What we don't cover

What we don't cover

These are the limitations that apply in addition to any personal exclusions detailed in your Certificate of Insurance. These include treatments that may be considered a matter of personal choice (such as cosmetic treatment) and other treatments that are excluded from cover to keep premiums at an affordable level.

We do not pay for Treatment of any condition resulting directly or indirectly from, or as a consequence of war,acts of foreign hostilities (whether or not war is declared), civil war, rebellion, revolution, insurrection or military or usurped power, mutiny, riot, strike, martial law or state of siege, or attempted overthrow of government,or any acts of terrorism, unless You are an innocent bystander. You are not covered for costs arising from taking part in any illegal act.

You are not covered for any charges made by a Medical Practitioner or Dental Practitioner for filling in claim forms or providing medical reports. You are not covered for any charges where a police report is required. You are not covered for the cost of shipping (including customs duty) on transporting medication.

You are not covered for costs for Treatment resulting from dependency on or abuse of alcohol, drugs, or other addictive substances and any illness or injury arising directly or indirectly from such dependency or abuse.

You are not covered for Treatment costs directly or indirectly caused by or contributed to or arising from: ionizing radiations or contamination by radioactivity from any nuclear waste from the combustion of nuclear fuel; the radioactive, toxic, explosive or other hazardous properties of any explosive nuclear assembly or nuclear component thereof.

You are not covered for Treatment costs relating to cosmetic or aesthetic Treatment or any Treatment related to previous cosmetic or reconstructive surgery (whether or not for psychological purposes) to enhance your appearance, even when medically prescribed, such as but not limited to acne, teeth whitening, lentigo and alopecia. The only exception is an initial reconstructive surgery necessary to restore function or appearance after a disfiguring accident, or as a result of surgery for cancer, if the accident or surgery occurs during your membership.

We do not pay for the Treatment of any conditions, or for any claim arising directly or indirectly from chemical or biological contamination, however caused, or from contamination by radioactivity from any nuclear material whatsoever, or asbestosis, including expenses in any way caused by or contributed to by an act of war or terrorism.

If You are insured under the Essential Group Plan option, You do not have cover for costs relating to the maintenance of Chronic Conditions. For Advance, Excel and Apex Group Plan options, the limits in the Benefit Schedule are a maximum per Period of Cover and not per Medical Condition.

You are not covered for any dental care unless these Benefits are included on Your Certificate of Insurance. However We will pay for Emergency In-Patient dental Treatment following an Accident as detailed in the Benefit Schedule. We will not pay for any telephone or travelling expenses incurred in seeking dental advice or Treatment, damage to dentures unless being worn at the time of the Accident, or the cost of Treatment made necessary by an accidental dental injury if:

  • The injury was caused by eating or drinking anything, even if it contains a foreign body
  • The damage was caused by normal wear and tear
  • The injury was caused when boxing or playing rugby (except school rugby) unless appropriate mouth protection was worn
  • The injury was caused by any means other than extra-oral impact
  • The damage was caused by tooth brushing or any other oral hygiene procedure
  • The damage is not apparent within 10 days of the impact which caused the injury
  • The costs are incurred more than 18 months after the date of the injury which made the Treatment necessary

 

You are not covered for Treatment of developmental, behavioural or learning problems such as attention deficit hyperactivity syndrome, speech disorders or dyslexia and physical developmental problems.

We do not pay for products classified as vitamins or minerals (except during pregnancy or to treat diagnosed, clinically significant vitamin deficiency syndromes), nutritional or dietary consultations and supplements, including, but not limited to, special infant formula and cosmetic products including but not limited to moisturizers, cleansers, lotions, soaps, shampoos, sunscreen, mouth wash, antiseptic lozenges, even if medically recommended or prescribed or acknowledged as having therapeutic effects.

You are not covered for costs relating to Treatment of eating disorders such as, but not limited to, anorexia nervosa and bulimia.

You are not covered for the amount of the Excess or Co-Insurance that is shown on Your Certificate of Insurance. We will treat any arrangement with or any offer by a provider to charge Us a higher fee to cover the amount of the Excess or Co-Insurance as fraud and We will take legal action.

You are not covered for Treatment or drugs which have not been established as being effective or which are experimental. For drugs this means they must be licensed for use by the European Medicines Agency or the Medicines and Healthcare products Regulatory Agency and be used within the terms of that licence. For established Treatment, this means procedures and practices that have undergone appropriate clinical trial and assessment, sufficiently evidenced and published medical journals and/or been approved by the National Institute for Health and Clinical Excellence for specific purposes to be considered proven safe and effective therapies.

