We will not provide benefits for any loss caused by or resulting from, a Pre-Existing Condition.
“Pre-Existing Conditions” mean any medical condition or Sickness for which medical advice, care, diagnosis, treatment, consultation, or medication was recommended by or received from a Doctor within the 5 years immediately prior to a Covered Person’s Effective Date of Coverage.
“Consultation” means evaluation, diagnosis or medical advice was given with or without the necessity of a personal examination or visit.
We will not pay for loss or expense caused by or resulting from any of the following:
- Expenses for the treatment of Preexisting Conditions, as defined in the Preexisting Conditions Limitation provision.
- Expenses incurred prior to the Effective Date of a Covered Person’s coverage or incurred after the Expiration Date, regardless of when the condition originated. except in accordance with the Extension of Benefits provision.
- Expenses to treat complications resulting from treatment of conditions which are not covered under the Policy. This does not include Emergency Services as defined.
- Experimental or Investigative services or treatment. “Experimental or Investigative” means services, supplies, devices, treatments, procedures, or drugs that have not been recognized as generally accepted medical treatments. Our determination of what constitutes Experimental or Investigative treatment will be based on, but not limited to, the approval of treatments from the American Medical Association, the U.S. Food and Drug Administration, and the Administrative Procedure Act. Experimental or Investigative includes treatments that have not been demonstrated through sufficient peer-reviewed medical literature to be safe and effective for the proposed use.
- Expenses for purposes determined by Us to be educational.
- Amounts in excess of the Usual, Reasonable and Customary charges made for covered services or supplies.
- Expenses You (or Your Covered Dependent) are not required to pay, or which would not have been billed, if no insurance existed.
- Charges that are eligible for payment by Medicare or any other government program except Medicaid.
- Costs for care in government institutions unless You (or Your Covered Dependent) are obligated to pay for such care.
- Expenses for the treatment of an occupational Injury or Sickness which are paid under any Workers’ Compensation Act only to the extent such services or supplies are the liability of the employee, employer, or workers’ compensation insurance carrier according to a final adjudication under any Workers’ Compensation.
- Medical expenses which are payable under any automobile insurance policy without regard to fault (does not apply in any state where prohibited).
- Charges incurred by a Covered Person while on active duty in the armed forces. Upon written notice to Us of entry into such active duty, the unused premium will be returned to You on a pro rated basis.
- Expenses resulting from a declared or undeclared war, or from voluntary participation in a riot or insurrection.
- Expenses incurred while engaging in an illegal act or occupation or during the commission, or the attempted commission, of a felony or assault.
- Expenses for the treatment of normal pregnancy or childbirth, except for Complications of Pregnancy.
- Charges for a Covered Dependent who is a newborn child not yet discharged from the Hospital, unless the charges are Medically Necessary to treat premature birth, congenital Injury or Sickness, or Sickness or Injury sustained during or after birth.
- Charges for voluntary termination of normal pregnancy, normal childbirth or elective cesarean section.
- The cost of any drug, including birth control pills, supply, treatment or procedure that prevents conception or childbirth.
- Expenses for the diagnosis and treatment of infertility, including but not limited to any attempt to, induce fertilization by any method, in vitro fertilization, artificial insemination or similar procedures, whether the Covered Person is a donor, recipient or surrogate.
- Expenses for sterilization or reversal of sterilization.
- Services, supplies or treatment related to sex transformation or sex dysfunction or inadequacies.
- Costs for physical exams or other services not needed for medical treatment, except as specifically covered.
- Expenses for prophylactic treatment, including surgery or diagnostic testing, except as specifically covered.
- Expenses for the treatment of Mental Illness or Nervous Disorders, including, but not limited to, neurosis, psychoneurosis, psychopathy, psychosis, attention deficit disorder, autism, hyperactivity, or mental or emotional disease or disorder of any kind, unless specifically covered.
- The costs of treatment of alcoholism or alcohol abuse, chemical dependency, substance abuse or drug addiction, unless specifically covered.
- Expenses incurred in the treatment of Injury or Sickness sustained by voluntary use of alcohol, illegal drugs or hallucinogenics.
- The cost of programs, treatment, or procedures for tobacco use cessation.
