Exclusion and Limitations of the Policy
- Additional hospital charges and physician’s professional fees resulting from:
- room-upgrading beyond twenty-four (24) hours during emergency conditions such as but not limited to difference in room and board, professional fees and incremental charges
- extension of hospital stays despite release of discharge order from MEMBER’s attending physician
- 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 Medicare Plus except for hospitals that do not have resident physicians to assist during surgeries subject to the prior approval of Medicare Plus
- use of extra bed, pillows, extra food, toilet articles like face towel, soap, toothbrush and the like, 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
- 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
- services of a private or a special nurse
- all other items not medically necessary in the medical management of the MEMBER.
- Medical Certificates and request for copy of hospital documents.
- 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.
- All expenses incurred in the process of organ donation and transplantation and its complications if the MEMBER is the donor.
- Benefits covered by PhilHealth and all other government funded healthcare entitlements as provided for by law.
- Cost of the medical services and professional fees in excess of the ABL.
- Long-term rehabilitation and psychiatric and/or psychological illnesses and conditions including neurotic, psychotic behavior disorders and psychosomatic illness; anxiety disorders.
- Developmental disorders including functional disorders of the mind, such as but not limited to Attention-Deficit Disorder (ADD)/Attention-Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Bipolar Disorders, Central Auditory Processing Disorder (CAPD), Cerebral Palsy, Down Syndrome, Neural Tube Defects, and Mental Retardation.
- Treatment for injury and its complications resulting from self-inflicted injuries including infections as a result of tattoos, piercing of the ear or in any body part, whether self-inflicted or done by a third party or attempted suicide or self-destruction, whether sane or insane.
- Treatment of any injury received when there is negligence, unauthorized use of prohibited drugs or regulated drugs, alcoholic liquor intake, direct or indirect participation in the commission of a crime whether consummated or not, violation of a law or ordinance or unnecessary exposure to imminent danger, knowingly or unknowingly or hazard to health, by the MEMBER. Medicare Plus may rely on the Police or Doctor’s report to evaluate such claim.
- Aesthetic, cosmetic and reconstructive surgery or any consultation or treatment for any beautification purposes except if necessary, to treat a functional defect due to accidental injury within the initial confinement.
- Oral surgery following accidental injury to teeth for purposes of beautification. Dental examinations, extractions, fillings, other dental treatment and their complications except to the extent that are medically necessary for repair or alleviation of damage to the MEMBER caused solely by an accident. Medical care resulting from any dental related conditions.
- Maternity care and all other conditions related to and/or resulting from pregnancy and/or delivery which affect the conditions of the MEMBER and the unborn child.
- Circumcision (except for treatment of urological conditions), sex transformation, diagnosis, treatment and procedures related to fertility or infertility including menopause, artificial insemination, sterilization or reversal of such and their complications.
- Experimental medical procedures and its complications.
- Acupuncture, chirotherapy and other forms of therapies and its complications.
- Purchase or lease of durable medical equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care.
- Corrective appliances, prosthetics and orthotics such as but not limited to eye glasses and contact lenses, hearing aids, pacemaker, artificial limbs, valves, knee-tibial insert for total knee arthroplasty, vascular grafts, titanium thread, myringotomy tube, intravascular catheters, vascular stents, prolene mesh, bone screws/plates, pins, wires, VP shunt, balloons, orthopedic internal fixator/fixation systems, orthopedic external fixator/fixation systems, intraocular lens, braces, crutches.
- Take-home medicine, immunizing agents (vitamins) and out-patient medicine except chemotherapy medicine and medicine administered during an emergency treatment.
- Congenital, genetic and hereditary diseases and their complications affecting functions of individuals.
- All congenital and physical deformities and abnormalities prior to enrollment.
- Treatment of injuries/illnesses caused directly or indirectly by engaging in any professional sport or hazardous activity such as but not limited to scuba diving, hang-gliding, surfing, water skiing, mountain climbing, rock climbing, mountaineering, parachuting, airsoft, drag racing, paintballing, wakeboarding and bungee jumping, except for activities under company-sponsored sports activities, and all other voluntary activities which pose a danger to life and limb.
- Injuries resulting from direct participation in riots, strikes, and other civil disturbances.
- Treatment of injuries or illnesses resulting from war or any combat-related activities while in military service.
- Sexually transmitted diseases, genital warts, AIDS and AIDS related diseases.
- 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).
- Infectious diseases (according to the local epidemiological patterns) that may arise in times of an epidemic or pandemic (i.e., Avian Flu, Meningococcemia, etc.) as declared by World Health Organization (WHO) and/or by Department of Health (DOH).
- Pre-existing Hepatitis B and screening and vaccines for all types of Hepatitis.
- Animal bite/scratch/lick or snake bite including its complications.
- Laser procedures/treatments.
- Speech therapy for developmental and congenital diseases.
- Weight reduction programs, surgical operation or procedure for treatment of obesity, including gastric stapling or balloon procedures and liposuction.
- Cost of vaccines for immunization, except passive and active vaccine for anti-tetanus, anti-venom, and anti-rabies vaccine as specified in the Agreement.
- All screening tests.
- Executive check-ups and confinement which are for purely diagnostic purposes except as specified in the Agreement.
- Allergens used for hypersensitivity testing regardless if administered as an out-patient or in-patient procedure.
- Provoked assault including domestic violence.
- Robotic surgery.
