Group Hospital Indemnity Insurance Limitations & Exclusions

The benefit amount payable is reduced by 50% if the Covered Person is age 67 or older on the date of a covered loss and coverage terminates at age 75.

General Limitations

Pre-existing Condition Limitation

No benefits are payable for any Covered Illness that results from, or is caused or contributed to by, a Pre-existing Condition. A condition will no longer be considered a Pre-existing Condition after the Covered Person’s coverage under the Policy has been in effect for 12 consecutive months. A Pre-existing Condition limitation will also apply to any benefit amount increase or the addition of any benefit under the Policy, including any changes from the Prior Policy (if applicable).

If a Covered Person becomes Confined as the result of a Pre-Existing Condition prior to completing the 12-month limitation period, benefits will only be payable for any day of Confinement that extends after the end of the limitation period.

Pregnancy Limitation Period

A Covered Person must complete a 10 month Pregnancy Limitation Period before becoming eligible for benefits for pregnancy or childbirth under the Policy. If a Covered Person receives Treatment for pregnancy or childbirth during this Pregnancy Limitation Period, benefits are not payable.

If the Covered Person becomes Confined as the result of pregnancy or childbirth prior to completing the Pregnancy Limitation Period, benefits will only be payable for any day of Confinement that extends after the end of the Pregnancy Limitation Period.

This limitation does not apply to Complications of Pregnancy.

Other Hospital Indemnity Policy Limitation (Over- Insurance Limitation)

If the Covered Person is insured under any Other Hospital Indemnity Policy, any claim for benefit is only payable under the one policy elected by You or Your beneficiary or estate, in the event of death.

We will return the amount of premium paid for any Other Hospital Indemnity Policy that is declined by You retroactive to the later of:

1. the last date any benefit was paid for any Covered Person under the Other Hospital Indemnity Policy; or
2. the effective date of insurance for You under the Other Hospital Indemnity Policy.

Limitation on Multiple Options. If a Covered Person suffers a Covered Loss under more than one Option, We will pay only one benefit, the largest benefit.

General Exclusions

Benefits will not be provided under the Policy for any Illness that is caused by, or results from:

In addition, We will not pay for any benefits under the Policy, unless required by law for:

1. suicide or attempted suicide while sane or insane or from intentionally self-inflicted injury.
2. war or any act of war, whether declared or undeclared.
3. involvement in any type of active military service. Reserve or National Guard active duty training is not excluded, unless it extends beyond 31 consecutive days. If you notify us of active duty service or training, We will refund any premiums paid for any period for which no coverage is provided as a result of the exclusion.
4. participation in the commission or attempted commission of any felony, insurrection or Participation in a Riot.
5. engaging in an illegal organization.
6. being intoxicated while operating a motor vehicle.
   • a Covered Person will be conclusively presumed to be intoxicated if the level of alcohol in a Covered Person’s blood exceeds the amount at which a person is presumed, under the law of the locale in which the Accident occurred, to be intoxicated, if operating a motor vehicle.
   • an autopsy report from a licensed medical examiner, law enforcement officer reports, or similar items will be considered proof of the Covered Person’s intoxication.
7. being under the influence of any Prescription Drug, controlled substance, or hallucinogen, unless such Prescription Drug, controlled substance, or hallucinogen was prescribed by a Physician and taken in accordance with the prescribed dosage.
8. ride in or on any motor vehicle or aircraft engaged in acrobatic tricks/ stunts (for motor vehicles), acrobatic/ stunt flying (for aircraft), endurance tests, off-road activities (for motor vehicles), or racing;
9. participation in any organized sport in a professional or semi-professional capacity;
10. elective abortion or complications thereof;
11. artificial insemination, in vitro fertilization, test tube fertilization;
12. gender change, sterilization, tubal litigation or vasectomy, and reversal thereof;
13. aroma therapeutic, herbal therapeutic, or homeopathic services;
14. any Mental and Nervous Disorder, unless specifically allowed by a provision of this Certificate;
15. Substance Abuse, unless specifically allowed by a provision of this Certificate;
16. medical mishap or negligence on the part of any Physician, Medical Professional, or Therapist, including malpractice;
17. Treatment, supplies or services provided by, through or, behalf of any government agency or program; unless payment is required by a Covered Person;
18. Custodial Care, unless specifically allowed by a benefit provision in this Certificate or any rider attached to the Policy (if applicable);
19. elective or cosmetic surgery or procedures, except for reconstructive surgery;
    • incidental to or following surgery for disease, infection or trauma of the involved body part; or
    • due to Congenital Anomaly or disease of a Dependent Child which has resulted in a functional defect;
20. dental care or Treatment, except for Treatment due to an Injury to sound natural teeth within 12 months of the Accident;
21. Treatment necessary due to Congenital Anomaly or disease; Congenital Anomalies of newborn and newly adopted children are not excluded if otherwise covered under the terms of the Policy.

Group Personal Accident Limitations & Exclusions

The principal sum payable for the Accidental Death Benefit is reduced by 50% if the Covered Person is age 67 or older on the date of a covered loss.

