Merritt Personal Lines Manual: No Coverage for Teeth, Babies or Face Lifts
g. dental treatment, except when due to injury
Dental treatment is usually excluded in hospital and medical expense policies because it is a different type of exposure and separate dental plans are available (usually, these cover preventive treatments as well as disease). But an exception is made for dental treatment required to repair an injury.
An example: If you broke your jaw and damaged your teeth because of an accident, your health insurance would cover the dental care.
h. pregnancy, except complications of pregnancy as defined
i. normal childbirth, except as provided by any optional rider attached
As we mentioned before, expenses related to normal pregnancy are not covered, but complications of pregnancy as defined in the policy are covered.
j. cosmetic surgery, except reconstructive surgery which is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part and reconstructive surgery due to congenital disease or anomaly of a covered newborn dependent child which results in a functional defect
Cosmetic surgery is generally excluded because it is often voluntary and not medically necessary. However, exceptions are made for reconstructive surgery following an injury or disease or to repair functional congenital defects of newborn children.
k. eye exams, glasses, contact lenses or hearing aids, except when due to injury
Eye care and hearing aids are excluded except when necessary because of an injury.
l. elective sterilization
Elective sterilizations -- vasectomies or tubal ligations -- are excluded because they are voluntary and other forms of birth control are available. However, a growing number of insurance companies have modified the standard language so that their contracts will cover these procedures.
m. hospital confinement or treatment for which you or the insured person are not legally required to pay
Hospitalization or treatment for which an insured is not legally obligated to pay is not covered. This prevents the payment of charges which might be made only because a person has insurance.
n. injury sustained or sickness which manifests itself while on full-time duty in the military forces of any country. Upon notice, we will refund the proportion of unearned premium paid for the insured person while in such forces.
There is no coverage for injury or sickness which begins while an insured is on active duty in the armed forces. Even in peacetime, military duty is hazardous and presents an above-average risk of loss. On request the insurance company will suspend coverage for a person in the armed forces and refund any unearned premium.
