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Exclusions |
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ACE American Insurance Company Limited Benefit Plan, Including Accidental Death & Dismemberment Benefits
The Limited Benefit Plan will not pay benefits for any loss, injury or sickness that is caused by, or results from:
- intentionally self-inflicted injury
- suicide or attempted suicide
- war or any act of war, whether declared or not
- service in the military, naval or air service of any country
- commission of, or attempt to commit, a felony, an assault or other illegal activity
- commission of or active participation in a riot, or insurrection
- 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
- travel or activity outside the United States, except for a medical emergency
- alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a doctor unless specifically provided herein
- repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration
- repair, replacement, examinations for prescriptions or the fitting of eyeglasses or contact lenses (except as provided in the Policy)
- 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
- injury to a covered person resulting from that covered person’s wilful violation of the participating organization’s rules or regulations. Wilful violation includes, but is not limited to: a) competing 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
- 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
- mental illness disorders (except as provided in the policy)
- cosmetic surgery, except for reconstructive surgery needed as the result of an injury or sickness
- experimental or investigational drugs, services, supplies or any procedure held to be experimental or investigatory by the insurer at the time the procedure is done
- treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications.
- treatment or services provided by a private duty nurse, unless provided for in the Policy.
- treatment by a family member or member of the Covered Person’s family.
- routine dental care and treatment, except for treatment of Injury as specified in the Policy.
- 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)
- bungi-cord jumping, parachuting, skydiving, parasailing, hang-gliding (for AD&D benefit only).
- 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).
- travel in or on any on-road and off-road motorized vehicle not requiring licensing as a motor vehicle (for AD&D benefit only).
- 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 ACE Dental Benefits:
- 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
- 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
- for any condition covered under any Worker’s Compensation Act or similar law
- for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence or insurance
- for services subject to a waiting period that were incurred during the waiting period
- 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
- for drugs or the dispensing of drugs
- 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)
- 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
- 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
- for the replacement of retainers
- during travel or activity outside the United States.
This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit ACE American Insurance Company from providing insurance, including, but not limited to, the payment of claims.
