Current through Register Vol. 54, No. 44, November 2, 2024
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.
This section cited in 31 Pa. Code §
88.86 (relating to
waivers).