You are not covered for routine eyesight or hearing tests or the cost of eyeglasses, contact lenses, hearing aids or cochlear implants. We do not pay for eye surgery to correct vision, however eye surgery to correct an Eligible Medical Condition is covered.

You are not covered for any costs relating to providing, maintaining and fitting of any external prosthesis or appliance or other equipment, medical or otherwise except as is specified under the Hospital Charges, Medical Practitioner and Specialist fees Benefit.

We do not pay for Treatment arising from or related to Your unreasonable failure to seek or follow medical advice and/or prescribed Treatment, or Your unreasonable delay in seeking or following such medical advice and/or prescribed Treatment. We do not pay for complications arising from ignoring such advice.

We do not cover the costs of surgery on a child while in its mother’s womb except as part of the maternity Benefits detailed in Your Certificate of Insurance.

We do not cover the cost of genetic tests, when those tests are undertaken to establish whether or not You may be genetically disposed to the development of a Medical Condition.

We do not cover Treatment of injuries sustained from base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts, free climbing, mountaineering with or without ropes, scuba diving to a depth of more than 10 metres, trekking to a height of over 2,500 metres, bungee jumping, canyoning, hang-gliding, paragliding or microlighting, parachuting, potholing, skiing off piste or any other winter sports activity carried out off piste.

You are not covered for Treatment for Acquired Immune Deficiency Syndrome (AIDS), AIDS-related Complex Syndrome (ARCS) and all diseases caused by or related to Human Immunodeficiency Virus (HIV) (or both) and sexually transmitted disease, other than stated in the Benefit Schedule.

You are not covered for the costs of Treatment for Hormone Replacement Therapy (HRT). We will cover Medical Practitioner’s fees including consultations, the cost of implants, patches or tablets which are Medically Necessary as a direct result of medical intervention, up to a maximum of 18 months from the date of medical intervention.

You are not covered for the costs of Treatment for, or related to, morbid obesity. You are not covered for costs arising from or relating to removing fat or surplus healthy tissue from any part of the body.

You are not covered for Treatment received in nursing homes, convalescence homes, health hydros, nature cure clinics or similar establishments. You are not covered for convalescence or where You are in Hospital for the purpose of supervision. You are not covered for extended nursing care if the reason for the extended nursing care is due to age related infirmity and/or if the Hospital has effectively become Your home.

You are not covered for costs relating to normal Pregnancy or childbirth, voluntary caesarean section, unless maternity Benefits are shown on Your Certificate of Insurance.

Your Plan does not cover You for Treatment of Pre-Existing Medical Conditions and Related Conditions unless accepted by Us in writing. A Pre-Existing Medical Condition means any disease, injury or illness for which:

  1. You have received Treatment, tests or investigations for, been diagnosed with or been hospitalised for; or
  2. You have suffered from or experienced symptoms; whether the Medical Condition has been diagnosed or not, at any time before your Start Date/Entry Date into the Plan.

You are not covered for any costs resulting from injuries or illness arising from You taking part in any form of professional sport. By professional sport, We mean where You are being paid to take part.

You are not covered for costs relating to investigations into or Treatment of infertility and fertility, sterilisation (or its reversal) or assisted conception. You are not covered for the costs in connection with contraception.

You are not covered for routine medical examinations including issuing medical certificates, health screening examinations or tests to rule out the existence of a condition for which You do not have any symptoms, unless these Benefits are shown on Your Certificate of Insurance.

We do not cover the costs of any second or subsequent medical opinions from a Medical Practitioner or Specialist for the same Medical Condition other than stated in Your Certificate of Insurance, unless authorised by Us.

You are not covered for any costs for Treatment resulting directly or indirectly from self-inflicted injury, suicide or attempted suicide.

You are not covered for Treatment costs relating to sexual problems including sexual dysfunction, or gender re-assignment operations or any other surgical or medical Treatment including psychotherapy or similar services which arise from, or are directly or indirectly associated with gender re-assignment. You are not covered for the costs of treating sexually transmitted infections.

You are not covered for Treatment costs related to snoring, insomnia, jet-lag, fatigue, or sleep apnoea including sleep studies or corrective surgery.

You are not covered for transport or accommodation costs You incur during trips made specifically to get medical Treatment unless these costs are for an Emergency medical Evacuation that We pre-authorised. You are not covered for any costs of Emergency medical Evacuation or repatriating Your body that We did not pre-authorise and arrange.

You are not covered for medical or other costs You incur if You travel against the advice given by Your treating Medical Practitioner.

You are not covered for the costs of Treatment by a family member or for self-therapy.

We will not pay Treatment charges when they are above the Reasonable and Customary Charges level.

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