AGU San Francisco Limited Accident & Sickness Indemnity Plan


Exclusions And Limitations

The Limited Accident & Sickness Indemnity 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 service 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. travel or activity outside the United States, except for a medical emergency
  9. alcoholism, the voluntary use of illegal drugs, the intentional taking of over the counter medication not in accordance with recommended dosage and warning instructions, intentional misuse of prescription drugs, unless specifically provided herein
  10. 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
  11. injury to a covered person resulting from that covered person's willful violation of the Participating Organization's rules or regulations. Willful violation includes, but is not limited to: a) working without protective clothing, helmets, gloves, etc. required by the Participating Organization's rules or regulations; or b) participating in any activity that is in violation of the Participating Organization's rules or regulations
  12. Pre-existing Conditions occurring within the first 6 months of coverage (applies to Hospital and Surgery benefits only)
  13. 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
  14. mental illness disorders (except as provided by the policy)
  15. cosmetic surgery, except for reconstructive surgery needed as the result of an injury or sickness
  16. Experimental or Investigational drugs, services, supplies or any procedure held to be Experimental or Investigatory 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
  17. treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications
  18. treatment or services provided by a private duty nurse, unless provided for in the policy
  19. treatment by a family member or member of the covered person's family
  20. routine dental care and treatment, except for treatment of injury as specified in the policy
  21. work-related injuries or injuries covered under Workers' Compensation, Employer's Liability Laws or similar occupational benefits or while engaging in activity for monetary gain from sources other than the Participating Organization
  22. 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)
  23. bungi-cord jumping, parachuting, skydiving, parasailing, hang-gliding (for AD&D benefit only)
  24. 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)
  25. travel in or on any on-road and off-road motorized vehicle not requiring licensing as a motor vehicle (for AD&D benefit only)
  26. travel in any Aircraft owned, leased or controlled by the Participating Organization, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be "controlled" by the Participating Organization if the Aircraft may be used as the Participating Organization wishes for more than 10 straight days, or more than 15 days in any year (for AD&D benefit only)


Exclusions Specific To Dental Benefits:
(Applicable to Large Employer Plans only)

No benefits will be paid for expenses incurred:

  1. for services and supplies not listed in the Schedule of Benefits or not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental
  2. for any treatment program which began prior to the date the insured is covered under the policy except for comprehensive orthodontic treatment or as provided in the Schedule of Benefits
  3. for services or supplies payable under any medical expense, auto or no-fault plan
  4. for any condition covered under any Worker's Compensation Act or similar law
  5. for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance
  6. for services subject to a waiting period that were incurred during the waiting period
  7. for charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services
  8. for drugs or the dispensing of drugs except injectable antibiotics administered by a Dentist as a result of dental treatment
  9. for oral hygiene instruction; plaque control; acid etch; prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes)
  10. for implants; myofunctional therapy; athletic mouth guards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia
  11. except as may be provided in the Schedule of Benefits, for services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits
  12. for the replacement of retainers
  13. during travel or activity outside the United States
  14. for services which result from the voluntary use of illegal drugs, the intentional taking of over-the-counter medication not in accordance with recommended dosage and warning instructions, intentional misuse of prescription drugs

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