Secure Advantage-New 2015
Secure Advantage-New 2015
Secure Advantage-New 2015
A Custom-Tailored Approach to
Sickness Accident
Cover age
Affordable
Experienced
Over 50 collective years of industry experience.
Over 15 MILLION customers helped and served.
Dependable
Over 1 billion dollars in CLAIMS PAID!
Average claim paid in LESS THAN 10 CALENDAR DAYS!2
Personalized
Dedicated PROFESSIONAL insurance agents to help You
navigate the complexities of Your insurance purchase!
PERSON to PERSON CUSTOMER SERVICE You dont have
to talk to a machine!
Innovative
Pioneered long-term fixed-rates to help keep Your
coverage affordable.
Access to online tools and resources so You can make
informed decisions about Your healthcare.
We offer two distinct Plans that, when packaged together,
work in harmony to provide coverage that is both affordable
and flexible.
ONLY FROM USHEALTH Group, Inc. - These unique insurance
plans are copyrighted. No other Association in America
offers them!
1
2
Our Concept
Because it is!
SecureAdvantage
A Tailored Approach to Insurance
Coverage that Fits Like its Made Just for You
Sickness Plan
Accident Plan
Select
Add
Ask Your Agent how You can lock in Your rates for up to
36 months!*
Choose the most appropriate deductible to meet Your needs and Your budget for
Your Sickness coverage and Your Accident coverage.
Get rewarded for Your Good Health with Our Increasing Lifetime Maximum for
Sickness and Accident coverage.
You can take it with You even if You move or change jobs.
*The Premium Rate Guarantee Period does not apply to any rate change due to: change of address; addition of Insureds; change
of benefits or options; change of Mode Of Premium Payment; group policy coverage, benefits, limitation or exclusion changes;
or any future requirements of any federal or state law.
**The individual mandate under the Affordable Care Act (ACA) generally requires individuals to maintain minimum essential
coverage in 2014 and beyond, or be subject to payment of the annual shared responsibility payment, the amount of
which is based, in part, upon the individuals household income each year (See page 23 of this brochure for details). The
SecureAdvantage Sickness Plans and SecureAdvantage Accident Plans are insurance plans which provide benefits on an
expense incurred basis up to an annual/lifetime maximum amount for covered services and are neither essential health
benefits plans under the ACA, traditional major medical insurance plans, nor Workers Compensation plans under state law.
SecureAdvantage Sickness Plans and SecureAdvantage Accident Plans are excepted benefit plans under the ACA, but are
not considered minimum essential coverage under it. Therefore, unless an insured under one of our SecureAdvantage
Sickness Plans and/or SecureAdvantage Accident Plans has an exemption from the ACAs individual mandate or maintains
minimum essential coverage under the ACA, the insured will be subject to the ACAs shared responsibility payment (See
page 23 of this brochure for details).
Sickness Accident
SecureAdvantage
Easy
Steps!
1
Select Your
Sickness
Plan
Lock In
Plan
Deductible
Coinsurance
Calendar Year
Maximum
Complete Your
24 Months
99 Accident Protector1
Excess Medical
Accident Insurance
36 Months
99 LifeProtector1
Term Life Insurance
Accident
99 IncomeProtector1
Short Term
Accident/Disability
Insurance
Deductible
Coinsurance
Calendar Year
Maximum
Sickness
Accident
You Need to KNOW You are Covered for Sickness from Head to Toe!!
The SecureAdvantage Sickness Plan covers sicknesses in all systems of the human body.2
Sicknesses
of the Brain &
Nervous System
Sicknesses
of the Respiratory
System
Sicknesses
of the Cardiovascular
System
Sicknesses
of the Musculoskeletal
System
Sicknesses
of the Digestive
System
Sicknesses
of the Reproductive
System
Sicknesses
of the Skin
Sicknesses
of the Immune
System
Sicknesses
of the Endocrine
System
Heart Attacks
the
Cancers
the
Strokes
1
2
Sickness
The SecureAdvantage Sickness plan provides benefits for covered sicknesses, but unlike a major medical plan, it does
not cover accidental bodily injuries or wellness exams.
accident or wellness coverage is appropriate for you and/or
If Accident
your family, please ask your agent for details on available
options.
