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MEDICAL
EXCLUSIONS
No benefits will be
paid for: a) loss or expense caused by or resulting from; or b) treatment,
services or supplies for, at or related to:
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Learning
Disabilities;
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Biofeedback;
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Circumcision;
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Cosmetic
procedures, except cosmetic surgery required to correct an Injury for
which benefits are otherwise payable under this policy or for newborn
or adopted children; removal of warts, non-malignant moles and
lesions;
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Dental treatment,
except for accidental Injury to Sound, Natural Teeth;
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Elective Surgery or
Elective Treatment;
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Elective abortion;
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Eye examinations,
eye refractions, eyeglasses, contact lenses, prescriptions or fitting
of eyeglasses or contact lenses, vision correction surgery, or other
treatment for visual defects and problems; except when due to a
disease process;
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Hearing
examinations or hearing aids; or other treatment for hearing defects
and problems. "Hearing defects" means any physical
defect of the ear which does or can impair normal hearing, apart from
the disease process.
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Hirsutism;
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Immunizations,
preventive medicines or vaccines, except where required for treatment
of a covered Injury;
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Injury caused by,
or resulting from the use of alcohol, intoxicants, hallucinogenics,
illegal drugs, or any drugs or medicines that are not taken in the
recommended dosage or for the purpose prescribed by the Insured
Person's Physician; intoxication is defined and determined by the laws
of the state where the loss or cause of the loss was incurred;
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Injury or Sickness
for which benefits are paid or payable under any Workers' Compensation
or Occupational Disease Law or Act, or similar legislation.
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Injury sustained
while (a) participating in any interscholastic, club,
intercollegiate, or professional sport, contest or competition; (b)
traveling to or from such sport, contest or competition as a
participant; or (c) while participating in any practice or
conditioning program for such sport, contest or competition;
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Organ transplants;
only those considered experimental are excluded.
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Pre-existing
Conditions, except for individuals who have been continuously insured
under the SOMA student insurance policy for at least 12
consecutive months; The Pre-existing condition exclusionary period
will be reduced by the total number of months that the Insured
provides documentation of continuous coverage under a prior health
insurance policy which provided benefits similar to this policy;
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Prescription Drugs,
services or supplies as follows:
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Therapeutic
devices or appliances, including hypodermic needles, syringes,
support garments and other non-medical substances,
regardless of intended use.
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Immunization
agents, biological sera, blood or blood products administered on
an outpatient basis;
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Drugs
labeled, "Caution - limited by federal law to
investigational use" or experimental drugs;
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Products
used for cosmetic purposes;
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Drugs
used to treat or cure baldness, and anabolic steroids used for
body building;
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Anorectics
- drugs used for the purpose of weight control;
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Fertility
agents or sexual enhancement drugs, such as Parlodel, Pergonal,
Clomid, Profasi, Metrodin, Serophene, or Viagra;
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Growth
hormones, except when a Medical Necessity; or
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Refills
in excess of the number specified or dispensed after one (1)
year of date of the prescription;
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Reproductive/infertility
services including but not limited to: family planning;
fertility tests; infertility (male or female), including
any services or supplies rendered for the purpose or with the intent
of inducing conception; premarital examinations; impotence, organic or
otherwise; tubal ligation; vasectomy; sexual reassignment surgery;
reversal of sterilization procedures;
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Routine Newborn
Infant care, well-baby nursery and related Physician charges in excess
of 48 hours for vaginal delivery or 96 hours for cesarean delivery;
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Routine physical
examinations and routine testing; preventive testing or treatment;
screening exams or testing in the absence of Injury or Sickness,
except as specifically provided in the Policy;
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Services provided
normally without charge by the Health Service of the Policyholder; or
services covered or provided by the student health fee;
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Skeletal
irregularities of one or both jaws, including orthognathia and
mandibular retrognathia; temporomandibular joint dysfunction;
deviated nasal septum, including submucous resection and/or others
surgical correction thereof; nasal and sinus surgery;
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Sleep disorders;
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Suicide or
attempted suicide while sane or insane (including drug overdose); or
intentionally self-inflicted Injury;
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Surgical breast
reduction, breast augmentation, breast implants, breast prosthetic
devices, or gynecomastia, except as specifically provided in the
policy;
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Treatment in a
Government hospital, unless there is a legal obligation for the
Insured Person to pay for such treatment;
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War or any act of
war, declared or undeclared; or while in the armed forces of any
country (a pro-rata premium will be refunded upon request for such
period not covered); and
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Weight management,
weight reduction, nutrition programs, treatment for obesity, surgery
for removal of excess skin or fat, and treatment of eating disorders
such as bulimia and anorexia, except as specifically provided in the
policy. Exception: benefits will be provided for the
treatment of dehydration and electrolyte imbalance associated with
eating disorders.
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