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Patriot Exchange

Charges for certain services, treatments and/or conditions, among others, are excluded from coverage under the Patriot plans and include but are not limited to:

  1. Economic Sanctions
  2. War; Military Action, mutiny, riot, strike, military or popular uprising, insurrection, insurgency, rebellion, revolution, military or usurped power
  3. Terrorism
  4. Pre-existing Conditions: Charges resulting directly or indirectly from or relating to any Pre-existing Condition, (whether physical or mental, regardless of the cause of the condition) are excluded from coverage under this insurance until the Insured Person has maintained coverage under this insurance plan continuously for at least twelve (12) months
  5. Maternity and Newborn Care: Charges for pre-natal care, delivery, post-natal care, and care of Newborns, including complications of Pregnancy, miscarriage, complications of delivery and/or of Newborns are excluded from this insurance.
  6. Preventative Care: Charges for Routine Physical Examinations and immunizations are excluded from coverage under this insurance
  7. Charges for any Treatment or supplies that are:
    1. not incurred, obtained or received by an Insured Person during the Period of Coverage
    2. not presented to the Company for payment by way of a completed Proof of Claim within one hundred eighty (180) days from the date such Charges are incurred
    3. not administered or ordered by a Physician
    4. not Medically Necessary for the diagnosis, care or Treatment of the physical or mental condition involved. This also applies when and if they are prescribed, recommended or approved by the attending Physician
    5. provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable
    6. in excess of Usual, Reasonable, and Customary
    7. related to Hospice care
    8. incurred by an Insured Person who was HIV + on or before the Initial Effective Date of this insurance, whether or not the Insured Person had knowledge of his/her HIV status prior to the Effective Date, and whether or not the Charges are incurred in relation to or as a result of said status. This exclusion includes Charges for any Treatment or supplies relating to or arising or resulting directly or indirectly from HIV, AIDS virus, AIDS related Illness, ARC Syndrome, AIDS and/or any other Illness arising or resulting from any complications or consequences of any of the foregoing conditions
    9. provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician
    10. performed or provided by a Relative of the Insured Person
    11. not expressly included in the ELIGIBLE MEDICAL EXPENSES provision
    12. provided by a person who resides or has resided with the Insured Person or in the Insured Person's home
    13. required or recommended as a result of complications or consequences arising from or related to any Treatment, Illness, Injury, or supply excluded from coverage or which is otherwise not covered under this insurance
    14. for Congenital Disorders and conditions arising out of or resulting therefrom
  8. Charges incurred for failure to keep a scheduled appointment
  9. Telemedicine consultations through an established Telemedicine protocol system will be considered individually based on medical necessity and appropriateness as determined by the Company under the plan
  10. Charges incurred for Surgeries, Treatment or supplies which are Investigational, Experimental, and for research purposes
  11. Charges incurred related to genetic medicine, genetic testing, surveillance testing and/or wellness screening procedures for genetically predisposed conditions indicated by genetic medicine or genetic testing, including, but not limited to amniocentesis, genetic screening, risk assessment, preventive and prophylactic surgeries recommended by genetic testing, and/or any procedures used to determine genetic pre-disposition, provide genetic counseling, or administration of gene therapy
  12. Charges incurred for testing that attempts to measure aspects of an Insured Person’s mental ability, intelligence, aptitude, personality and stress management. Such testing may include but is not limited to psychometric, behavioral and educational testing
  13. Charges incurred for Custodial Care
  14. Charges incurred for Educational or Rehabilitative Care that specifically relates to training or retraining an Insured Person to function in a normal or near-normal manner. Such care may include but is not limited to job or vocational training, counseling, occupational therapy and speech therapy
  15. Charges for weight modification or any Inpatient, Outpatient, Surgical or other Treatment of obesity (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms or procedures of bariatric Surgery by whatever name called, or reversal thereof, including without limitation intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling
  16. Charges for modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Insured Person (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof)
  17. Charges or Treatment for cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and/or follows a Surgery which was covered under this insurance
  18. elective Surgery or Treatment of any kind
  19. Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception, insemination (natural or otherwise) or birth, including but not limited to: artificial insemination; oral contraceptives; Treatment for infertility or impotency; vasectomy, or reversal of vasectomy; sterilization; reversal of sterilization; surrogacy or abortion
  20. Charges incurred for any Treatment or supply that either promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction
  21. any Illness or Injury sustained while taking part in, practicing or training for: Amateur Athletics; Professional Athletics; or athletic activities that are sponsored by any Governing Body or Authority including the National Collegiate Athletic Association, any other collegiate sanctioning or Governing Body or the International Olympic Committee
  22. any Illness or Injury sustained while taking part in activities designated as Adventure Sports, which are limited to the following: abseiling; BMX; bobsledding; bungee jumping; canyoning; caving; hot air ballooning; jungle zip lining; parachuting; paragliding; parascending; rappelling; skydiving; spelunking; whitewater kayaking or whitewater rafting in water less than Class V difficulty; wildlife safaris; and windsurfing
  23. any Illness or Injury sustained while taking part in activities designated as Extreme Sports, which include but are in no way limited to the following (and include any combination or derivative of the following): BASE jumping; cave diving; cliff diving; downhill mountain biking and racing; extreme skiing; freediving; free flying; free running; free skiing; freestyle scootering; gliding; heli-skiing; ice canoeing; ice climbing; kitesurfing; mixed martial arts; motocross; motorcycle racing; motor rally; mountaineering above elevation of 4500 meters from Ground Level; parkour; piloting a commercial or non-commercial aircraft; powerbocking; scuba diving or sub aqua pursuits below a depth of 40 meters; snowmobile racing; truck racing; whitewater kayaking or whitewater rafting Class VI and higher difficulty; and wingsuit flying.
  24. any Illness or Injury sustained while taking part in snow skiing, snowboarding or snowmobiling where the Insured Person is in violation of applicable laws, rules or regulations of a ski resort, out of bounds or in unmarked or unpatrolled areas
  25. any Illness or Injury sustained while taking part in backcountry skiing
  26. any Illness or Injury sustained while taking part in skiing off-piste
  27. any Illness or Injury sustained while taking part in athletic or recreational activities where the Insured Person is not physically or medically fit or does not hold the necessary qualifications to engage in said activities
  28. any Illness or Injury sustained while taking part in Collision Sports
  29. any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where such activity is undertaken against the advice or direction of any local authority or any qualified instructor or contrary to the rules, recommendations and procedures of a recognized governing body for the sport or activity
  30. any Illness or Injury sustained while participating in any activity where such activity is undertaken in disregard of or against the recommendations, Treatment programs, or medical advice of a Physician or other healthcare provider
  31. any Injury or Illness sustained as a result of being under the influence of or due wholly or partly to the effects of alcohol, liquor, intoxicating substance, narcotics or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician but not for the Treatment of Substance Abuse
  32. any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs in excess of the applicable blood/alcohol legal limit, other than drugs taken in accordance with Treatment prescribed and directed by a Physician. For purposes of this exclusion, “vehicle” shall include motorized devices regardless of whether or not a driver or operator license is required (including watercraft and aircraft) and non-motorized bicycles and scooters for which no permit or license is required
  33. any willfully Self-inflicted Injury or Illness
  34. any sexually transmitted or venereal disease
  35. any testing for the following when not Medically Necessary: HIV, seropositivity to the AIDS virus, AIDS related Illnesses, ARC Syndrome, AIDS
  36. any Illness or Injury resulting from or occurring during the commission of a violation of law by the Insured Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations
  37. biofeedback, acupuncture, music, occupational, recreational, sleep, speech, or vocational therapy
  38. orthoptics, visual therapy or visual eye training
  39. any non-surgical Illness or Treatment of the feet, including without limitation: orthopedic shoes; orthopedic prescription devices to be attached to or placed in shoes; Treatment of weak, strained, flat, unstable or unbalanced feet; metatarsalgia, bone spurs, hammer toes or bunions; and any Treatment or supplies for corns, calluses or toenails; except as otherwise expressly set forth
  40. hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician
  41. any sleep disorder, including without limitation sleep apnea
  42. any exercise and/or fitness program or equipment, whether or not prescribed or recommended by a Physician
  43. any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s)
  44. any organ or tissue or other transplant or related services, Treatment or supplies
  45. any artificial or mechanical devices designed to replace human organs temporarily or permanently after termination of Inpatient status
  46. any efforts to keep a donor alive for a transplant procedure
  47. any Illness or Injury incurred in the Destination Country, Affected Area or Country of Residence as a result of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, unless coverage is expressly provided under the Public Health Emergency provision of this insurance.