Sickness
Sickness
Accident
Sickness Coverages
Benefits Provided
for
Covered Sicknesses :
The individual mandate under the Affordable Care Act (ACA) generally requires individuals to maintain minimum essential coverage in 2014 and beyond, or be subject to
payment of the annual shared responsibility payment, the amount of which is based, in part, upon the individuals household income each year (See page 23 of this brochure
for details). The SecureAdvantage Sickness Plans are insurance plans which provide benefits on an expense incurred basis up to an annual/lifetime maximum amount for
covered services and are neither essential health benefits plans under the ACA, traditional major medical insurance plans, nor Workers Compensation plans under state law.
SecureAdvantage Sickness Plans are excepted benefit plans under the ACA, but are not considered minimum essential coverage under it. Therefore, unless an insured under
one of our SecureAdvantage Sickness Plans has an exemption from the ACAs individual mandate or maintains minimum essential coverage under the ACA, the insured will be
subject to the ACAs shared responsibility payment (See page 23 of this brochure for details).
Sickness
Accident
Benefit Options
Select Your Calendar Year Deductible for Participating Providers (PPO)1,2:
$3,000
$6,000
$9,000
$12,000
$15,000
In-network
Out of Pocket Maximum
Out-of-network
Coinsurance Options
Out-of-network
Out of Pocket Maximum
80% - 20%
$4,000
60% - 40%
$16,000
70% - 30%
$7,500
50% - 50%
$25,000
60% - 40%
$10,000
50% - 50%
$25,000
for 24 months
for 36 months
When 3 Insureds satisfy the Sickness Plans Calendar Year Deductible, no additional Calendar Year Deductible for the Sickness Plan will be required for the remainder of the Calendar Year.
An additional deductible equal to Your Calendar Year Deductible is required for Non-PPO Providers.
3
Subject to any coverage limits of this plan and after satisfaction of the Sickness Plans Calendar Year Deductible selected above, as well as payment of Access Fees, the
Separate Deductible For Non-Participating Providers and the Failure to Pre-Certify Treatment Deductible, if any. The Insured is responsible for paying the applicable
coinsurance percentage for all Covered Expenses incurred during the Calendar Year.
4
Does not include Calendar Year Deductible or Access Fees.
5
The Premium Rate Guarantee Period does not apply to any rate change due to: change of address; addition of Insureds; change of benefits or options; change of Mode Of
Premium Payment; different Participating Provider network; Participating Provider network availability, negotiated discounts, or its relationship to the Company; group policy
coverage, benefits, limitations, exclusions or premium change; requirements of any federal or state law.
1
2
Sickness
Accident
Sickness
Accident
The SecureAdvantage Plan will supplement an essential health benefits plan. These Claims payment examples show how
a SecureAdvantage Sickness Plan can supplement a Bronze essential health benefits plan.
