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Aspen American Insurance Company

Help Center»Benefits»Exclusions


  1. Pre-Existing Conditions:

    1. Charges resulting directly or indirectly from a condition for which a Covered Person received medical treatment, diagnosis, care or advice, including diagnostic tests or medications, within the 24 month period immediately preceding such person’s Certificate Effective Date of coverage under the Policy.
    2. Pre-Existing Conditions includes conditions that produced any symptoms which would have caused a reasonably prudent person to seek diagnosis, care or treatment within the 24 month period immediately prior to the Covered Person’s Certificate Effective Date of coverage under the Policy.

    This exclusion does not apply to any Eligible Expense payable for Pre-Existing Conditions until the Allowance Benefit maximum shown in the Schedule of Benefits has been reached. This exclusion does not apply to a newborn child or newborn adopted child who is added to coverage in accordance with PART II – ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE.

  2. Waiting Period:

    1. Covered Persons will only be entitled to receive benefits for Sicknesses that begin, by occurrence of symptoms and/or receipt of treatment, more than five (5) days following the Covered Person’s Certificate Effective Date of coverage under the Policy.
    2. Covered Persons will only be entitled to receive benefits for Cancer that begins, by occurrence of symptoms or receipt of treatment more than 30 days following the Covered Person’s Certificate Effective Date of coverage under the Policy.
  3. Charges during the first 6 months after the Certificate Effective Date of coverage for a Covered Person for the following:

    1. Total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis of carcinoma;
    2. Tonsillectomy;
    3. Adenoidectomy;
    4. Repair of deviated nasal septum or any type of surgery involving the sinus;
    5. Myringotomy;
    6. Tympanotomy;
    7. Herniorrhaphy; or
    8. Cholecystectomy (Gallbladder). However, if such a condition is a Pre-Existing Condition, any benefit consideration will be in accordance with the Pre-Existing Conditions limitation.
  4. The benefits payable for the following conditions or procedures are limited to the specified amounts shown in the Schedule of Benefits:

    1. Kidney stones
    2. Appendectomy
    3. Joint or tendon surgery
    4. Knee Injury or disorder
    5. Acquired Immune Deficiency Syndrome (AIDS)/ Human Immuno-deficiency Virus (HIV)
    6. Gallbladder surgery
  5. Charges which are not incurred by a Covered Person during his/her Coverage Period.
  6. Charges which exceed any limits or limitations specified in this Certificate, including the Schedule of Benefits.
  7. Charges for services of supplies in excess of the Maximum Allowable Expense.
  8. Charges for services or supplies which are not administered by or under the supervision of a Doctor.
  9. Mental, emotional or nervous disorders or counseling of any type, unless specifically covered as an Eligible Expense.
  10. Marital counseling or social counseling.
  11. Treatment for Substance Abuse, unless specifically covered as an Eligible Expense.
  12. Outpatient Prescription Drugs, unless specifically covered as an Eligible Expense. This does not include those administered by a Doctor in an Inpatient or Outpatient setting covered as an Eligible Expense.
  13. Medications, vitamins, and minerals or food supplements including prenatal vitamins, or any over-the-counter medicines, whether or not ordered by a Doctor.
  14. Any drug, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal of sterilization.
  15. Any drug, treatment or procedure that corrects impotency or non-organic sexual dysfunction.
  16. Modifications of the physical body in order to improve the psychological, mental or emotional well-being of the Covered Person, such as sex-change surgery.
  17. Cosmetic Treatment, except for reconstructive surgery where expressly covered as an Eligible Expense.
  18. Weight modification or surgical treatment of obesity.
  19. Eye surgery, including LASIK, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
  20. Dental Expenses, except as necessary to restore or replace sound and natural teeth lost or damaged as a result of an Injury. The Injury must be severe enough that the contact with the Doctor occurs within seventy-two (72) hours of the Accident, unless extenuating circumstances exist due to the severity of the Injury that prevent you from contacting the Doctor.
  21. Expenses incurred in the treatment by any method for jaw joint problems including temporomandibular joint dysfunction (TMJ), TMJ pain syndromes, craniomandibular disorders, myofascial pain dysfunction or other conditions of the joint linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the joint, unless specifically covered as an Eligible Expense.
  22. Routine prenatal care, Pregnancy, childbirth, and post-natal care. (This exclusion does not apply to “Complications of Pregnancy” as defined.)
  23. Sclerotherapy for veins of the extremities.
  24. Abortions, except in connection with covered Complications of Pregnancy or if the life of the expectant mother would be at risk.
  25. Joint replacement or other treatment of joints, spine, bones or connective tissue including tendons, ligaments and cartilage. This exclusion does not apply if these treatments are related to a covered Injury.
  26. Surgeries, treatments, services or supplies which are deemed to be Experimental Treatment.
  27. Chronic fatigue or pain disorders.
  28. Kidney or end stage renal disease.
  29. Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions.
  30. Treatment for cataracts.
  31. Treatment of sleep disorders.
  32. Treatment required as a result of complications or consequences of a treatment or condition not covered under this Certificate.
  33. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
  34. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.
  35. Treatment for or related to any Congenital Condition, except as it relates to a newborn child or newborn adopted child added as a Covered Person pursuant to the terms of this Certificate.
  36. Treatment, medication or hormones to stimulate growth, or treatment of learning disorders, disabilities, developmental delays or deficiencies, including therapy.
  37. Spinal manipulation or adjustment.
  38. Biofeedback, acupuncture, recreational, sleep or MIST Therapy®, holistic care of any nature, massage and kinesiotherapy, unless specifically covered as an Eligible Expense.
  39. Hypnotherapy when used to treat conditions that are not recognized as Mental Disorders by the American Psychiatric Association, and non-medical self-care or self-help programs.
  40. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, orthoptics, visual eye training and any examination or fitting related to these devices, and all vision and hearing tests and examinations.
  41. Care, treatment or supplies for the feet, and orthopedic prescription devices to be attached to or placed in shoes.
  42. Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions; treatment of corns, calluses or toenails; and orthopedic shoes.
  43. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Doctor.
  44. Exercise programs, whether or not prescribed or recommended by a Doctor.
  45. Telephone or Internet consultations and/or treatment or failure to keep a scheduled appointment.
  46. Charges for travel or accommodations, except as expressly provided for local ambulance.
  47. All charges incurred while confined primarily to receive Custodial or Convalescent Care.
  48. Services received or supplies purchased outside the United States, its territories or possessions, or Canada unless specifically covered as an Eligible Expense.
  49. Any services or supplies in connection with cigarette smoking cessation.
  50. Any services performed or supplies provided by a member of a Covered Person’s Immediate Family.
  51. Services received for any condition caused by a Covered Person’s commission of or attempt to commit an assault, battery, or felony, whether charged or not, or to which a contributing cause was the Covered Person being engaged in an illegal occupation.
  52. Services or supplies which are not included as Eligible Expenses as described herein.
  53. Participating in hazardous occupations or other activity including participating, instructing, demonstrating, guiding or accompanying others in the following operation of a flight in an aircraft other than a regularly scheduled flight by a commercial airline