General Limitations

This section applies to all Hazards, Coverages and Benefits unless otherwise stated.

Limitation on Multiple Covered Losses. If a Covered Person suffers more than one Covered Loss as a result of the same Accident, We will pay only one benefit, the largest benefit.

Limitation on Multiple Coverages and Benefits. If a Covered Person suffers a Covered Loss which is payable under more than one benefit as a result of the same Accident, the most We will pay for these benefits in total is the Covered Person’s Principal Sum.

General Exclusions

This section applies to all Hazards, Coverages and Benefits unless otherwise stated.

A loss will not be a Covered Loss if it is the direct result of:

1. War or any Act of War, whether declared or undeclared; or the release of radiation which is the result of war;
2. involvement in any type of active military service.
3. illness or disease, regardless of how contracted; medical or surgical treatment of illness or disease; or complications following the surgical treatment of illness or disease; except for Accidental ingestion of contaminated foods;
4. participation in the commission or attempted commission of any felony, an assault, insurrection or riot;
5. parasailing, bungee jumping, heli-skiing, scuba diving or any other activity that would reasonably be deemed extra-hazardous;
6. being legally intoxicated.
   1. a Covered Person will be conclusively presumed to be legally intoxicated if the level of alcohol in his or her blood exceeds the amount at which a person is presumed, under the law of the state in which the Accident occurred, to be intoxicated, if operating a motorized vehicle.
   2. a Covered Person will be conclusively presumed to be legally intoxicated if the level of alcohol in his or her blood exceeds the amount at which a person is presumed, under the law of the state in which the Accident occurred, to be intoxicated, if operating a motorized vehicle.
7. intentional use of illegal drugs or intentional misuse of prescription or over the counter drugs (not taken as directed);
8. travel or flight in any aircraft except to the extent stated below:
   1. Coverage for air travel is limited to a Covered Loss sustained by Covered Person as a passenger, during a trip while riding in or on, boarding, or alighting from:
   2. an Air Travel Carrier; or any aircraft which is not subject to a certificate of airworthiness; whose design and customary and regular purpose is for transporting passengers; and which is operated by the Armed Forces of the United States of American or the Armed Forces of any foreign government.
9. a cardiovascular event or stroke caused by exertion prior to or at the same time as an Accident;
10. alcoholism.

In addition, the following exclusions apply to the Accident Medical Expense Benefit:

1. cosmetic, plastic or restorative surgery unless Medically Necessary for the treatment of the Injury;
2. any medical expenses related to pregnancy unless Medically Necessary for the treatment of the Injury;
3. personal comfort or convenience items, such as but not limited to Hospital telephone charges, television rental, or guest meals;
4. treatment by any person Related to the Covered Person;
5. expenses incurred for dental care, treatment, repair or replacement of Sound Natural Teeth unless Medically Necessary for the treatment of the Injury;
6. expenses incurred for eye examinations, eye glasses, contact lenses or hearing aids or the fitting, repair or replacement of these items unless Medically Necessary for the treatment of the Injury;
7. routine physical examinations and related medical services, elective treatment or surgery, or experimental or investigative treatments or procedures;
8. a Medical Repatriation;
9. expenses incurred for psychological or psychiatric counseling of any kind or any expense for treatment of mental or nervous diseases or disorders;
10. expenses which the Covered Person is not legally obligated to pay;
11. expenses for Custodial Services or services provided by a private duty nurse unless such expenses are incurred as a result of an Injury;
12. expenses related to the repair or replacement of existing artificial limbs, eyes, or other prosthetic appliances, or rental of existing medical equipment unless for the purpose of modifying the item because the Injury has caused further impairment in the underlying bodily condition;
13. treatment involving conditions caused by repetitive motion injuries or cumulative trauma and not a result of an Injury;
14. treatment of Osgood-Schlatter’s Disease.

Disclaimers:

The Hospital Indemnity and Accident insurance benefits described are underwritten by Zurich American Insurance Company (Zurich), 1299 Zurich Way, Schaumburg, Illinois 60196, 1 800 987 3373 (NAIC # 16535). This document provides a general description of certain provisions and features of this insurance program for informational purposes only and does not revise or amend the applicable policies. In the event of a discrepancy between this document and your certificate of insurance or the group policy, the terms of the group policy shall apply. All benefits are subject to the terms and conditions of the group policy. Please refer to your certificate of insurance for a detailed description of the insurance coverage, including the exclusions, limitations, reductions and termination.

Coverage may not be available in all states or certain terms, conditions and exclusions may be different where required by state law. Benefits decrease at age 67. Coverage terminates at age 75. This insurance provides limited benefits. Limited benefits plans are insurance products with reduced benefits and are not intended to be an alternative, it is intended to help supplement Comprehensive coverage. This insurance does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.

American Online Benefits Group is not a subsidiary or affiliate of Zurich, and use of American Online Benefit Group’s products and services are independent of and not included within the applicable group policy. Zurich expressly disclaims any and all damages or costs related to your use of or reliance upon the products, services, representations or warranties made by or on behalf of American Online Benefits Group.