    This exclusion DOES NOT apply to Charges resulting from COVID-19/SARS-CoV-2.
  48. Charges incurred for eyeglasses, contact lenses, hearing aids or hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason
  49. Charges incurred for eye Surgery, such as but not limited to radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness, or astigmatism
  50. Charges incurred for Treatment or supplies for temporomandibular joint (TMJ) including but not limited to TMJ syndrome, craniomandibular syndrome, chronic TMJ pain, orthognathic Surgery, Le-Fort Surgery or splints
  51. Charges incurred in the Insured Person’s Country of Residence, except as otherwise expressly provided for in this insurance
  52. Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance
  53. Charges or expenses incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the United States Food and Drug Administration or which are considered “off-label” drug use; and for drugs or medicines not prescribed by a Physician
  54. Any Treatment for an Illness or Injury requiring an unapproved U.S. Food and Drug Administration (FDA) medical product, services, Surgery, Surgical Procedure, prescription Medication, drug, biological product, Durable Medical Equipment (DME) or device when an Emergency Use Authorization (EUA) is in place issued by the U.S. Food and Drug Administration (FDA)
  55. Charges and all costs related to or arising from or in connection with all trips to the Destination Country undertaken for the purpose of securing medical Treatment or supplies
  56. Charges incurred for Dental Treatment, except as specifically provided for hereunder
  57. Wear and tear of teeth due to cavities and chewing or biting down on hard objects, such as but not limited to pencils, ice cubes, nuts, popcorn, and hard candies
  58. Dental Injury without associated face, skull, neck and/or jaws Injury or that can be evaluated and treated in a dental office
  59. Dental Treatment for services which provide oral care maintenance including tooth repair by fillings, root canals, tooth removal and x-rays
  60. Charges for Treatment of an Illness or Injury for which payment is made or available through a workers' compensation law or a similar law
  61. Charges incurred for massage therapy
  62. Charges incurred at a Hospital or Facility when the Insured Person checks himself or herself out Against Medical Advice of their Physician or leaves before reaching a Medically Necessary specified endpoint of Treatment
  63. Charges incurred for the Worsening of an Illness or Injury after the Insured Person left a Hospital or Facility Against Medical Advice or was a Discharge Against Medical Advice
  64. Accidental Death or Dismemberment when the Insured Person’s death or dismemberment is caused directly or indirectly by, results from, or where there is a contribution from, any of the following:
    1. bodily or mental infirmity, Illness or disease
    2. infection, other than infection occurring simultaneously with, and as a direct result of, the accidental Injury

Please note: The exclusions listed above is a consolidated version of the full policy wording. Please view the plan certificate ( America | International) for the full benefits and limitations of the plan.

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