Group hospital indemnity exclusions and limitations
What are the exclusions that apply in the event of a sickness, accident, or injury?
In no event will we pay benefits where the insured’s accident, injury or sickness is caused directly or indirectly by, results in whole or in part from or during, or there is contribution from, any of the following: self-inflicted injury, self-destruction, or autoeroticism, whether sane or insane; or suicide or attempted suicide, whether sane or insane; or your participation in, or your attempt to commit, a crime, assault, felony, or any illegal activity, regardless of any legal proceedings thereto; or the use of alcohol [(this exclusion does not apply to the drug and/or alcohol treatment (inpatient) benefit and the mental health treatment (inpatient) benefit)]; or the use of prescription drugs, non-prescription drugs, illegal drugs, medications, poisons, gases, fumes or other substances taken, absorbed, inhaled, ingested or injected [(this exclusion does not apply to the drug and/or alcohol treatment (inpatient) benefit and the mental health treatment (inpatient) benefit)]; or war or any act of war, whether declared or undeclared; or dental or plastic surgery for cosmetic purposes except when due to: a) reconstructive surgery, when the service is related to or follows surgery resulting from a covered accident or sickness; or b) a congenital disease or anomaly of a covered dependent child; or c) congenital defects in newborns; or a newborn child’s routine nursing or routine well baby care during the initial confinement in a hospital; or routine vaginal delivery of a child or children or delivery of a child or children by non-emergency cesarean section for the first 10 months following the insured’s coverage effective date.
What additional exclusions apply in the event of an accident or injury?
In no event will we pay benefits where the insured’s accident or injury is caused directly or indirectly by, results in whole or in part from or during, or there is contribution from, any of the following:
(1) motor vehicle collision or accident where the insured is the operator of the motor vehicle and the insured’s blood alcohol level meets or exceeds the level at which intoxication is defined in the state where the collision or accident occurred, regardless of any legal proceedings thereto; or (2) bodily or mental infirmity, sickness; or (3) infection, other than infection occurring simultaneously with, and as a direct and independent result of, the injury; or (4) travel in or descent from any aircraft, except as a fare-paying passenger on a regularly scheduled commercial flight on a licensed passenger aircraft carrier; or (5) participation in the following activities: scuba diving, bungee jumping, base jumping, hang gliding, sail gliding, parasailing, parakiting, or mountain climbing; or (6) riding or driving in any motor-driven vehicle in a race, stunt show or speed test; or (7) resulting complications from medical or surgical treatment or diagnostic procedures when the outcome is not as planned or expected, including claims of medical malpractice; or (8) practicing for or participating in any semi-professional or professional competitive athletics.
Are there any additional limitations that apply?
Yes. Benefits are not payable for any confinement, care, treatment or diagnostic measures which were received outside of the United States or United States territory.