The following is a list of United States Fire Insurance Company limitations and exclusions for the Student Health Plan.
No benefits will be paid for loss or expense caused by or resulting from:
- Injury of the primary insured covered under any student accident insurance policy underwritten by United States Fire Insurance Company.
- Any Sickness or Injury, as defined, that was initially diagnosed, treated or recommended for treatment prior to the Term of Coverage for a Covered Person, unless continuous coverage is applied
- Services and supplies furnished normally without charge by the participating institution’s infirmary, its employees, or doctors who work for the participating institution.
- Services covered or provided by the student health fee
- Normal health checkups, preventive testing or treatment, screening exams or testing in the absence of injury, unless specifically provided.
- Eye examinations, prescriptions or fitting of eyeglasses and contact lenses, or other treatment for visual defects and problems, unless payable as a covered expense associated with a sickness or injury covered by the policy.
- Hearing examinations or hearing aids, or other treatment for hearing defects and problems, unless payable as a covered expense associated with an injury covered by the policy.
- Dental treatment, except as specifically provided for in the Schedule. War or any act of war, declared or undeclared, or while in the armed forces of any country.
- Participation in a riot or civil disorder, commission of or attempt to commit a felony, or fighting, except in self-defense;
- Injury of any covered person sustained while: (a) Participating in any school, professional or organized sports contest or competition, unless specifically list in the Schedule; (b) Traveling to or from such sport, contest or competition as a participant; or (c) During participation in any practice or conditioning program for such sport, contest or competition.
- Skydiving; parachuting or bungi-cord jumping, hang gliding, glider flying, parasailing, sail planing, or flight in any kind of aircraft, except while riding as passenger on a regularly scheduled flight of a commercial airline.
- Treatment in a military or Veterans Hospital or a hospital contracted for or operated by a national government or its agency unless: (a) The services are rendered on an medical emergency basis; and (b) A legal liability exists for the charges made on behalf of a covered person for the services given in the absence of insurance.
- Injury caused by, or resulting from, the use of controlled substances, illegal drugs, or any drugs or medicines that are not taken in the dosage or for the purpose prescribed by the person’s doctor.
- Elective surgery and elective treatment, except as required to correct an injury for which benefits are otherwise payable under the policy.
- Any loss covered by state or federal worker’s compensation law, employers liability law, occupational disease law, or similar laws or act
- Physiotherapy, except as specifically provided for in the Schedule. Braces and appliances, except as specifically provided for in the Schedule. Replacement braces and appliances. Assistant surgeon services, except as specifically provided for in the Schedule.
- Services rendered for detection and correction by manual or mechanical means (including x- rays incidental thereto) of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column.
- That part of medical expense payable by any automobile insurance policy without regard to fault.
- Nuclear reaction or the release of nuclear energy. However, this exclusion will not apply if the loss is sustained within 180 days of the initial incident and: (i) The loss was caused by fire, heat, explosion or other physical trauma which was a result of the release of nuclear energy; and (ii) The covered person is within a 25 mile radius of the site of the release either: At the time of the release; or Within 24 hours of the start of the release
- Travel in or upon: (a) A snowmobile; (b) Any two-or three-wheeled motor vehicle; or (c) Any off road motorized vehicle not requiring licensing as a motor vehicle.
- Any accident where the covered person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator’s license.
- Preventive medicines, serums, vaccines, unless specifically provided.
- Expenses to the extent that they are paid or payable under other valid and collectible group insurance or medical prepayment plan.
- Rest cures or custodial care. Personal services such as television and telephone or transportation.
Pre-Existing Conditions Limitation
A “Pre-existing Condition” is a Sickness, Injury, or related condition for which medical advice, diagnosis, care or treatment was recommended or received by a Doctor during the 6 consecutive months prior to the effective date of the Insured Person’s coverage under this Plan. The Pre-existing Condition Waiting Period is 12 months. Coverage will not be provided for a Pre-existing Condition until the Waiting Period has elapsed. The Pre-existing Condition Waiting Period applies to all persons covered under this Plan and begins on the Insured Person’s effective date. If the Insured Person receives treatment for a service for a Pre-existing Condition: (a) We will not pay benefits for such a condition until: the day after a 12 consecutive month period has passed from the Insured Person’s effective date; (b) With respect to a pregnancy, the day after a 10 consecutive month period has passed from the Insured Person’s effective date; and (c) We will pay only for Loss or Expense incurred after such 12 consecutive month period or ten (10) consecutive months with respect to pregnancy. A period of Creditable Coverage will be credited if the previous Creditable Coverage was continuous to a date not more than 63 days prior to the effective date of the new coverage. Payment will be in accordance with the provisions of this Plan.
The Pre-existing Conditions exclusion does not apply to any of the following: (a) Genetic information in the absence of a diagnosis of a condition related to such information; (b) A covered newborn dependent child who, as of the last day of the 31-day period beginning with the date of birth, is covered under Creditable Coverage; or (c) A covered adopted dependent child under the age of 18, who, as of the last day of the 31-day period beginning on the date of adoption or placement for adoption, is covered under Creditable Coverage.
Your benefits are payable for covered expenses not otherwise covered and payable by any other plan providing medical expense benefits. If there are no other valid and collectible benefits available from any other source, this plan will pay the covered expenses up to the limits of the policy. If there is other valid and collectible benefits available from any other source. We will pay any excess amount unpaid from Your primary insurance.
If a Covered Person is continuously covered under the policy offered through the Policyholder or any other group plan, he will be covered for an Injury sustained or sickness first manifested while so covered. If You enroll for coverage offered through Your Policyholder within 63 days of the end of any preceding company’s policy, You will be considered to have maintained continuous coverage, except for expenses that are the liability of the previous policy. Coverage cannot be considered continuous if a break in enrollment of more than 63 days occurs.
Extension of Benefits
If a Covered Person is confined to a Hospital, benefits will continue to be paid for that condition for a period of up to 3 months following the end of the term of coverage, or until the maximum benefits of the policy, whichever occurs first.