Heart Attack 1
Total Charges:
PPO Network Discount:
Remaining Charges:
Patient Deductible:
$113,289
($39,651)
$73,638
Total Charges:
PPO Network Discount:
Remaining Charges:
$113,289
($39,651)
$73,638
$6,250
Patient Deductible:
Patient Coinsurance:
Emergency Room Access Fee
(waived on Hospital Admission)
$3,000
$4,000
Waived
Plan Pays:
$66,638
Plan Pays:
$67,388
Patient Responsibility:
$6,250
Patient Deductible:
$52,038
($18,213)
$33,825
Total Charges:
PPO Network Discount:
Remaining Charges:
$52,038
($18,213)
$33,825
$6,250
Patient Deductible:
Patient Coinsurance:
Emergency Room Access Fee
(waived on Hospital Admission)
$3,000
$4,000
Waived
Plan Pays:
$26,825
Plan Pays:
$27,575
Patient Responsibility:
$6,250
$204,094
($71,433)
$132,661
Total Charges:
PPO Network Discount:
Remaining Charges:
$204,094
($71,433)
$132,661
Patient Deductible:
$6,250
Patient Deductible:
Patient Coinsurance:
Lab & Diagnostic Testing Access Fee
$3,000
$4,000
$250
Plan Pays:
$126,411
Patient Responsibility:
$6,250
Plan Pays:
$125,411
Sickness
Accident
Count on Your SecureAdvantage Accident Plan to Cover Your Accidental Bodily Injury Medical Costs.2
Muscle Strains
Bone Injuries
Poisoning Injuries
Back Injuries
Knee Injuries
Accidental Injuries
Covered 24/7 On or Off the Job!
Burn Injuries
Head Injuries
Sports Injuries
1
Centers for Disease Control and Prevention Data and Statistics: Cost of Injury Reports, Unintentional Non-Fatal Injuries, U.S., both sexes, all ages, most recent
data available as of October, 2014.
2
Subject to Exclusions and Limitations of the Plan (see pages 21-23).
Accident
The SecureAdvantage Accident plan provides benefits for covered accidents, but unlike a major medical plan, it
does not cover sicknesses or wellness exams. If sickness or wellness coverage is appropriate for you and/or your
Sickness
on available options.
family, please ask your
agent for details
Accident
Sickness
Accident
Accident Coverages
Benefits Provided
for
Covered Accidents :
for
Covered Accidents :
10
The individual mandate under the Affordable Care Act (ACA) generally requires individuals to maintain minimum essential coverage in 2014 and beyond, or be subject to
payment of the annual shared responsibility payment, the amount of which is based, in part, upon the individuals household income each year (See page 23 of this brochure
for details). The SecureAdvantage Accident Plans are insurance plans which provide benefits on an expense incurred basis up to an annual/lifetime maximum amount for
covered services and are neither essential health benefits plans under the ACA, traditional major medical insurance plans, nor Workers Compensation plans under state law.
SecureAdvantage Accident Plans are excepted benefit plans under the ACA, but are not considered minimum essential coverage under it. Therefore, unless an insured under
one of our SecureAdvantage Accident Plans has an exemption from the ACAs individual mandate or maintains minimum essential coverage under the ACA, the insured will be
subject to the ACAs shared responsibility payment (See page 23 of this brochure for details).
Sickness
Accident
Benefit Options
Customize Your Calendar Year Deductible for Participating Providers (PPO)1,2:
$1,500
$7,500
$3,000
$9,000
$4,500
$12,000
$6,000
$15,000
In-network
Out of Pocket Maximum
Out-of-network
Coinsurance Options
Out-of-network
Out of Pocket Maximum
80% - 20%
$4,000
60% - 40%
$16,000
70% - 30%
$7,500
50% - 50%
$25,000
60% - 40%
$10,000
50% - 50%
$25,000
for 24 months
for 36 months
When 3 Insureds satisfy the Accident Plans Calendar Year Deductible, no additional Calendar Year Deductible for the Accident Plan will be required for the remainder of the Calendar Year.
An additional deductible equal to Your Calendar Year Deductible is required for Non-PPO Providers.
Subject to any coverage limits of this plan and after satisfaction of the Accident Plans Calendar Year Deductible selected above, as well as payment of Access Fees, the
Separate Deductible For Non-Participating Providers and the Failure to Pre-Certify Treatment Deductible, if any. The Insured is responsible for paying the applicable
coinsurance percentage for all Covered Expenses incurred during the Calendar Year.
4
Does not include Calendar Year Deductible or Access Fees.
5
The Premium Rate Guarantee Period does not apply to any rate change due to: change of address; addition of Insureds; change of benefits or options; change of Mode Of
Premium Payment; different Participating Provider network; Participating Provider network availability, negotiated discounts, or its relationship to the Company; group policy
coverage, benefits, limitations, exclusions or premium change; requirements of any federal or state law.
