PERMANENT EXCLUSIONS (examples of)
- Care by non-accredited Physician and / or in a non-preferred hospital/clinic except in emergencies wherein the emergency provision of the agreement will apply
- All pregnancy related conditions requiring medical/surgical care and screen tests related thereto
- Sterilization of either sex or reversal of such, artificial insemination, sex transformations or diagnosis and treatment of infertility, and circumcision
- Rest cures, custodial, domiciliary or convalescent care
- Cosmetic surgery, dental/oral surgery, and dermatological procedures for the purpose of beautification except reconstructive surgery to treat a dysfunctional defect due to disease or accident
- Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, adjustment disorders, alcoholism and its complications or conditions related to substance or drug abuse, addiction and intoxication
- Sexually transmitted diseases
- Medical and surgical procedures which are not generally accepted as standard treatment by the medical profession
- Procurement or use of corrective appliances, artificial aids, durable equipment, and orthopedic prosthesis and implants
- Surcharges resulting from additional personal (luxuries/accommodation) request or service including special nursing services
- Physical examination required for obtaining employment, medical certification, insurance or a government license
- Injuries or illnesses due to military, paramilitary, police service, high risk activities, or suffered under conditions of war
- Reimbursement of procedures obtained through government programs
- Injuries or illnesses, which are self-inflicted, caused by attempt at suicide or incurred as a result of or while participating in a crime or acts involving the violation of laws or ordinances
- Out-patient/take-home medicines
- Valvular Heart Disease and Rheumatic Heart Disease
- Medico-legal consultations
- When a member is discharged against medical advice, and all subsequent benefits/services related thereto.
- Blood / Organ Donor screening / other screening procedures that are purely diagnostic or for screening purposes including among others, Purified Protein Derivative (PPD), and procedures conducted prior to hormonal replacement therapy
- All hospital charges and professional fees after the day and time hospital discharge has been duly authorized and professional fees of Assistant Surgeons
- All conditions and complications requiring dental care
- Hypersensitivity/allergy tests
- Diseases declared by the Department of Health (DOH) as Epidemic
- Use of Emergency Room Facilities on non-emergency cases or by reason of condition/injuries not falling under the term "Emergency" as defined in the Agreement ("Emergency" shall mean the sudden, unexpected onset of illnes or injury having the potential of causing immediate disability or death, or requiring the immediate alleviation of severe pain or discomfort.) For the purpose of implementation, the final diagnosis shall be the basis for a member's eligibility to emergency care benefits under the plan.
