Summary of Plan Limitations and Exclusions (for GP-1-CI-14)
The policy has exclusions and limitations that may impact the eligibility for or entitlement to benefits under each covered condition. There are limitations & special requirements for each condition. See the certificate of coverage or contact your sales representative for full details.
This policy will not pay for a diagnosis of a listed critical illness that is made before the covered person's Critical Illness effective date with Guardian.
We will not pay benefits for the First Occurrence of a Critical Illness if it occurs less than 3 months after the First Occurrence of a related Critical Illness for which this Plan paid benefits. By related we mean either: (a) both Critical Illnesses are contained within the Cancer Related Conditions category; or (b) both Critical Illnesses are contained within the Vascular Conditions category.
We will not pay benefits for a second occurrence (recurrence) of a Critical Illness unless the Covered Person has not exhibited symptoms or received care or treatment for that Critical Illness for at least 12 months in a row prior to the recurrence. For purposes of this exclusion, care or treatment does not include: (1) preventive medications in the absence of disease; and (2) routine scheduled follow-up visits to a Doctor.
We do not pay for a third or later occurrence of a critical illness.
First & second occurrence refers to the first & second time an insured experiences or is diagnosed with a covered critical illness while covered under Guardian Critical Illness insurance.
A pre-existing condition includes any condition for which an employee, in the specified period of time prior to coverage in this plan, consults with a physician, receives treatment, or takes prescribed drugs. Please refer to the plan documents for specific time periods.
If the plan is new (not transferred): During the exclusion period, this critical illness plan does not pay charges relating to a preexisting condition. If this plan is transferred from another insurance carrier, the time an insured is covered under that plan will count toward satisfying Guardian’s pre-existing condition limitation period. Please refer to the plan details for specific time periods. State variations may apply.
We do not pay benefits for charges relating to a covered person: taking part in any war or act of war (including service in the armed forces), committing a felony or taking part in any riot or other civil disorder or intentionally injuring themselves or attempting suicide while sane, or insane.
In order to be eligible for coverage: Employees must be legally working: (a) in the United States or (b) outside the United States, for a US-based employer, in a country or region approved by Guardian. Subject to state-specific variations.
Employees must be working full-time on the effective date of coverage; otherwise, coverage becomes effective after the completion of the specific waiting period.
Health questions are required for all late enrollees. Benefit increases may require underwriting.
This coverage will not be effective until approved by a Guardian underwriter. This proposal is subject to satisfactory financial evaluation. Please refer to certificate of coverage for full plan description; plan documents are the final arbiter of coverage.
Summary of Plan Limitations and Exclusions (for CI-23-P)
No benefits are payable for the following:
An illness that’s not listed in the Covered Illnesses section.
An illness that’s diagnosed after your death unless there’s an exception specifically listed in this guide that we’ll accept a death certificate or autopsy report confirming the diagnosis of that illness.
An illness that’s diagnosed when you’re not covered by this Plan.
Any care, service or treatment that’s received when this coverage isn’t in place.
An illness or condition that’s contributed to or results from any of the following:
Participating in a felony, riot, or insurrection
Intentionally causing a self-inflicted injury
Suicide or attempted suicide while sane or insane
Engaging in any illegal activity
Serving in the armed forces or any auxiliary unit of the armed forces of any country(This exclusion doesn’t apply to the PTSD benefit.)
The voluntary use of any poison, chemical, substance defined as a controlled substance by Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, or prescription drug, unless prescribed by a physician and used as prescribed
The voluntary use of a non-prescription drug inconsistent with package instructions
War or act of war, even if war isn’t declared (This exclusion doesn’t apply to the PTSD benefit.)
An illness or condition that’s diagnosed outside the United States unless the diagnosis is confirmed in the United States. If the diagnosis is confirmed in the United States, the diagnosis will be considered to have been made on the date it was made outside the United States
Any care, treatment or service received outside the United States
Any illness, care, treatment, or service that violates local, state or federal law or for which our paying a benefit would violate local, state or federal law
Any claim for a benefit that isn’t specifically listed as an available benefit under the member guide
An illness that’s diagnosed by you or a member of your immediate family or a business associate*
Immediate family includes the following:
Your spouse or anyone with whom you live and share financial assets and obligations.
Your child
Your parents, including stepparents and mother-in-law and father-in-law
Your siblings, including stepbrothers and stepsisters
Your brothers-in-law and sisters-in-law
Your grandparents, including step-grandparents
Your grandchildren, including step-grandchildren
Any relative living with you
Immediate family also includes the spouse of anyone listed above
*This Exclusion is not included for Arizona
This policy will not pay for a diagnosis of a listed critical illness that is made before the covered person's Critical Illness effective date with Guardian.
A pre-existing condition includes any condition for which an employee, in the specified period of time prior to coverage in this plan, consults with a physician, receives treatment, or takes prescribed drugs.
Benefits for the second occurrence (recurrence) of that same illness will be available only if the illness occurs again after a period of at least 6 months in a row during which: 1) This coverage was in place without interruption; 2) No symptoms were exhibited; 3) No care or treatment was received for the illness. For the purposes of this limitation, care or treatment doesn’t include preventive medications taken in the absence of disease. Care or treatment also doesn’t include any routine, regularly scheduled follow-up visits with a physician.
Guardian's Accident, Cancer, Critical Illness and Hospital Indemnity Insurance products are underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Products are not available in all states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Accident, Cancer, Critical Illness and Hospital Indemnity are limited plans of supplemental health insurance that provide the specified financial support, as a lump sum or indemnity benefit, for insured injury from a covered accident, following the diagnosis of a covered accident or a covered critical illness, or following a covered hospitalization. This is not minimum essential coverage as defined by federal law. This coverage will not reimburse for hospital or medical expenses. Generic Policy Form #s: GP-1-ACC-18; GP-1-CAN-IC-12, et al; GP-1-LAH-12R; GP-1-CI-14; GP-1-HI-1. The state approved form is the governing document.