Sickness
Accident
11
Sickness
Accident
The SecureAdvantage Plan will supplement an essential health benefits plan. These Claims payment examples show how
a SecureAdvantage Accident Plan can supplement a Bronze essential health benefits plan.
$126,763
($44,367)
$82,396
Total Charges:
PPO Network Discount:
Remaining Charges:
$126,763
($44,367)
$82,396
Patient Deductible:
$6,250
Patient Deductible:
Patient Coinsurance:
Emergency Room Access Fee
Plan Pays:
$76,146
$3,000
$4,000
Waived
$250.00
Plan Pays:
$75,146
Patient Responsibility:
$6,250
With Our Accident Protector Plan, Your responsibility could be as little as $250!
Motor Vehicle Accident - Multiple Fr actures1
Total Charges:
PPO Network Discount:
Remaining Charges:
Patient Deductible:
Plan Pays:
Patient Responsibility:
$85,281
($29,848)
$55,433
Total Charges:
PPO Network Discount:
Remaining Charges:
$85,281
($29,848)
$55,433
$6,250
Patient Deductible:
Patient Coinsurance:
Emergency Room Access Fee
Lab & Diagnostic Testing Access Fee
$3,000
$4,000
Waived
$250.00
Plan Pays:
$48,183
$49,183
$6,250
With Our Accident Protector Plan, Your responsibility could be as little as $250!
Snow Skiing - Broken Collar Bone1
Total Charges:
PPO Network Discount:
Remaining Charges:
Patient Deductible:
Plan Pays:
Patient Responsibility:
$63,112
($22,089)
$41,023
Total Charges:
PPO Network Discount:
Remaining Charges:
$63,112
($22,089)
$41,023
$6,250
Patient Deductible:
Patient Coinsurance:
Emergency Room Access Fee
Lab & Diagnostic Testing Access Fee
$3,000
$4,000
Waived
$250.00
Plan Pays:
$33,773
$34,773
$6,250
With Our Accident Protector Plan, Your responsibility could be as little as $250!
Figures shown are for a SecureAdvantage Accident Plan with a $3,000 deductible and 80-20% coinsurance to $4,000 and a Bronze essential health benefits plan with a $6,250
deductible. Individual results may vary based on the level of coverage selected, provider charges, PPO network discounts, geographic location and any applicable covered healthcare
services. Exclusions and limitations may apply.
12
Dental
SecureDental*
Dental Insur ance
Deductibles: $50 for an Individual; $150 for a Family; Additional Orthodontic Deductible $150 per Insured
Covers Preventive Care, Basic Care, Major Care & Orthodontic Care
Calendar Year Maximum Per Insured $1,500; Orthodontic Calendar Year Maximum Per Insured $400
Saver Plan*
Preventive Care
Benefits include:
Initial & Periodic oral examinations*
Intraoral X-rays, with/without bitewings*
Prophylaxis (cleaning of the teeth) with/without oral examination*
... and more
Basic Care
Benefits include:
Amalgam, silicate cement, acrylic or plastic fillings
Simple tooth Extractions
Oral Surgery
... and more
Major Care
(Covered on Premier Plan & Saver Plus Plans. For Saver Plan, Insured(s) receive discounted services at participating providers for Major Care.)
Benefits include:
Single Crown restorations
Dentures, including fixed or removable prosthetic devices, complete Dentures, upper & lower
Root Canal Therapy, including treatment plan & followup care
... and more
Orthodontic Care
(Covered on Premier Plan. For Saver Plus Plan & Saver Plans, Insured(s) receive discounted services at participating providers for Orthodontic Care.)
