EXCLUSIONS / LIMITATIONS

    1. Services obtained for non-emergency conditions from physicians and hospitals in any of the following circumstances:
      1. non-Affiliated Physicians in non-Affiliated Hospitals or non-Affiliated Clinics
      2. non-Affiliated Physicians in Affiliated Hospitals or Affiliated Clinics
      3. Affiliated Physicians in non-Affiliated Hospitals or non-affiliated Clinics or other healthcare facility.

    2. Additional hospital charges and physician’s professional fees resulting from:
      1. room-upgrading beyond twenty-four (24) hours during Emergency Conditions;
      2. extension of hospital stay despite release of discharge order from Member’s Attending Physician;
      3. fees of the assistant surgeons for surgeries with less than 250 RUV units / resident doctors who assisted the Attending Physician in the process of rendering the medical services shall not be chargeable to the Member and/or HEALTH CARE & DEVELOPMENT CORPORATION OF THE PHILIPPINES (HC&D) except for hospitals that do not have resident physicians to assist during surgeries subject to the prior approval of HEALTH CARE & DEVELOPMENT CORPORATION OF THE PHILIPPINES (HC&D);
      4. use of extra bed, TV, electric fan, DVD/ VCD, and other similar items unless such appliances and items are necessarily and ordinarily included in the Member’s Room and Board Accommodation;
      5. extra food; toilet articles like face towel, soap, toothbrush and the like;
      6. difference in Room and Board Accommodation, the incremental rate differences for professional fees, diagnostic and laboratory examinations, and other ancillary medical services brought about by obtaining a room and board accommodation higher than the Member’s Room and Board Accommodation limit;
      7. services of a private or a special nurse;
      8. all other items not medically necessary in the medical management of the Member.

    3. Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance/travel or government licensing, health permit and other similar purposes.

    4. Custodial, Domiciliary, Convalescent and Intermediate care.

    5. Medical certificates.

    6. Professional fees of medico-legal officer/s.

    7. All   expenses incurred in the process of organ donation and   transplantation if the   Member is the donor, and its complications.

    8. Cost of the medical services and professional fees in excess of the MBL.

    9. Purchase or lease of any Durable Medical Equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care.

    10. All pregnancy related conditions requiring medical and surgical care.

    11. Circumcision (except treatment of urological conditions), sterilization of either sex or reversal of such, artificial insemination, sex transformation or diagnosis and treatment of infertility.

    12. Cosmetic procedure and surgery and oral surgery solely for purpose of beautification, including but not limited to wart removals through excision or electrodessication/ cauterization except reconstructive surgery to treat functional defects due to disease or accidental injury.

    13. Dental care following accidental injury to teeth requiring reconstructive surgery, orthodontic   procedures or supply of dentures.

    14. Long term rehabilitation and all forms of behavioral disorders whether congenital or acquired; developmental or psychiatric disorder; psychosomatic illness.

    15. Any injury, illness or condition which the Member may suffer after he has taken intoxicating drugs or alcoholic beverage as evidenced by clinical history or alcoholic breath as determined by the examining physician and/or conditions or illnesses resulting from Alcoholism and Drug Addiction.

    16. Medical or surgical procedures that are experimental in nature and not generally    accepted as standard medical treatment by the medical profession that may include but is not limited to, Chiropractic Services and Acupuncture.

    17. Allergens used for hypersensitivity testing regardless if administered as an out-patient or in-patient procedure.

    18. Injuries or illnesses resulting from hazardous activities in which a Member has engaged in leisure that may include but is not limited to:  bungee jumping, scuba diving, hang-gliding, mountain climbing and all such other voluntary activities which pose a danger to life and limb, except those related to or directly connected with the Member’s occupation as declared in the application for health care coverage under the Agreement.

    19. Injuries or illnesses due to military service or suffered under conditions of war.

    20. Executive check-ups and confinement which are for purely diagnostic purposes except as specified in the Agreement.

    21. Injuries or illnesses 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 or ordinances.

    22. Take-home medicine, immunizing agents and out-patient medicines, with the exception of intravenous chemotherapy medicine and those administered during an emergency treatment.

    23. Vaccines, whether elective or administered during an emergency treatment are not covered, except passive and active vaccine for anti-tetanus, anti-venom, and anti-rabies vaccine as specified in the Agreement.

    24. Laser Treatment for the purpose of corrective eye refraction.

    25. Medico-Legal Fees.  These are professional fees of a medico-legal consultant to whom a patient is referred primarily for the issuance of a medical certificate for legal purposes.

    26. Laser therapy and Speech therapy except for the coverage as provided for under the Agreement.

    27. Pre-existing Hepatitis B and Hepatitis screening and vaccines unless specified in the Schedule of Benefits.

    28. All physical deformities prior to enrollment except for pre-existing scoliosis unless specified in this Agreement.

    29. Sexually transmitted diseases, AIDS and AIDS related diseases.

    30. Congenital deformities and abnormalities unless specified in this Agreement.

    31. Infectious diseases (according to the local epidemiological patterns) that may arise in times of an epidemic (i.e. Avian Flu, Meningococcemia, etc.) as declared by World Health Organization (WHO) and/or by Department of Health (DOH).

    32. Chronic Dermatoses, Psycho-dermatologic Disorders such as (a) Psycho Physiological Disorders (e.g. Alopecia Areata, Atopic Dermatitis, Psoriasis, Psychogenic Purpura, Rosacea, Seborrheic Dermatitis, Urticaria); (b) Primary Psychiatric Dermatologic Disorder (e.g. Bromosiderophobia, Delusion of Parasitosis, Dysmorphophobia, Factitial Dermatitis, Trichotillomonania); (c) Secondary Psychiatric Dermatologic Disorders (e.g. Alopecia Areata, Cystic Acne, Hemangiomas, Ichthyosis, Kaposis Sarcoma, Psoriasis, Vitiligo).

    33. Any disease, condition, or complications, the proximate cause of which is animal bite or snake bite, except as provided for under the Agreement if any.

    34. Financial Responsibility for medical care covered by PhilHealth and Employee’s Compensation Act Benefits already enjoyed by the Member by reason of compulsory coverage therein, and all other government funded healthcare entitlements as provided for by law.

    35. Dietary consultations, weight reduction programs, surgical operation or procedure for weight reduction, treatment of obesity, including gastric stapling or balloon procedures and liposuction.