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SMC|Enrollment Development|International Education Center|General Exclusions

General Exclusions

Medical Insurance 2013-2014

General Exclusions


The Policy does not cover nor provide benefits for loss or expenses incurred:


  1. As a result of dental treatment, except for treatment resulting from Injury to natural teeth. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.
  2. For eye examinations, eyeglasses, contact lenses, or prescription for such; radial keratotomy or laser surgery; hearing aids; except as required for repair caused by a covered Injury. This exclusion does not apply to Preventative Services mandated by the Patient Protection Care Act.
  3. As a result of a Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a scheduled airline.
  4. For Injury or Sickness resulting from war or act of war, declared or undeclared.
  5. As a result of an Injury or Sickness for which benefits are paid under any Worker's Compensation or Occupational Disease Law.
  6. As a result of Injury sustained or Sickness contracted while in the service of the Armed Forces of any country. Upon the Covered Person entering the Armed Forces of any country, the Company will refund any unearned pro-rata premium. This does not include Reserve or National Guard Duty for training unless it exceeds 31 days.
  7. For treatment provided in a government Hospital unless there is a legal obligation to pay such charges in the absence of insurance.
  8. For cosmetic surgery except as required to correct an Injury which requires medical treatment within 24 hours of an Accident. "Cosmetic surgery" shall not include reconstructive surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: 1) improve function; or 2) create a normal appearance, to the extent possible. It also shall not include breast reconstructive surgery after a mastectomy.
  9. As a result of committing or attempting to commit a felony or participation in a riot.
  10. For Elective Treatment or elective surgery unless otherwise provided in the Policy.
  11. After the date insurance terminates for a Covered Person except as may be specifically provided in the Extension of Benefits Provision.
  12. For services normally provided without charge by the school and covered by the school fee for services.
  13. For any services rendered by a Covered Person's Immediate Family Member.
  14. For any treatment, service or supply which is not Medically Necessary.
  15. As a result of suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted Injury.
  16. For non-surgical treatment of temporomandibular joint dysfunction.
  17. For surgery and/or treatment of: weak, strained or flat feet; corns, calluses and bunions; deviated nasal septum, including sub mucous resection and/or other surgical correction thereof; hair growth or removal; and weight reduction. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.
  18. For routine physical examinations, health examinations or preschool physical examinations, including routine care of a newborn infant. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.
  19. By a Covered Person who is not a United States Citizen for services performed within the Covered Person's home country in excess of $10,000 if the Covered Person's home country provides national health insurance.
  20. For sterilization or sterilization reversal, including surgical procedures and devices except as specifically provided; or for birth control, except prescription contraceptive drugs and devices.
  21. For maintenance therapy which is defined as those therapy services rendered to a Covered Person who is no longer making documentable progress to maintain the level of progress previously attained.
  22. For treatment of infertility, including diagnosis, diagnostic tests, medication, surgery, except as specifically provided.
  23. For voluntary or elective abortions except as specifically provided.
  24. For Physiotherapy except as specifically provided under the Policy.
  25. For Injury resulting from: the practicing for, participating in, or traveling as a team member to and from interscholastic, intercollegiate, professional, and semi-professional sports; racing or speed contests; skin diving; sky diving; or mountaineering (where ropes or guides are customarily used).
  26. For treatment, services, drugs, device, procedures or supplies that are Experimental or Investigational.
  27. For treatment, service or supply for which a charge would not have been made in the absence of insurance.


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