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Group Hospital Indemnity Exclusions and Limitations

Benefits are never payable for an accident, injury or loss, or covered condition that it 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) motor vehicle collision or accident where you are the operator of the motor vehicle and our 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; (5) war or any act of war, whether declared or undeclared.

In addition, benefits are never payable for an accident, injury or sickness that 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) the use of alcohol; (2) the use of prescription drugs, non-prescription drugs, illegal drugs, medications, poisons, gases, fumes or other substances taken, absorbed, inhaled, ingested or injected; (3) bodily or mental infirmity, illness or disease; or (4) infection other than infection occurring simultaneously with, and as a direct and independent result of, the injury; or (5) repetitive stress syndromes including but not limited to rotator cuff syndrome, bursitis, tendonitis, carpal tunnel syndrome, ulnar nerve syndrome, stress fractures, neuropathy, epicondylitis or neuritis; or (6)
complications resulting from medical or surgical treatment when the outcome is not as planned or expected, including claims of medical malpractices; or (7) 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 (8) participation in the following activities: scuba diving, bungee jumping, base jumping, hang gliding, sail gliding, parasailing, para-kiting, or mountain climbing; or (9) riding or driving in any motor-driven vehicle in a race, stunt show or speed test; or (10) practicing for or participating in any semi-professional or professional competitive athletics.

Benefits are not payable for: 1) any confinement, care, treatment or diagnostic measures which were received outside of the United States or United States territory; 2a) 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.

Pre-existing condition limitation (12/12) (sickness benefits only)

A pre-existing condition is a condition or symptoms for which medical advice, care, diagnostic measures, or treatment was received or 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 sickness 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.

 

DOFU 6-2016
51142