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If an injury or illness occurs during the Term of Insurance, only those expenses specifically described below, and which are incurred within the Maximum Coverage Period of the Plan and which are not excluded (see Exclusions section) are considered Covered Medical Expenses. Initial treatment of an injury must occur within 60 days of the accident. For Plans 1 and 2, the Maximum Coverage Period per injury or illness is 52 weeks from the date of such injury or onset of such illness. For Plan 3, the Maximum Coverage Period is continuous during expatriate assignment, otherwise ends 30 days from Expiration Date of this insurance.
- Charges made by a hospital for room and board, floor nursing and other services, exclusive of charges for professional service and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the hospital's average charge for semiprivate room and board accommodation, or intensive care when medically necessary;
- Charges made for diagnosis, treatment and surgery by a physician;
- Charges made for the cost and administration of anesthetics;
- Charges for medication, X-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood transfusions and medical treatment;
- Charges for physiotherapy, if recommended by a physician for the treatment of a specific disablement and administered by a licensed physiotherapist;
- Dressings, drugs and medicines that can only be obtained upon a written
prescription of a physician or surgeon;
- Return Visit Coverage: Expenses described in 1-6 above resulting from onset of injury or illness during a visit in the Home Country/Country of Residence is afforded for a maximum total of 60 accumulated days per each 12 month Term of Insurance (or pro-rata thereof) subject to the following terms and conditions: a) Insured Person has been outside their Home Country/Country of Residence for a minimum of 3 consecutive months from Effective Date of insurance; b) visit is immediately followed by return to international location; c) medical maximum is limited to $50,000; d) coverage must be activated through written notification to the Administrator.
- After 12 months of continuous coverage, the Insured Person will be covered for expenses related to Pregnancy, including: Pre and Post-natal care, Normal delivery or C-section, associated newborn nursery hospital charges, complications of pregnancy and miscarriage. The following maximums apply: $5,000 for normal delivery for each pregnancy; and a maximum of $7,500 for C-section delivery for each pregnancy. (This coverage applies to Plan 3 only.)
- Well Child Care is provided by the Plan for covered eligible dependents until age 6. Coverage is provided for: a) six well child visits from age one week to age 12 months; b) three well child visits from age one year to age 2; and c) one well child visit per year from age 2 to age 6. Only services of family practitioners, pediatricians, and internal medicine specialists are covered. (This coverage applies to Plan 3 only.)
- After 12 months of continuous coverage, this Plan will pay the reasonable and customary charge for treatment of a mental or nervous disorder on an in-patient/out-patient basis from a hospital, an approved or licensed community mental health center or clinic, or a licensed psychiatrist or consulting psychologist, subject to a maximum benefit of $10,000 for Inpatient care or $1,000 for Outpatient care. (This coverage applies to Plan 3 only.)
The charges listed above shall in no event include any amount of such charges which are in excess of reasonable and customary charges.
For Medical Expenses, this insurance does not cover:
- Pre-existing Conditions, defined as illness, injury or manifestation of symptoms for which a licensed physician was consulted, or for which treatment or medication was prescribed, within
12 months prior to the Insured Person's Effective Date of insurance;
- Services, supplies or treatment, including any period of hospital confinement, which are not recommended, approved and certified as necessary and reasonable by a physician, or expenses which are
non-medical in nature;
- Expenses incurred as a result of or in connection with a) declared or undeclared war or any act thereof; b) injury sustained while participating in professional sports, sponsored scholastic or amateur athletics, which are defined as organized sports activities associated with a team, league, or other similar group; c) intentionally self-inflicted injury, suicide while sane or attempted suicide while insane; d) scuba diving, mountain climbing, sky diving, professional or amateur racing, piloting an aircraft; or e) commission of a felony;
- Expenses for a) pregnancy, childbirth or miscarriage, except as provided for in Plan 3; b) routine physicals; c) cosmetic or plastic surgery, except as the result of an accident; d) elective surgery; e) any mental and nervous disorders or rest cures, except as provided for in Plan 3; f) dental care, except as the result of injury to natural teeth caused by accident; g) eye refractions or eye examinations for the purpose of prescribing corrective lenses for eye glasses or for the fitting thereof, unless caused by accidental bodily injury incurred while insured; h) alcoholism or drug addiction or use of any drug or narcotic agent; or i) treatment by a family member;
- Treatment paid for or furnished under any other individual or group policy, or other service or medical pre-payment plan arranged through an employer to the extent so furnished or paid, or under any mandatory government program or facility set up for treatment without cost to any individual;
- Loss or expense caused by, contributed to, or resulting from any loss that occurs while traveling or enrolling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a physician.
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