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If accidental Injury or emergency Illness occurs during the Term of Insurance, the Plan will pay, subject to a $100 Deductible, reasonable and customary charges for Covered Medical Expenses resulting from such occurrence, up to the Medical Expense Maximum selected-$25,000 or $100,000. Only those expenses specifically described below and which are incurred within the Maximum Coverage Period (26 weeks from the onset of an Injury or emergency Illness) and which are not excluded are considered Covered Medical Expenses. Initial treatment of an Injury or emergency Illness must occur within 72 hours of the accident or onset of emergency Illness, defined as a condition requiring immediate care and/or hospitalization.
- Charges made by a hospital for room and board, floor nursing and other services-exclusive of charges for professional services 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 a semiprivate room and board accommodation, or intensive care when medically necessary;
- Charges made for physician's diagnosis, treatment and surgery;
- 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 the written prescription of a physician or surgeon;
- Charges for miscarriage subject to a maximum benefit of $1,000;
- Charges for treatment of mental and nervous disorders subject to the following limits: up to a maximum of 30 days for in-patient care and one Physician visit per day, to a 30 visit maximum, for out-patient care.
For Medical Expense, this insurance does not cover:
- Charges for Pre-existing Conditions, defined as any injury or illness for which a licensed physician was consulted, or for which treatment or medication was prescribed within 12 months prior to the Effective Date of insurance, except for conditions that remained controlled by prescribed medication as long as the prescribed drugs and medicine (maintenance prescriptions) did not change during the 12 months prior to the Effective Date of insurance. The costs of the maintenance prescriptions, which were required or continued during the Term of Insurance, are not a Covered Expense;
- 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 interscholastic or intercollegiate sports, or amateur athletic competition; 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 or childbirth; b) routine physicals; c) cosmetic or plastic surgery, except as the result of an accident; d) elective surgery; e) dental care, except as the result of injury to natural teeth caused by accident; f) 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; g) alcoholism or drug addiction; or h) 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.
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