SLPC 26461 04/15 (exp. 04/17)
Specified Disease insurance
Exclusions and Limitations for Specified Disease in New York
What exclusions apply to the benefits payable?
In addition to the exclusions stated in the Covered Conditions section of the Certificate, we will not pay any benefit that is caused by, contributed to in any way, or resulting from any Specified Disease condition Diagnosed outside the United States, its possessions, Mexico, or Canada without confirmation of the Diagnosis by the type of Specialist Physician specified for each of the Covered Conditions in Section 7 of the Certificate who practices in the United States, its possessions, Mexico, or Canada.
We will not pay a benefit for any Specified Disease that is due to or results from:
- intentionally self inflicted injuries;
- cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered Dependent Child which has resulted in a functional defect;
- active military duty;
- participation in war, declared or undeclared, or any act of war;
- participation in a riot, rebellion or insurrection;
- committing or attempting to commit a felony or being engaged in an illegal occupation;
- your engagement in aviation and related activities, such as skydiving and parachuting, and participation as a professional in athletics or sports; or
- being legally intoxicated or under the influence of any narcotic unless taken on the advice of a Physician and taken as prescribed.
What limitations apply to the benefits payable?
In addition to the limitations stated in the Covered Conditions section of the Certificate, we will not pay any benefit for any Specified Disease that is Diagnosed in the first 6 months following the effective date of any Insured’s insurance and results from a Pre-Existing Condition.
Pre-Existing Condition means during the 6 months prior to any Insured’s effective date of insurance or the effective date of an increase in any Insured’s amount of insurance, any condition for which any Insured:
received medical Treatment, consultation, advice, care or services from a licensed health care provider, including diagnostic measures for the condition, regardless of whether the condition was Diagnosed or suspected at that time; or took prescribed drugs or medicines for the condition.
When newborn children or newly adopted children are added to your Dependent Children Insurance within 31 days of the birth or adoption, the Pre-Existing Condition limitation does not apply.