    • professional or semi-professional sports
    • extreme sports
    • parachute jumping
    • hot-air ballooning
    • Hang-gliding
    • base jumping
    • mountain climbing
    • bungee jumping
    • scuba diving
    • sail gliding
    • Parasailing
    • para kiting
    • rock or mountain climbing
    • cave exploration
    • Parkour
    • racing including stunt show or speed test of any motorized or non-motorized vehicle
    • rodeo activities
    • or similar hazardous activities.

    Also excluded is Injury received while practicing, exercising, undergoing conditional or physical preparation for such activity.

  54. Injuries or Sicknesses resulting from participation in interscholastic, intercollegiate or organized competitive sports. This does not include dependent children participating in local community sports activities.
  55. Injury resulting from being under the influence of or due wholly or partly to the effects of alcohol or drugs, other than drugs taken in accordance with treatment prescribed by a Doctor.
  56. Intentionally self-inflicted Injury or Sickness (whether the Covered Person is sane or insane).
  57. Charges resulting from a declared or undeclared war, or from voluntary participation in a riot or insurrection.
  58. Charges incurred by a Covered Person while on active duty in the armed forces. Upon written notice to us of entry into such active duty, the unused premium will be returned to the Covered Person on a prorated basis.
  59. Costs for Routine Physical Exams or other services not needed for medical treatment, unless specifically covered as an Eligible Expense.
  60. Charges You or Your Covered Dependent are not required to pay, or which would not have been billed, if no insurance existed.
  61. Charges to the extent that they are paid or payable under other valid or collectible group insurance or medical prepayment plan.
  62. Charges that are eligible for payment by Medicare or any other government program except Medicaid. Costs for care in government institutions unless You or Your Covered Dependent are obligated to pay for such care.
  63. Charges related to Injury or Sickness arising out of or in the course of any occupation for compensation, wage or profit, if the Covered Person is insured, or is required to be insured, by occupational disease or workers’ compensation insurance pursuant to applicable state or federal law, whether or not application for such benefits have been made.
  64. Medical expenses which are payable under any automobile insurance policy without regard to fault (does not apply in any state where prohibited).