What is not covered?
EXCLUSIONS – what is not covered?
There are some medical events that we do not cover. We believe they do not diminish the benefits of our plans and by excluding them we can make the plans more affordable for everyone.
By excluding necessary risks (e.g. consequences of alcohol consumption) or expenses which are incurred due to personal preferences (e.g. cosmetic treatment) – medical costs can be minimized; thus ensuring the long term stability and affordability of our plan for all our members.
The following risks are excluded from coverage:
- Expenses incurred prior to the effective date of coverage or after termination of coverage;
- Travel and accommodation expenses in relation with medical care;
- Any medical and surgical cost that is not prescribed by a competent medical authority in the country of care;
- Any medical and surgical cost that is not medically necessary according to the Insurer;
- Regarding prescription drugs, any product that is not considered as a medicinal: such as sun cream, make-up, parapharmaceutical items, etc;
- Costs for esthetic treatment, thalassotherapy, treatment for rejuvenation, weight loss or gaining treatment;
- Costs of non-direct medical nature such as telephone expenses in case of hospitalization;
- Costs deemed extravagant, unreasonable or unaccustomed in view of the country in which they were incurred;
- Transport costs, excluding ambulance, to the nearest adequate treatment facility;
- Costs for medical hospitalization or stay in a sanatorium or preventorium if the facilities where the insured Member was treated are not approved by competent public authorities;
- Costs for induced termination of pregnancy;
- Costs for treatments against infertility;
- Consequences if the Covered Person commits a violation of the law of the country where he/she resides;
- Costs for psychomotility; Care provided in a retirement home, or expenses incurred for assistance to a person in their daily activities, even if said person has been declared temporarily or permanently disabled;
As well as consequences of:
- Intentional action by the Covered Person;
- Civil or international wars, rioting, fights, irrespective of the place where these events happen and of protagonists; however, coverage is provided in cases of self-defense;
- The Covered Person's attempted suicide or use of non-medically prescribed narcotics;
- The Covered Person's being in a state of inebriety or under the influence of alcohol;
- Direct or indirect effects of disintegration of the atomic nucleus;
- Participating in any official sporting competition and training for these competitions;
- Practicing any sport as a professional;
- Medical expenses incurred outside of the geographical area as specified in Article 12.1.
However, an initiation into sports (excluding extreme sports), such as "first-time sessions", are covered if they are supervised by a professional instructor with state-required certificates and skills.
MEDICAL EXPENSES deemed extravagant, unreasonable or unaccustomed in view of the country in which they were incurred MAY BE DECLINED OR SUBJECT TO A LIMITED AMOUNT OF COVERAGE.