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Silver and Gold:
After coverage has been in effect for 24 continuous months, the Silver and Gold plan options provide a US$50,000 lifetime benefit for eligible pre-existing conditions that existed at or prior to the effective date, subject to a maximum of US$5,000 per period of coverage. This benefit is payable whether or not you have received consultation or treatment for the condition(s) during the 24-month period. The Silver and Gold plans do not "rider" or charge additional premium for pre-existing conditions. If you properly disclose a pre-existing condition at the time of application and are accepted into the plan, you will be covered for eligible medical expenses after 24 months of continuous coverage, subject to the foregoing limits and the other terms of the plan.*
The following illnesses which exist, manifest themselves or are treated or have treatment recommended prior to or during the first 180 days of coverage from the initial effective date are considered pre-existing conditions under the plan, and are subject to the waiting period and other limitations of coverage described above: asthma, allergies, tonsillectomy, back conditions, adenoidectomy, hemorrhoids or hemorrhoidectomy, disorders of the reproductive system, hysterectomy, hernia, gall stones or kidney stones, any condition of the breast, and any condition of the prostate.
Platinum:
On the Platinum plan option, conditions that are fully disclosed on the application and have not been excluded or restricted by rider will be covered the same as any illness. Conditions, including any complications there from, that are not fully disclosed on the application will not be covered.
Other Exclusions And Limitations*
- Treatment not ordered or received by a physician
- Treatment or supplies not medically necessary
- Investigational, experimental or research procedures
- Custodial care
- Weight modification
- Elective cosmetic or plastic surgery
- Treatment of impotency
- Contraceptive medication or treatment
- Drug and alcohol abuse treatment
- Organ transplants not specifically listed
- Routine foot care
- Treatment by a relative or family member
- Treatment as a result of war or riot
- Treatment resulting from illegal activities
- Speech therapy
- Persons HIV+ at effective date
- Organized amateur or professional sports
- Maternity and newborn care (unless the maternity rider or Platinum plan option is purchased – see Summary Schedule of Benefits on page 6 of brochure)
- Services and treatment eligible for payment by any government or other insurance
- Adult routine physical examinations are excluded under the Silver plan option and for the first 12 months for the Gold and Platinum options
- Devices to correct sight or hearing are excluded under the Silver and Gold plan options
- Inpatient mental and nervous is excluded under the Silver plan option for the first 12 months for the Gold and Platinum plan options
- Outpatient mental and nervous for the first 12 months on all plan options
* See certificate wording for a definition of pre-existing conditions and a complete list of exclusions and limitations, and for all other specific terms and conditions of the plan. Certificate wording is available upon request.
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