ACE Limited Accident and Sickness Plan

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Exclusions

The Limited Accident & Sickness Indemnity Insurance Plan will not pay benefits for any loss or injury 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 force 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 license, except while participating in driver's education program.
travel or activity outside the United States except for a medical emergency.
alcoholism, the voluntary use of illegal drugs; the intentional taking of over the counter medication not in accordance with recommended dosage and warning instructions; intentional misuse of prescription drugs, unless specifically provided in the Policy.
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.
injury to a covered person resulting from that covered person’s willful violation of the employer’s rules or regulations. Willful violation includes, but is not limited to: a) working without protective clothing, helmets, gloves, etc., required by the employer’s rules or regulations; or b) participating in any activity that is in violation of the employer’s rules or regulations.
pre-existing conditions* occurring within the first 6 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 illness disorders except as provided by the 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 investigational by the company at the time the procedure is done. For the purposes of this exclusion, “experimental or investigational” means medical services, supplies or treatments provided or performed in a special setting for research purposes, under a treatment protocol or as part of a clinical trial (Phase I, II or III). The covered service will also be considered experimental or investigational if the covered person is required to sign a consent form that indicates the proposed treatment or procedure is part of a scientific study or medical research to determine its effectiveness or safety. Medical treatment, that is not considered standard treatment by the majority of the medical community or by Medicare, Medicaid or any other government financed programs or the National Cancer Institute regarding malignancies, will be considered experimental or investigational. A drug, device or biological product is considered experimental or investigational if it does not have FDA approval or approval under an interim step in the FDA process, i.e., an investigational device exemption or an investigational new drug exemption.
treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications.
treatment or services provided by a private duty nurse, unless provided for in the Policy.
treatment by a family member or member of the covered person’s family.
routine dental care and treatment, except for treatment of Injury as specified in the Policy.
piloting or serving as a crewmember or riding in any aircraft except as a fare-paying passenger on a regularly scheduled or charter airline (for AD&D benefit only).
bungi-cord jumping, parachuting, skydiving, parasailing, hang-gliding (for AD&D benefit only).
flight in, boarding or alighting from an aircraft except as a fare-paying passenger on a regularly scheduled commercial airline (for AD&D benefit only).
travel in or on any on-road and off-road motorized vehicle not requiring licensing as a motor vehicle (for AD&D benefit only).
travel in any aircraft owned, leased or controlled by the employer, or any of its subsidiaries or affiliates. An aircraft will be deemed to be “controlled” by the employer if the aircraft may be used as the employer wishes for more than 10 straight days, or more than 15 days in any year (for AD&D benefit only).

*A pre-existing condition is an illness, 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 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.

This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit ACE American Insurance Company from providing insurance, including, but not limited to, the payment of claims.

Exclusions Specific To Dental Coverage

No Dental indemnity Benefits will be paid for expenses incurred:

for services and supplies not listed in the Schedule of Benefits, and/or not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.
for any treatment program which began prior to the date the Insured is covered under the Policy except comprehensive orthodontic treatment or as provided in the Schedule of Benefits.
for any condition covered under any Worker’s Compensation Act or similar law.
for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance.
for services subject to a waiting period that were incurred during the waiting period.
for charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services.
for drugs or the dispensing of drugs except injectible antibiotics administered by a doctor as a result of dental treatment.
for oral hygiene instruction; plaque control; acid etch; prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes).
for athletic mouth guards; TMJ dysfunction.
for orthodontia, unless included within the Schedule of Benefits.
for services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage under this Plan unless provided in the Schedule of Benefits. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits.
for the replacement of retainers.
during travel or activity outside the United States.
for services which result from the voluntary use of illegal drugs, the intentional taking of over-the-counter medication not in accordance with recommended dosage and warning instructions, intentional misuse of prescription drugs.

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