covered under Worker's Compensation, Medicare, Medicaid or other governmental program.
- Drugs, medicines or products which are not Medically Necessary.
- Diaphragms; erectile dysfunction Legend Drugs; and infertility Legend Drugs.
- Epi-Pen, Epi-Pen Jr., Ana-Kit, Ana-Guard; Glucagon-auto injection; and Imitrex-auto injection.
- Smoking deterrents, Legend or over-the-counter drugs.
- Replacement of stolen medication (except under circumstances approved by Us), or lost, spilled, broken or dropped Prescription Drugs.
- Vacation supplies of Prescription Drugs (except under circumstances approved by Us).
- All newly marketed pharmaceuticals or currently market pharmaceuticals with a new FDA approved indication for a period of one year from such FDA approval for its intended indication.