Benefits include:
Comprehensive Orthodontic Treatment of the adult dentition
Comprehensive Orthodontic Treatment of the adolescent dentition
Orthodontic retention (removal of appliances, construction & placement of retainer(s))
... and more
13
Dental
Critical Illness
MedGuard
Critical Illness Insur ance
Filling The Gap Between Health Cover age And Life Insur ance
FACTS:
Men have a 1-in-2 lifetime risk of getting cancer. Women have a 1-in-3 lifetime risk.1
There are 9.6 million cancer survivors in the U.S.2
1.4 million heart attacks occur each year thats one every 33 seconds!3
There are 14 million heart attack survivors in the U.S.3
About 700,000 Americans will have a stroke this year thats one every 45 seconds!3
Surveillance, Epidemiology and End Results (SEER) Program, National Cancer Institute.
American Cancer Society, Cancer Facts & Figures
3
American Heart Association, Heart Disease and Stroke Statistics
1
2
Benefit
Heart Attack
Stroke
Kidney Failure
Permanent Paralysis
Terminal Illness
Coronary Angioplasty
1st through 90th day Total Benefit Amount for any Life Threatening Cancer
$500
1st through 30th day Total Benefit Amount other than Life Threatening Cancer
$500
14
Dental
Critical Illness
Why MedGuard?
Health coverage provides benefits for medical treatment but doesnt
include benefits for non-medical expenses. Traditional life insurance
pays benefits after death. What if You survive a critical illness? Where
will You find the financial resources to cover non-medical costs during
Your recovery?
Fill in the gap between Your Sickness Plans Calendar Year Deductible,
Access Fees, and out-of-pocket Coinsurance expenses!
If You are diagnosed with a covered condition, MedGuard will give You a lump-sum cash payment!
You can use the cash for any purpose You deem necessary, such as helping to:
Protect Your assets from being spent on recovery Pay COBRA or other insurance premiums
Replace lost income for You and Your
caregiving spouse
covered by insurance
$20
$55
$25
$60
$30
$65
$90
$35
$70
$95
$40
$75
$100
$45
$80
$50
$85
The benefit amount You receive can help You focus on recovering
instead of worrying where You will find the money to pay Your bills.
Not available in all states. Limitations and Exclusions apply. The MedGuard Plan has a separate brochure.
If interested in this coverage, please see the MedGuard brochure and Certificate for complete details.
15
Excess Accident
Accident Protector
Supplemental Excess Accident Insur ance
FACTS:
In 2010, nonfatal injuries cost society more than $471 billion in
productivity losses and over $111 billion in medical costs.1
More than 29 million people are treated in emergency rooms for
injuries each year.2
Each year, nearly 9.2 million children aged 0 to 19 years are seen
in emergency rooms for injuries.3
More than 2.8 million people hospitalized with injuries each year.4
Finkelstein E, Corso PS, Miller TR. The incidence and economic burden of injuries in the United States. New York, NY: Oxford University Press.
NCIPC: Web-based Injury Statistics Query and Reporting System (WISQARS)
3
Centers for Disease Control and Prevention Safe Kids Fact sheet
4
NCHS. National hospital discharge survey: National health statistics reports, no. 29. Atlanta, GA; 2010.
1
2
Americas Choice Accident Protector provides extra coverage to help Fill in the gap between Your Accident
Plans Calendar Year Deductible, Access Fees, and out-of-pocket Coinsurance expenses!
Ambulance
Outpatient Surgery
Oxygen
Rental of Durable Medical Equipment for a Covered Accident or Injury Casts, Splints & Crutches
Prescription Drugs & Compounded Prescription Drugs
Over-the-Counter Drugs
*Benefits are subject to Your Excess Medical Expense Deductible per Accident per Insured.
