§ 88.84. Listing of exclusions.
The following is a list of the exclusions which shall be permitted in addition to those specified under § 618 of The Insurance Company Law of 1921 (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, as follows:
(1) General exclusions shall conform with the following:
(i) Loss sustained or expenses incurred while on active duty as a member of the armed forces of any nation, or losses sustained or expenses incurred as a result of act of war whether declared or undeclared.
(ii) Suicide or intentionally self-inflicted injuries.
(iii) Sickness or injury covered by any Workmen’s Compensation Act or Occupational Disease Law or by United States Longshoreman’s Harbor Worker’s Compensation Act (33 U.S.C.A. § § 901—950).
(iv) Mental, nervous, or emotional disorders.
(v) Aviation hazards except while flying as a fare-paying passenger on a commercial airline.
(vi) Participation in a riot or insurrection.
(vii) Cosmetic surgery, except when necessitated by covered sickness or injury.
(viii) Named hazardous occupations.
(ix) Named hazardous sports or hobbies.
(x) Normal pregnancy, childbirth, and miscarriage.
(xi) Exclusions which, in the opinion of the Commissioner, are justified by special circumstances or the particular coverage of the policy.
(2) Exclusions pertaining to hospital or basic coverage and major medical policies may include the following:
(i) Eye examinations, refractions, eye glasses, contact lenses or hearing aids, or hearing examinations.
(ii) Any services, use of a facility, or supply which is not recommended or approved by a licensed medical or dental practitioner practicing within the scope of the practitioner’s 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) Expenses for transportation except local ambulance services for the insured or covered person.
(viii) Sickness or injuries to the extent that any covered person under the policy is eligible to receive benefits under ‘‘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.
(ix) Services performed by the insured’s spouse, child, parent, brother, or sister or persons who ordinarily reside in the household of the insured.
(x) Medical care of members of the armed forces in a United States Government facility.
(xi) Specified foot conditions.
Cross References This section cited in 31 Pa. Code § 88.86 (relating to waivers).
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