EXCLUSIONS
Benefits are not payable for any of the following or loss that results from them:
1. Dental care or Treatment. This exclusion does not apply to care of sound, natural teeth and gums required due to an Injury resulting from an Accident while the Covered
Person is insured under the Policy, and rendered within 12 months of the Accident.
2.
W
ar or any act of war, declared or undeclared.
3.
P
articipation in a riot or civil disorder; fighting or brawling, except in self-defense; commission of or attempt to commit a felony or violating or attempting to violate any
duly enacted law.
4.
S
uicide, attempted suicide or intentionally self-inflicted Injury while sane or insane.
5.
I
njury or Sickness contributed to by the use of alcohol or drugs unless taken in the dosage and for the purpose prescribed by the Covered Person’s Physician (Does not
apply in the State of Nevada)
6.
P
ractice or play in interscholastic high school tackle football (unless separate football coverage is purchased), intercollegiate sports, semi-professional sports, or
professional sports. (Does not apply to the Dental Accident Plan.)
7.
I
njury or Sickness covered by Worker’s Compensation or Employer’s Liability Laws, or by any coverage provided or required by law including, but not limited to group,
group type, and individual automobile “No Fault” coverage (excluding School Vehicle coverage).
8.
T
reatment, services or supplies provided by the School’s infirmary or its employees, or Physicians who work for the School, or by any member of the Covered Person’s
immediate family; or for which no charge is normally made.
9. Treatment, services or supplies provided or paid for by any governmental program or law, except Medicaid.
10.
T
reatment of Sickness, ailment, or infections (except pyogenic infections or bacterial infections which result from the accidental ingestion of contaminated substances).
(Does not apply to the Sickness-Only Coverage under the Student Accident & Sickness Plan.)
11.
T
he diagnosis and Treatment of non-malignant warts, moles and lesions, acne or allergies, including allergy testing.
12. Injury sustained as a result of riding in or on, entering or alighting from, a two or three-wheeled motor vehicle. (Does not apply to the Dental Accident Plan.)
13.
T
reatment of osteomyelitis, pathological fractures and hernia. (Does not apply to the Sickness-Only Coverage under the Student Accident & Sickness Plan.)
14.
D
etached retina (unless directly caused by an Injury). (Does not apply to the Sickness-Only Coverage under the Student Accident & Sickness Plan.)
15.
A
ny expenses related to the Treatment of tonsils, adenoids, epilepsy, seizure disorder or congenital weakness; or expenses for Treatment of congenital anomalies and
conditions arising or resulting directly there from.
16.
S
upplies, except as otherwise provided in the Policy.
This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit Us from providing insurance, including but not limited to,
the payment of claims.
Requirements and Limitations
Aggravations of injuries which did not occur while insured under this plan are paid up to $500 maximum benefit per policy term. Injuries sustained as a result of riding in or on,
entering or alighting from or being struck by a Motor Vehicle are limited to a $25,000 maximum benefit. Some Motor Vehicle injuries are not covered - see exclusions above for
details. School-time and high school tackle football injuries must be reported to the School within 60 days of the date of Injury if you reside in California or 72 hours if you reside in
Arizona or Nevada. The first Physician’s visit must be within 120 days after the Accident occurs. A claim form must be filed with Myers-Stevens & Toohey & Co., Inc. within 90 days
after the date of loss. The School-Time, Tackle Football and Full-Time (24/7) plans pay for covered expenses incurred within up to 104 weeks from the date of injury. The Student
Accident & Sickness and Dental Accident plans pay for covered expenses incurred within up to 52 weeks from the date of first treatment, however, should the Injury sustained
under the Student Accident & Sickness plan require the removal of surgical pins, continued Treatment for serious burns, or Treatment of a non-union or mal-union fracture, the
benefit period will be extended to 104 weeks. Each covered condition may be subject to a deductible - see plan details.
Facility of Payment
Whenever payments that should have been made under the Policy are made by any other policy, the Company reserves the right to pay over to any plan making such other
payments, any amounts the Company determines are warranted in order to satisfy the intent of this provision. The amounts paid are considered benefits paid under the Policy
and, to the extent of such payments, the Company shall be fully discharged from liability under the Policy. In no event will the Company pay more than the benefits payable under
the Policy for all policies providing the same or similar benefits issued to the Policyholder and underwritten by the Company.
Definitions
An Accident is defined as a sudden, unexpected and unintended incident. Covered Accident means an Accident that results in Injury or loss covered by this Policy. An Injury
is defined as Accidental bodily harm sustained by the Covered Person that results directly from an Accident (independently of all other causes) and occurs while coverage under
the Policy is in force. Medically Necessary is defined as the services or supplies provided by a Hospital, Physician, or other provider that are required to identify or treat an Injury
or Sickness and which, as determined by the Company, are: (1) consistent with the symptoms or diagnosis and Treatment of the Injury or Sickness; (2) appropriate with regard to
standards of good medical practice; (3) not solely for the convenience of the Insured Person; (4) the most appropriate supply or level of service which can be safely provided. When
applied to the care of an Inpatient, it further means that the Insured Person’s medical symptoms or condition requires that the services cannot be safely provided as an Outpatient.
Sickness is defined as illness or disease contracted by and causing loss to the Insured Person whose Sickness is the basis of claim. Any complications or any condition arising out
of a Sickness for which the Insured Person is being treated or has received Treatment will be considered as part of the original Sickness. School Activities means any activity that
is sponsored and under the direct, immediate supervision of the School that: (a) the School requires the Insured Person to attend; or (b) is under the sole control and supervision
of School authorities. It does not include an activity related to athletics or cheerleading that is under joint sponsorship or supervision arrangement with any non-School group.
Excess Provision:
In order to keep premiums as affordable as possible, these plans pay benefits on a non-duplicating basis. This means, if a person is covered by one or more of these plans and
by any other valid insurance or health agreement, any amount payable or provided by the other coverages will be subtracted from the covered expenses and we will pay benefits
based on the remaining amount. (In Arizona: Does not apply to the Sickness-Only coverage under the Student Accident & Sickness Plan.)
IMPORTANT NOTICE:
Some plans referenced within provide short-term, limited duration sickness benefits. They do not constitute comprehensive health insurance coverage
(often referred to as “major medical coverage”) and do not satisfy a person’s individual obligation to secure the requirement of minimum essential coverage under the Affordable Care
Act (ACA). For more information about the ACA, please refer to www.HealthCare.gov.
ALL PREMIUMS ARE FULLY EARNED UPON RECEIPT AND CANNOT BE REFUNDED OR CONVERTED
For a brochure in Spanish, or for assistance in Spanish, please call 800-827-4695
Para un folleto en Español, o para asistencia en Español, por favor llame a 800-827-4695
10
AZ/CA/NV NBP 640 05/21
