§ 90h.4. Exclusions and restrictions.
(a) The form contains none or one or more of the following exclusions and restrictions:
(1) War, declared or undeclared, or an act of war, whether or not serving in the military forces or a civilian noncombatant unit serving with the forces.
(2) Active duty as a member of the armed forces of any nation.
(3) Committing an assault or felony, whether sane or insane.
(4) Participating in a riot or insurrection.
(5) A fight in which the insured is a voluntary participant.
(6) Suicide or attempted suicide, whether sane or insane.
(7) Intentionally self-inflicted injury, whether sane or insane.
(8) Engaging in an illegal occupation.
(9) Travel or flight in an aircraft or spacecraft or descent from such a craft while in flight, or subsequent drowning, if the insured is a pilot, officer or crew member of the craft; is giving or receiving aviation training or instruction; has any duties on or relating to the craft; or is being flown for the purpose of descent from the craft while in flight.
(10) Voluntary taking or injection of drugs, unless prescribed or administered by a licensed physician. The wording ‘‘taken as prescribed’’ or ‘‘taken in the manner prescribed’’ is not present.
(11) Voluntary taking or injection of drugs, whether legal or illegal, unless prescribed or administered by a licensed physician. The wording ‘‘taken as prescribed’’ or ‘‘taken in the manner prescribed’’ is not present.
(12) The voluntary taking of any drugs prescribed for the insured by a licensed physician and intentionally not taken as prescribed.
(13) The voluntary taking of any drugs, whether legal or illegal, prescribed for the insured by a licensed physician and intentionally not taken as prescribed.
(14) Sensitivity to drugs voluntarily taken, unless prescribed by a physician.
(15) Sensitivity to drugs, whether legal or illegal, voluntarily taken, unless prescribed by a physician.
(16) Drug addiction, unless addiction results from the voluntary taking of drugs prescribed or administered by a licensed physician or from the involuntary taking of drugs.
(17) Drug addiction, unless addiction results from the voluntary taking of drugs, whether legal or illegal, prescribed or administered by a licensed physician or from the involuntary taking of drugs, whether legal or illegal.
(18) Alcoholism treatment.
(19) Chronic alcoholism.
(20) Loss resulting directly or indirectly from the voluntary taking of alcohol alone or in combination with a drug, medication or sedative when this action results in legal intoxication as defined by Pennsylvania law. The insurer provides a certification that the Pennsylvania legal definition for intoxication will be used if the form does not refer to ‘‘intoxication as defined by Pennsylvania law.’’
(21) Care or confinement prescribed for convenience only.
(22) Care or confinement prescribed for custodial purpose only.
(23) Care or confinement prescribed for rest cures.
(24) Benefit payment denial if services are provided by a health care facility operated by a member of the insured’s immediate family.
(25) Benefit payment denial if services are provided by a health care facility which does not maintain at least a daily record for each patient.
(26) Mental, nervous, emotional or personality disorder without demonstrable organic disease, including, but not limited to, neurosis, psychoneurosis, psychopathy or psychosis.
(27) Services provided outside either the United States or the United States or Canada.
(28) Reimbursement for services covered by Medicare or another government program.
(b) The form contains none of the following exclusions and restrictions:
(1) Riot or insurrection.
(2) Gunshot or pistol wound, unless unintentionally caused by someone else.
(3) Gunshot or pistol wound, unless intentionally or unintentionally caused by someone else.
(4) Travel in any kind of military aircraft or seacraft or aircraft or seacraft operated for the armed forces.
(5) Air travel.
(6) Air travel except as a fare paying passenger on a regularly scheduled commercial airline.
(7) Illegal drug use.
(8) Drug addiction.
(9) Involuntary taking of drugs or poison.
(10) Voluntary taking of drugs or poison.
(11) Preexisting conditions.
(12) Requirement that the form be in force for a specific period of time prior to eligibility for coverage.
(13) Alzheimer’s Disease or another disorder with a demonstrable organic origin.
(14) Benefit payment denial due to the insured’s financial resources, income or need.
(15) Benefit payment denial if there is not a reasonable expectation that a significant improvement will occur in the insured’s condition.
(16) Benefit payment denial if services are provided by a health care facility for the insured less often than on a daily basis.
(17) Benefit payment denial if services are not provided in the least costly setting.
(18) Benefit payment denial if the health care facility does not accommodate a minimum number of persons.
(19) Benefit payment denial if reimbursement for services is provided by another insurer.
(20) Other exclusions or restrictions that are unfair or unduly restrictive.
Cross References This section cited in 31 Pa. Code § 90h.3 (relating to benefit provisions).
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