16
Excess Accident
Unintentional Injuries continue to be the fifth leading cause of death in America. With Accident Protector, if an Insureds
Injury results in a loss, We will pay You up to 100% of the AD&D maximum2 based on this schedule:
Covered Losses:
Loss of
Loss of
Loss of
Loss of
Loss of
Loss of
Loss of
Loss of
Loss of
Loss of
Loss of
Loss of
Life
Limbs (two or more)
Speech & Loss of Hearing (both ears)
Sight (both eyes)
Limb (one)
Speech
Hearing (both ears)
Sight (one eye)
Hand (one)
Foot (one)
Hearing (one ear)
Thumb & Index Finger (same hand)
AD&D
Maximums2
100%
100%
100%
100%
50%
50%
50%
50%
50%
50%
25%
25%
Many accidents require emergency transportation to a Hospital or other facility. You can rest easy knowing weve got You
covered regardless of the Excess Medical Expense Coverage selected.
Up to $4,000 per Accident per Insured
Your coverage includes the amount of Emergency Air Ambulance expense up to the maximum of $4,000 per Accident
per Insured for Medically Necessary transportation by air to the nearest Hospital qualified to render treatment in an
Emergency within 90 days from the date of Injury sustained in an Accident.
We give You the option to select coverage that fits Your budget and needs. Choose Your coverage amount
from the list below:
17
Term Life
Disability
LifeProtector
Renewable Ter m Life Insur ance
Provides protection to help with obligations like mortgage, car payment, childcare or educational expenses and other obligations.
Peace of Mind
Provides valuable life insurance benefits that in most instances are free from income tax for the
beneficiary.
Economical
With premium payment options from $10 to $50, all in $5 increments, its easy to find an
economical solution to Your life insurance needs.
$10
$35
$15
$40
$20
$45
$25
$50
$30
Not available in all states. Limitations and Exclusions apply. The LifeProtector Plan has a separate brochure.
If interested in this coverage, please see the LifeProtector brochure and Policy for complete details.
18
Disability
IncomeProtector
Short Ter m Accident Disability Insur ance
1
2
If You become disabled due to a covered accident, IncomeProtector can help pay Your bills for up to 12 months.
This means You can spend more time on Your recovery and less time worrying about how You will pay Your bills.
Choose Your
Elimination
Period
Not available in all states. Limitations and Exclusions
apply. The IncomeProtector Plan has a separate
brochure. If interested in this coverage, please see the
IncomeProtector brochure and Certificate for complete
details.
14 Days
30 Days
Choose Your
Monthly Total
Disability
Benefits
$500
$1,000
$1,500
Choose Your
Maximum
Period for
Benefit
Payments
3 months
6 months
12 months
19
Sickness Accident
Sickness Accident
A dditional Features
to
Pre-Certify
Certain procedures that You or Your Provider do not pre-certify with Us under
the Sickness Plan or the Accident Plan are subject to the $500 Failure to
Pre-Certify Treatment Deductible under the applicable plan.1
See the applicable Sickness Plan or Accident Plan Certificate of coverage for details.
20
Sickness Accident
LIMITATIONS-WAITING PERIODS SICKNESS PLAN
Coverage under the Certificate is limited as provided by the definitions, limitations, exclusions, and terms contained in each and every Section of
the Certificate, as well as the following limitations and waiting periods:
Any treatment, medical service, surgery, medication, equipment, claim, loss or expense received, purchased, leased or otherwise incurred as a result of
an Insureds Pre-existing Condition is not covered under the Certificate unless such treatment, medical service, surgery, medication, equipment, claim,
loss or expense constitutes Covered Expenses incurred by such Insured more than twelve (12) months after the Issue Date, and such treatment, medical
service, surgery, medication, equipment, claim, loss or expense are not otherwise limited or excluded by the Certificate or any riders, endorsements, or
amendments attached to the Certificate;
Pre-existing Condition means a condition, whether physical or mental, and regardless of the cause for which medical advice, diagnosis, care or treatment
was recommended or received during the twelve (12) month period immediately preceding the effective date of coverage under the Certificate for the
Insured incurring the expense;
Any Specified Disease loss or expense which is incurred before the expiration of six (6) months from the Issue Date which results from the diagnosis, care
or treatment of hernia, hemorrhoids, varicose veins, tonsils and/or adenoids, or otitis media shall be limited under the Certificate to $500 provided that
