General Exclusions

ER Care series

1. Viral and bacterial illnesses that are complications of or contracted due to a compromised or impaired immune system. The following are examples but not limited to:
   1. Patients with malnutrition
   2. Patients with uncontrolled diabetes mellitus
   3. Recipients of organ transplant
   4. Patients with hematologic malignancies
   5. Patients undergoing radiation, chemotherapy and immunosuppressive therapy
   6. Patients with HIV / AIDS infection
   7. Patients with foreign objects/implants such as venous or urinary catheters
   8. Patients with auto-immune diseases such as Systemic Lupus Erythematous (SLE), Rheumatoid Arthritis, Multiple Sclerosis, Guillain-Barre syndrome
2. Viral infections like:
   1. Hepatitis B, C, D & E
   2. Herpes infections like Epstein-Barr and Cytomegalovirus
3. Accidents and viral / bacterial illnesses that are secondary to or contracted due to having a degenerative disease such as but not limited to Alzheimer’s disease, Amyotrophic lateral sclerosis (ALS), Parkinson’s disease.
4. Conditions secondary to all pregnancy and fertility-related illnesses / treatments.
5. Lithiasis/stones of the gallbladder and genito-urinary system.
6. Sexually transmitted infections such as but not limited to syphilis, gonorrhea, chlamydia, human papillomavirus infection, HIV/AIDS.
7. Pre-existing conditions except Hepatitis A.
8. Chronic viral and bacterial illnesses.
9. Congenital illnesses acquired through viral and bacterial infections.
10. Care by non-accredited Physician and/or in a non-accredited hospital.
11. All dental related conditions and services.
12. Complications from sterilization of either sex or reversal of such, artificial insemination, sex transformations, and circumcision.
13. Rest cures, custodial, domiciliary, or convalescent care.
14. Complications arising from cosmetic surgery, dental/oral surgery and dermatological procedures for the purpose of beautification, including reconstructive surgery to treat a dysfunctional defect due to a disease or accident.
15. Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, stress related conditions, adjustment disorders, alcoholism and its complications or conditions related to substance or drug abuse, addiction and intoxication.
16. 16. Medical and/or surgical procedures which are not generally accepted as standard treatment by the medical profession like acupuncture.
17. Procurement or use of corrective appliances, artificial aids and durable equipment, and orthopedic prosthesis and implants.
18. Surcharges resulting from additional personal (luxuries/accommodation) request or service including special nursing services.
19. Injuries or illnesses due to military, paramilitary, police service, high risk activities, or suffered under conditions of war.
20. 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 law, administrative order or ordinances.
21. Professional sports and high-risk sports.
22. Outpatient/Take home medicines.
23. Valvular Heart Disease and/or Rheumatic Heart Disease.
24. All hospital expenses and professional fees incurred by a Member when discharged against medical advise and those subsequent expenses incurred by the said Member for the same condition and its complications after such discharge during the contract period.
25. All hospital charges and professional fees after the day and time hospital discharge have been duly authorized.
26. Professional fees of assistant surgeons.
27. Use of emergency room facilities on non- emergency cases or by reason of conditions/ injuries not falling under the term “Emergency” as defined under this Agreement.
28. Diseases declared by the Department of Health as “epidemic”.
29. Miscellaneous Fees not related in the diagnosis and treatment of a member’s condition such as, but not limited to, “nursing fee”, waste/biologic hazard disposal fee, management fee, local taxes, and other analogous fees.
30. Medico-legal consultations and confinements.
31. All expenses incurred in the process of organ donation and transplantation as donor or recipient.

Medconsult series

The Out-patient Consultation Voucher shall cover consultations made only in a doctor’s office and if not listed below as exclusion:

1. Consultations in emergency room facilities.
2. Consultations with non-accredited Physician and/or in a non-accredited hospital.
3.  Conditions secondary to all pregnancy and fertility-related illnesses / treatments.
4. Sexually transmitted infections such as but not limited to syphilis, gonorrhea, chlamydia, human papillomavirus infection and HIV/AIDS.
5. Consultations for complications resulting from sterilization of either sex or reversal of such, artificial insemination, sex transformations, and circumcision.
6. All in-clinic procedures. The following are examples but not limited to:
   1. Ophthalmology procedures like visual acuity, refraction, slit lamp exam, fundoscopy, tonometry, etc.
   2. Ears, nose, throat (ENT) procedures like ear irrigation/cleaning, ear/nasal suctioning, rhinoscopy, laryngoscopy, etc.
   3. Surgical procedures like incision and drainage, wound cleaning, debridement, suture removal, etc.
   4. Injection administration
   5.  Pap smear
7.  Dermatological consultations and procedures for purpose of beautification. Examples are but not limited to acne, warts, hyperpigmentation and milia
8. Consultations with neurologists.
9. Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, stress related conditions, adjustment disorders, childhood and developmental disorders, alcoholism and its complications or conditions related to substance or drug abuse, addiction and intoxication.
10. Hypersensitivity and allergy tests.
11. Cardio-pulmonary (CP) clearance required prior to surgery or medical procedures.
12. Physical examination required for obtaining employment, medical certification, insurance or government license, including cardio-pulmonary (CP) clearance required prior to surgery or other medical procedures.
13. Injuries or illnesses due to military, paramilitary, police service, high risk activities, or suffered under conditions of war.
14. 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 law, administrative order or ordinances.
15. Diseases declared by the Department of Health as “epidemic”.
16. Outpatient medicines.
17. Medico-legal consultations.
18. Physical therapy