General Exclusions and Limitations

The Limited Accident & Sickness Insurance Plan will not pay benefits for any loss or injury that is caused by, or results from:

1. intentionally self-inflicted injury.
2. suicide or attempted suicide.
3. war or any act of war, whether declared or not.
4. service in the military, naval or air force of any country.
5. commission of or attempt to commit a felony, an assault or other illegal activity.
6. commission of or active participation in a riot, or insurrection.
7. 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.
8. medical or surgical treatment, diagnostic procedure, administration of anesthesia related to medical mishap or negligence, including malpractice.
9. travel or activity outside the United States except for a medical emergency.
10. alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a doctor unless specifically provided herein.
11. repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration.
12. repair, replacement, examinations for prescriptions or the fitting of eyeglasses or contact lenses.
13. 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.
14. medical expenses and disability for which the covered person is entitled to benefits under any Worker's Compensation Act.
15. medical expenses paid or payable under any mandatory no fault automobile insurance contract or mandatory basic reparations benefit of no fault.
16. 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) competing or 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.
17. pre-existing conditions* occurring within the first 6 months of coverage (applies to hospital & surgery benefits only).
18. 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.
19. mental illness disorders except as provided by the policy.
20. covered medical expenses for which the covered person would not be responsible for in the absence of this plan.
21. cosmetic surgery, except for reconstructive surgery needed as the result of an injury or sickness.
22. 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.
23. 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).
24. bungi-cord jumping, parachuting, skydiving, parasailing, hang-gliding (for AD&D benefit only).
25. 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).
26. travel in or on any on-road and off-road motorized vehicle not requiring licensing as a motor vehicle (for AD&D benefit only).
27. 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.

Exclusions Specific to the Dental Care Benefits of the Plan

Benefits are not provided for any charges or expenses incurred by a covered person which result directly or indirectly, wholly or partly from:

• Replacement of a tooth extracted prior to the covered person’s effective date;
• Dentures, crowns, inlays, onlays, bridgework or appliances or services for increasing vertical dimensions;
• Denture or bridgework adjustments;
• Replacement of a lost or stolen prosthesis or for a duplicate prosthesis;
• Oral hygiene, diet or plague control instructions and programs;
• Athletic mouth guards;
• Temporary denture or bridge;
• Failure to appear as scheduled for an appointment;
• Tooth re-implantology not resulting from an accident;
• Drugs except for injectable antibiotics administered by a dentist;
• Procedures, services, or supplies, which do not meet accepted standards of dental practice;
• Treatment initiated prior to coverage under the plan, except for comprehensive orthodontic treatment as defined by the policy; or
• Expenses which are not specifically listed in the Schedule of Benefits.

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