(i) such loss or expenses constitutes Covered Expenses incurred by an Insured after the Issue Date, (ii) such Specified Diseases are not otherwise limited or
excluded by the Certificate or any riders, endorsements, or amendments attached to the Certificate,(iii) care for such Specified Disease is Provided on
an Emergency basis, and such Specified Disease is not a Pre-existing Condition;
If as the result of an Emergency treatment of a Specified Disease services are rendered for an Insured by a Non-Participating Provider when a Participating
Provider was not reasonably available in connection with either: (i) on an Outpatient basis in the emergency room of a Hospital, or (ii) an Emergency
Inpatient admission to a Hospital, then the Covered Expenses incurred will be reimbursed by Us as if such Non-Participating Provider were a Participating
Provider up to the point when the Insured can be safely transferred to a Participating Provider. If the Insured refuses or is unwilling to be transferred
to the care of a Participating Provider after such Insured can be safely transferred, then reimbursement shall thereafter be reduced to the Companys
Insurance Percentage for Non-Participating Providers; and
Specified Disease Benefits under the Certificate for any Insured who is eligible for or has coverage under Medicare, and/or amendments thereto, shall be
limited to only the Usual and Customary charges for services, supplies, care or treatment covered under the Certificate that are not payable or reimbursable
by Medicare and/or its amendments, subject to all provisions, limitations, exclusions, reductions and maximum benefits set forth in the Certificate.
Sickness Accident
21
Sickness Accident
NON-COVERED ITEMS AT A GLANCE SICKNESS PLAN AND ACCIDENT PLAN cont'd
any treatment, care, procedures, services or supplies incurred for the any spinal manipulations;
diagnosis, care or treatment of Alcoholism, addiction to illegal drugs or any treatment, care, procedures, services or supplies of Temporomandibular
substances, and/or abuse or illegal drugs or substances;
Joint Disorder (TMJ) and Craniomandibular Disorder (CMD);
any treatment care, procedures, services or supplies incurred for the any treatment received outside of the United States, except as provided
diagnosis, care or treatment of cirrhosis of the liver;
for in the EXTRATERRITORIAL MEDICAL EXPENSES provision; and
any intentional misuse or abuse of Prescription Drugs, including Prescription any services or supplies for personal convenience, including custodial care
Drugs purchased by an Insured for consumption by someone other than
or homemaker services, except as provided for in the Certificate.
such Insured;
ADDITIONAL NON-COVERED ITEMS AT A GLANCE
any accidental bodily injury suffered by an Insured;
any disease, ailment, illness or sickness that is not a Specified Disease;
any eyeglasses, contact lenses, radial keratotomy, lasik surgery, hearing
aids and exams for their prescription or fitting;
any Cochlear implants;
any voluntary abortions, abortifacients or any other drug or device that
terminates a pregnancy;
any treatment, care, procedures, services or supplies incurred by an
Insured which were caused or contributed to by such Insured's being
intoxicated or under the influence of any drug, narcotic or hallucinogens
unless administered on the advice of a Provider, and taken in accordance
with the limits of such advice;
any cosmetic surgery or reconstructive procedures, except for Medically
Necessary cosmetic surgery or reconstructive procedures performed under
the following circumstances: (i) where such cosmetic surgery is incidental to
or following surgery resulting from Bacterial Infection or Viral Infection; (ii)
to correct a normal bodily function in connection with the treatment of a
covered Specified Disease; or (iii) such cosmetic surgery constitutes Breast
Reconstruction that is incident to a Mastectomy; provided any of the above
occurred while the Insured was covered under the Certificate;
any treatment, care, procedures, services or supplies for breast reduction
or augmentation or complications arising from these procedures;
any treatment, care, procedures, services or supplies for voluntary sterilization,
reversal or attempted reversal of a previous elective attempt to induce or
SICKNESS PLAN
facilitate sterilization;
any treatment, care, procedures, services or supplies for treatment of
infertility, including fertility hormone therapy and/or fertility devices for any
type fertility therapy, artificial insemination or any other direct conception;
