I. PERMANENT EXCLUSION

A permanent exclusion is a pre-existing condition which will not be covered by PhilamCare even after the one year membership period is over. A permanent exclusion , if any is explicitly stated in an endorsement form which is attached to your Health Care Agreement.

II. GENERAL EXCLUSIONS APPLICABLE TO HEALTH CARE COVERAGE

No Health Care benefits shall be paid for the following services, products or conditions:

1. Care by non-affiliated physicians or in non-affiliated hospitals except in emergencies wherein the Emergency Provision of the Agreement shall apply;

2. Additional hospital charges and professional fees resulting from taking a room accommodation different from that specified in the Member's Benefit Classification and/or at a rate in excess of the maximum room allowance, or additional personal comfort items, e.g., telephone and television, admission kit and/or such other items of the same nature;

3. All pregnancy related conditions requiring medical/surgical care except for pre-natal and post-natal consultation at PhilamCare clinics;

4. Circumcision, sterilization of either sex or reversal of such, artificial insemination, sex transformation or diagnosis and treatment of infertility;

5. Rest cures, custodial, domiciliary or convalescent care;

6. Cosmetic surgery and oral surgery for purpose of beautification except constructive surgery to treat functional defect due to disease or accidental injury;

7. Dental examination, extractions, fillings and general dental attention except to the extent that are necessary for repair or alleviation of damage to the covered person caused solely by accidental bodily injuries;

8. Psychiatric disorders, psychosomatic illnesses, any injury, illness or condition which the member may suffer after he has taken intoxicating liquors or drugs, and/or conditions or illnesses resulting from alcoholism;

9. Congenital anomalies and conditions, and their complications;

10. Medical or surgical procedures which are experimental in nature or not generally accepted as standard medical treatment by the medical profession;

11. Procurement or use of corrective appliances, artificial aids and durable equipment;

12. All expenses incurred in the process of organ donation;

13. Physical examination required for obtaining or continuing employment, insurance or government licensing;

14. Injuries or illness due to military service or suffered under conditions of war;

15. Executive check-ups and confinement which are for purely diagnostic purposes;

16. Diseases or injuries wherein the care or reimbursement of services is provided by law or a government program, up to the stipulated limits;

17. Injuries or illness which are self-inflicted, caused by attempt at suicide, or incurred as a result of or while participating in the commission of a crime or acts involving the violation of laws/ordinances;

18. Take-home medicines; out-patient medicines except intravenous chemotherapy medicine and medicine administered during an emergency treatment; vaccines except the first dose of passive immunization for rabies, tetanus and snake bites, if medically prescribed.

19. All hospital charges and professional fees incurred after the day and time the discharge from the hospital has been duly authorized; and,

20. Laser treatment for the purpose of corrective eye refraction.

 

III. GENERAL LIMITATIONS

The rights of the Member and obligations of PhilamCare are subject to the following limitations:

1. If a major disaster or epidemic cause unavailability of facilities or personnel, or if circumstances not within the control of PhilamCare such as temporary lack of hospital facilities, complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes, or similar causes occur, then PhilamCare shall not be liable for any delay or failure to provide services to the enrollee. PhilamCare shall, however, exert its best efforts to provide services to the enrollee, as the circumstances permit.

2. If a member avails of the latest modalities of treatment and or diagnostic tests, the liability of PhilamCare shall be limited to the prevailing costs of hospital bills, professional fees and related expenses ordinarily charged for traditionally accepted treatment modality and/or diagnostic tests. Notwithstanding this provision, PhilamCare 's liability shall be limited to the amounts specified in your Health Care Agreement in case of Laparoscopic Cholecystectomy, Lithotripsy, Magnetic Resonance Imaging (MRI), Nuclear or Radioactive Isotope Scans, and Hysterescopic Myoma Resection. The availment of Laparoscopic Cholecystectomy or Lithotripsy procedure is limited only to once per contract year. Where the member choose newer modalities of treatment, PhilamCare will no longer be liable for the cost of further or additional traditional modes of treatment/diagnostics for the same illness should they be necessary.

3. If the member refuses to follow the recommended treatment or procedure and the PhilamCare physician or the affiliated physician believes that no professional acceptable alternative exists, then PhilamCare shall no longer be responsible to provide care for the condition under treatment.

4. Hospital service is subject to all rules and regulations of the hospital selected, including the rules and regulations governing admission.

5. The total liability of PhilamCare on any dreaded disease and its complications during the entire lifetime of a member shall be limited to the Maximum Sum Per Disability.

 

IV. INVALIDATION OF A MEMBER'S COVERAGE