- Expenses resulting from suicide or attempted suicide or intentionally self-inflicted Injury, whether while sane or insane.
- The cost of dental treatment or care or orthodontia or other treatment involving the teeth or supporting structures, except as specifically covered.
- Expenses incurred in the treatment by any method for jaw joint problems including temporomandibular joint dysfunction (TMJ), TMJ pain syndromes, craniomandibular disorders, myofacial pain dysfunction or other conditions of the joint linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the joint, except as specifically covered.
- Expenses of radial keratotomy or correction of refractive error, eye refractions, vision therapy, routine vision exams to assess the initial need for, or changes to prescription eyeglasses or contact lenses, the purchase, fitting or adjustment of eyeglasses or contact lenses, or treatment of cataracts.
- The costs for routine hearing exams to assess the need for or change to hearing aids, or the purchase, fittings or adjustments of hearing aids.
- The costs of cosmetic or reconstructive procedures, services or supplies, except as specifically covered.
- Charges for breast reduction or augmentation or complications arising from these procedures.
- Outpatient Prescription or Legend Drugs, medications, vitamins and mineral or food supplements, including pre-natal vitamins, or any over-the-counter medicines, whether or not ordered by a Doctor.
- The cost of any drug or other item used to treat hair loss.
- Expenses incurred in the treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia, bunions, spurs, or the removal of corns, calluses or toenails, unless specifically for the treatment of a metabolic or peripheral vascular disease or for the prompt repair of an Injury sustained while coverage is in force for the Covered Person.
- Expenses incurred in the treatment of acne or varicose veins.
- The costs of weight loss programs, diets, or treatment of obesity.
- Transportation charges, except as specifically covered.
- Expenses for rest or recuperation cures or care in an extended care facility, convalescent nursing home, a facility providing rehabilitative treatment, Skilled Nursing Facility, or home for the aged, whether or not part of a Hospital, unless specifically covered.
- Costs of services or supplies for personal comfort or convenience, including homemaker services or supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to bathing, dressing, feeding, routine skin care, bladder care and administration of oral medications or eye drops, except as specifically covered.
- Costs of services or supplies furnished or provided by a member of Your Immediate Family.
- Expenses for diagnosis or treatment of a sleeping disorder.
- Expenses incurred in the treatment of Injury or Sickness resulting from participation in skydiving, scuba diving, hang or ultra light gliding, riding an all-terrain vehicle such as a dirt bike, snowmobile or go-cart, racing with a motorcycle, boat or any form of aircraft, any participation in sports for pay or profit, or participation in rodeo contests.
- Expenses for the purchase of a noninvasive osteogenesis stimulator (bone stimulator).
- The costs of services or supplies of a common household use, such as exercise cycles, air or water purifiers, air conditioners, allergenic mattresses, and blood pressure kits.
- Expenses for surgery during the first 6 months after the Effective Date of Coverage for a Covered Person for a total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis or carcinoma (subject to all other coverage provisions, including but not limited to, the Pre-Existing Conditions exclusion); tonsillectomy, adenoidectomy, repair of deviated nasal septum or any type of surgery involving the sinus, myringotomy, tympanotomy, herniorraphy, or cholecystectomies.
- Knee Injury or Disorder: Expenses do not include charges incurred to diagnose or treat an Injury or disorder of the knee including surgery in excess of the Knee Injury or Disorder Maximum shown in the schedule.
- Gallbladder Surgery: Expenses do not include charges incurred in excess of the Gallbladder Surgery Maximum shown in the Schedule.
- Participating in Interscholastic or Intercollegiate Organized Competitive Sports.
- Medical care, treatment, services, or supplies received outside of the United States or its possessions.
Starr Indemnity & Liability Company is an admitted insurer rated “A” (Excellent) by A.M. Best Company. A.M. Best ratings range from D to A++.
Legal Disclaimer: This web site provides a brief description of the plan. You must be 18 years old to apply. The policy will contain reductions, limitations,exclusions, and termination provisions. Full details of the coverage are contained in policy form number AH-60001. If there are any conflicts between this document and the Policy, the Policy shall govern.
Med Plus STM is not available in all U.S states or any other countries outside the U.S and coverage and benefits may vary by state as well.