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Group Critical Illness Exclusions and Limitations

Pre-existing condition limitation (12/12)

A pre-existing condition is a condition or symptoms for which you received medical advice, care, diagnostic measures, or treatment or for which medical advice, care, diagnostic measures or treatment was recommended for that same or a related condition or symptoms in the 12 month period prior to the original effective date of your coverage or an increase in coverage. A specific diagnosis does not need to be made in the 12 month period prior to the original effective date or increase date for a condition or symptoms to be considered preexisting. Additionally, a change in diagnosis for the same or related condition or symptoms after the date your coverage becomes effective will still be considered preexisting.

During the first 12 months after the original effective date of coverage or an increase in coverage, benefits are not payable for any covered condition that is the result of a pre-existing condition. For any increase in coverage, the pre-existing limitation period will only apply to the increased amount.

General exclusions

Benefits for covered conditions will be payable upon a diagnosis of a covered condition that satisfies the requirements of the policy and when all other policy requirements are met. Benefits are never payable for a covered condition that is caused directly or indirectly by, results in whole or in part from, or for which there is contribution from any of the following: (1) self-inflicted injury, self-destruction, or autoeroticism, whether sane or insane; (2) suicide or attempted suicide, whether sane or insane; (3) your participation in, or your attempt to commit, a crime, assault, felony, or any illegal activity, regardless of any legal proceedings thereto; (4) the use of alcohol, drugs, medications, poisons, gases, fumes or other substances taken, absorbed, inhaled, ingested or injected; (5) motor vehicle collision or accident where you are the operator of the motor vehicle and your 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; (6) war or any act of war, whether declared or undeclared; or (7) your service in the armed forces or units auxiliary to it of any nation.

Additional limitations

Full benefit cancer

The following cancers are not considered full benefit cancer and are excluded: (1 ) all tumors which are histologically described as benign, non-malignant, pre-malignant, borderline, low malignant potential, dysplasia (all grades), or intraepithelial neoplasia; (2) any lesion described as Ta by the AJCC Staging System or as carcinoma in-situ classified as (Tis) by the AJCC Staging System; (3) all non-melanoma skin cancers unless there are lymph node or distant metastases; (4) prostate cancer that is classified as T1 by the AJCC Staging System and has a Gleason Score that is less than or equal to 6, without lymph node or distant metastasis; (5) any melanoma that is less than or equal to 1.0 mm in Breslow thickness, without lymph node or distant metastasis; (6) early thyroid cancer that is classified as T1 by the AJCC Staging System and is less than or equal to 2 cm in diameter, without lymph node or distant metastasis.

Heart attack

Angina and all other forms of acute coronary syndromes are not covered. The diagnosis must be made by a specialist, supported by all three (3) of the following criteria and be diagnostic of a new acute myocardial infarction: (1) Symptoms clinically accepted as consistent with the diagnosis of an acute myocardial infarction; (2) New characteristic electrocardiographic changes; and (3) The characteristic rise above laboratory accepted normal values of biochemical cardiac specific markers such as CK-MB or cardiac troponins.

Stroke

The diagnosis must also be supported by findings on brain imaging and must be consistent with the diagnosis o f a new stroke. The following are excluded: (1) transient ischemic attacks (TIA) or reversible ischemic neurologic deficit (RIND); (2) brain damage due to an accident or injury; (3) disorders of the blood vessels affecting the eye including infarction of the optic nerve or retina; (4) ischemic disorders of the peripheral vestibular system; (5) asymptomatic silent stroke found on imaging.

Major organ failure

A specialist must state that the insured needs a transplant of the mentioned organs and the insured is included on an official U SA transplant waiting list such as the United Network for Organ Sharing (UNOS) or the National Marrow Donor Program (NMDP). The transplant must be deemed necessary by a specialist to treat organ failure in the insured. If an insured is on the UNOS list for a combined transplant (example: heart and lung), a single benefit will be paid. The following are not covered: (1) transplant of any other organs, tissues or cells; (2) registration on an official USA transplant waiting list as a donor.

Kidney failure

Permanent regular renal dialysis or kidney transplant must be deemed medically necessary by a specialist. Acute reversible kidney failure that only needs temporary renal dialysis is not covered.

Partial benefit cancer

The following cancers are excluded: (1) all tumors which are histologically described as benign, non-malignant, pre-malignant, borderline, low malignant potential, dysplasia (all grades) or intraepithelial neoplasia; (2) non-melanoma skin cancer; (3) carcinoma in-situ of the skin; (4) melanoma in-situ.

Coronary artery disease needing surgery or angioplasty

A specialist must report that the insured requires surgical intervention on the coronary artery(s) following clinically accepted cardiovascular surgery guidelines, either for prognostic benefit or for symptomatic coronary artery disease that cannot be adequately managed on optimal medical therapy. Diagnostic coronary angiography is not considered a 'surgical intervention' under this definition and it is specifically excluded.

 

DOFU 6-2016
51142