Non-Covered Illnesses and Diseases


What are covered and not covered for PhilCare’s prepaid consultation cards?

Pre-existing conditions is covered. The only exceptions are maternity-related cases and cases related to all forms of behavioural disorders, developmental or psychiatric disorders and psychosomatic illnesses whether acquired or congenital.

 

What are the non-covered illnesses and diseases for emergency and hospitalization health cards?

 

The following are the diseases and conditions in which the emergency and hospitalization health cards cannot be used. No health care benefits shall be paid for the following services, procedures or conditions. This is not a complete list of non-covered illnesses and diseases. PhilCare reserves the right to have the final interpretation of all definition, provisions and articles relating to the health cards.


A. List of diseases not covered but not limited to:


Anal fistulae / Asthma / Auto immune conditions / Cardiovascular diseases / Calculi of the urinary system / Cataracts / Sinus conditions requiring surgery / Cerebrovascular diseases / Cholecystitis/cholelithiasis / Chronic skin conditions / Cirrhosis of the liver / Collagen disease / Degenerative conditions / Diabetes mellitus / Diseased tonsils requiring surgery / Endometriosis / Epilepsy / Gastric or duodenal ulcer / Hallux valgus / Hemorrhoids / Hernia / HIV/AIDS / Hypertension / Neurologic conditions  / Obesity, dyslipidemia  and other metabolic conditions / Pathological abnormalities of nasal septum and turbinates / Thyroid conditions / Tuberculosis / Tumors, whether benign or malignant of all organs and organ systems, including malignancies of the blood or bone marrow / Non-emergency case during point of availment / Pre-existing and congenital conditions Pre-existing and congenital conditions – An illness or condition shall be considered pre-existing if, prior to the effective date of health coverage the pathogenesis of such illness or condition has started, whether or not the member is aware of such illness or condition.


B. General exclusions applicable to health care coverage

·         Care by Non-Accredited Physician in either Accredited or Non-Accredited Hospitals

·         Care by an Accredited Physician in Non-Accredited Hospital

·         Additional hospital charges and professional fees resulting from taking a room category higher than that specified in the member’s benefit schedule

·         Additional personal comfort items (e.g., telephone and television, additional food trays, admission kit and such other items of the same nature)

·         Procurement or use of corrective appliances, prosthesis, artificial aids and durable equipment such as but not limited to the following: stents, prolene mesh, pins, screws, plates, wires, VP shunt, clips, hearing aids, intraocular lens, eyeglasses, contact lenses, balloons, valves;  braces, crutches , pace maker

·         All pregnancy-related conditions and complications relating to mother and unborn child, requiring medical and surgical care, regardless of time/date of occurrence (during the actual time of pregnancy or thereafter)

·         All sexually transmitted diseases

·         Blood screening, blood typing, cross-matching for potential donors in relation to blood donation and transfusion

·         All forms of behavioral disorders whether congenital or acquired; developmental or psychiatric disorder; psychosomatic illness

·         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

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

·         Allergens used for hypersensitivity testing regardless if administered as an outpatient or in patient procedure.

·         Treatment of injuries or illnesses resulting from the voluntary participation of a member in any hazardous sport or activity that may include but is not limited to:  bungee jumping, scuba diving, hang-gliding, mountain climbing, parachuting, surfing, rock climbing, airsoft, paintballing, boxing, wrestling, martial arts (such as taekwondo, judo, karate, etc.), gymnastics, motor sports (drag racing, jet skiing), wakeboarding, water skiing and all such other voluntary activities which pose a grave danger to life and limb.

·         Treatment of injuries or illnesses due to military service or suffered under conditions of treatment of injuries or illnesses wherein the care or reimbursement of services is provided by law or a government program, up to the stipulated limits

·         Treatment of any injury which is proven to be attributable to the member’s own misconduct such as negligence, intemperate use of drugs or alcoholic liquor, direct or indirect participation in the commission of a crime, whether consummated or not, violation of a law or ordinance, unnecessary exposure to imminent danger or hazard to health, including fireworks related injuries, infections or complications as a result of tattoos and piercing of the ear or any body part, whether self-inflicted or done by a third party, or attempted suicide or self-destruction, whether sane or insane

·         All cases of assault perpetrated by the Member including domestic violence which result in harm or injury to the Member perpetrator

·         Vaccines, whether elective or administered during an emergency treatment are not covered

·         In-patient pain management necessitating specialized pain management team and/or the use of specialize equipment

·         All diseases declared as epidemic by the Department of Health (DOH) and any other recognized health agencies

·         All hospital charges and professional fees incurred after the day and time the discharge from hospital has been duly authorized

·         All procedures and/ or services considered screening

·         Pre-existing and congenital anomalies and conditions, and their complications

Additional hospital charges and professional fees resulting from taking a room category higher than that specified in the member’s benefit schedule