§ 89.77. Exclusions.
(a) The following is a list of the maximum applicable exclusions which shall be permitted in addition to those specified under section 618 of the act (40 P. S. § 753). The wording of the exclusions is illustrative and is intended to indicate the general intent of the Department. Alternate wording is permissible as long as the meaning preserves the general intent of the exclusions:
(1) General exclusions. General exclusions shall conform with the following:
(i) Loss sustained or expenses incurred while a member of the armed forces of any nation, or losses sustained or expenses incurred as a result of enemy action or act of war whether declared or undeclared.
(ii) Normal pregnancy, childbirth, miscarriage and abortion.
(iii) Suicide or intentionally self-inflicted injuries.
(iv) Sickness or injury covered by a workmen’s compensation act or occupational disease law or by United States Longshoreman’s and Harbor Worker’s Compensation Act.
(v) Mental or nervous or emotional disorders.
(vi) Exclusions which, in the opinion of the Commissioner, are justified by special circumstances or the unique character of the policy.
(2) Exclusions pertaining to hospital or basic coverage and major medical policies. Other exclusions shall include the following:
(i) Eye examinations, refractions, eye glasses, contact lenses or hearing aids or hearing examinations.
(ii) Services, use of a facility or supply which is not recommended or approved by a licensed medical practitioner practicing within the scope of his license.
(iii) Charges for services, use of facilities or supplies that neither the insured nor any other covered person is legally obligated to pay.
(iv) Routine physical examinations.
(v) Dentistry, dental x-rays or dental services, dental prosthetic appliances, except expenses otherwise covered on account of accidental bodily injury to sound natural teeth.
(vi) Expenses of a covered person for cosmetic surgery, except expenses otherwise covered which are necessary for repair of an accidental bodily injury.
(vii) Elective surgery not to exceed 6 months. The following is a list of surgical procedures which may be considered elective surgery:
(A) Cataract operations
(B) Strabismus operations
(C) Tonsilectomies, adenoidectomies
(D) Herniotomies
(E) Arthrotomies
(F) Hemorrhoidectomies
(G) Laminectomies
(H) Varicose veins
(I) Gall bladder
(J) Appendectomies concurrent with a gall bladder operation.
(viii) Expenses for transportation except local ambulance service for the insured or covered person.
(ix) Sickness or injuries to the extent that any covered person under the policy is indemnified by ‘‘Medicare’’ for the expenses incurred. This exclusion may include other specifically enumerated national, state or other governmental plans. It may not include or be interpreted to include plans which may possibly be enacted at some future time.
(x) Services performed by the insured’s spouse, child, parent, brother or sister or persons who ordinarily reside in the insured’s household.
(xi) Medical care of members of the armed forces in a United States Government facility.
(xii) Specified foot conditions.
(b) A policy which contains unusual limitations, reductions or conditions of a restrictive nature that the payment of benefits under the policies is limited in frequency or in amounts should carry the legend ‘‘This Is A Limited Policy—Read It Carefully’’ imprinted in not less than 18-point outline type of contrasting color diagonally across the face and filing back, if any, of the policy.
(c) A policy may not provide an exclusion for the use of alcohol and narcotics except as permitted by section 618(b)(11) of the act (40 P. S. § 753(b)(11)).
Notes of Decisions Applicability limited
The exclusions and other provisions of § 89.77 apply only to individual policies and not to group policies. Giangreco v. United States Life Ins. Co., 168 F. Supp. 2d 417 (E.D. Pa. 2001).
Sections 89.77(a)(2)(ix) and 89.97(c) evidence a public policy favoring the use of policy clauses to prevent overinsurance and avoid bonus recoveries. Weiss v. CNA, 468 F. Supp. 1291 (W.D. Pa. 1979).
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