any treatment, care, procedures, services or supplies for any operation or
treatment performed, Prescription or medication prescribed in connection
with sex transformations or any type of sexual or erectile dysfunction,
including complications arising from any such operation or treatment;
any treatment, care, procedures, services or supplies for appetite suppressants,
including but not limited to, anorectics or any other drugs used for the
purpose of weight control, or services, treatments, or surgical procedures
rendered or performed in connection with an overweight condition or a
condition of obesity or related conditions;
any treatment, care, procedures, services or supplies (including Prescriptions)
incurred for the diagnosis, care or treatment of Attention Deficit Disorder
(ADD) or Attention Deficit Hyperactivity Disorder (ADHD);
any treatment, care, procedures, services or supplies incurred for the
diagnosis, care or treatment of autism;
any treatment, care, procedures, services or supplies incurred for the
diagnosis, care or treatment of routine maternity or any other expenses
related to normal labor and delivery, including routine nursery charges
and well-baby care; and
any contraceptives, oral or otherwise, whether medication or device,
regardless of intended use.
ACCIDENT PLAN
any damage or harm to the physical structure of the body of an Insured
occurring while the Insured is engaged in hang gliding, paragliding, hot
air ballooning or any other form of aviation, except as a fare paying
passenger traveling on a regularly scheduled commercial airline flight;
any damage or harm to the physical structure of the body of an Insured
occurring while the Insured is participating, as a professional contestant,
in any boxing, martial arts or mixed martial arts event, including the
sanctioned practice thereof;
any damage or harm to the physical structure of the body of an Insured while
the Insured is participating, as driver or passenger contestant (professional
or amateur), in any race competition, race, or speed contest, including
sanctioned practice thereof, involving any land vehicle or water craft;
any damage or harm to the physical structure of the body of an Insured
occurring while the Insured is participating, as a professional contestant, in
any race competition, race or speed contest, including sanctioned practice
thereof, on snow skis or a snowboard;
any damage or harm to the physical structure of the body of an Insured
occurring while the Insured is intoxicated or under the influence of alcohol
or any drug, narcotic or hallucinogens unless administered via a prescription
and on the advice of a Provider, and taken in accordance with the limits
of such advice. An Insured is conclusively determined to be intoxicated by
drug or alcohol if: (i) a chemical test administered in the jurisdiction where
either the Accident occurred or the Insured was medically treated is at or
above the legal limit set by that jurisdiction; or (ii) the level of alcohol was
such that a persons coordination, ability to reason, was impaired, regardless
of the legal limit set by that jurisdiction;
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Sickness Accident
ADDITIONAL NON-COVERED ITEMS AT A GLANCE
any damage or harm to the physical structure of the body of an Insured
occurring during any surgical procedure or operation performed in the
treatment of any disease, illness, sickness or ailment;
any damage or harm to the physical structure of the body of an Insured
occurring as a result of the intentional inhalation or ingestion of any poison,
gas or fumes;
any damage or harm to the physical structure of the body of an Insured
occurring as a result of the operation by an Insured of any motor vehicle
without the permission/consent of the owner of such vehicle;
any damage or harm to the physical structure of the body of an Insured
occurring as a result of the operation by an Insured of any motor vehicle
without a valid operators license/permit;
any damage or harm to the physical structure of the body of an Insured
that did not occur Accidentally;
any disease, illness, ailment or sickness of any type or character suffered
or sustained by an Insured;
any damage or harm to the physical structure of the body of an Insured
received as a result of any voluntary abortions, abortifacients or any other
drug or device that terminates a pregnancy;
cosmetic surgery or reconstructive procedures, except for Medically
Necessary cosmetic surgery or reconstructive procedures performed under
Sickness Accident
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