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Care by non-affiliated hospitals except in
emergencies wherein the Emergency Provision of the Agreement shall
apply;
-
Additional hospital charges and professional
fees resulting from taking a room accommodation different from the
specific in the Member's Benefit Classification and/or at a rate
in excess of the maximum room allowance, or additional personal
comfort items, e.g., telephone and TV, admission kit and/or such
other items of the same nature. If the Member's benefit
Classification specifies only the room accommodation of a higher
type than his room entitlement, the Member shall be entitled to
room and board benefits that is equal to the average of highest
and lowest room and board rates of the hospital where the Member
is confined for the type of room accommodation to which the Member
is entitled. Any excess between the rate of the higher type
availed of and such average shall be for the account of the
Member;
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All pregnancy related conditions requiring
medical/surgical care;
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Circumcision, sterilization of either sex or
reversal of such, artificial insemination, sex transformation or
diagnosis and treatment of infertility;
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Rest cures, custodial, domiciliary or
convalescent care;
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Cosmetic procedures/surgery and oral surgery
solely for purpose of beautification except reconstructive surgery
to treat functional defect/s due to disease or accidental injury;
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Dental examination, extractions, fillings,
and general dental attention and conditions and all complications
arising from them, except to the extent that these are necessary
for repair or alleviation of damage to the covered person caused
solely by accidental bodily injury;
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Psychiatric disorder, psychosomatic illness,
any injury, illness or condition which the member may suffer after
he has taken intoxicating drugs or alcoholic beverages as
evidenced by an alcoholic breath as determined by the examining
physician and/or conditions or illnesses resulting from
alcoholism;
-
Medical or surgical procedures which are
experimental in nature or not generally accepted as standard
medical treatment by the medical profession, that may include but
is not limited to, Chiropractic Services and Acupuncture;
-
Allergens used for hypersensitivity testing
regardless if administered as an out-patient or in-patient
procedure;
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Procurement or use of corrective appliances,
artificial aids and durable equipment;
-
All expense incurred in the process of organ
donation;
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Injuries or illnesses resulting from
hazardous activities in which a Member has engaged in a sport or
for pleasure, that may include but not limited to, bungee jumping,
scuba diving, hang gliding, mountain climbing and all such other
coluntary 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.
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Physical examinations and other related
Services required for obtaining or continuing employment,
insurance or government licensing, or not related to the health
maintenance of the client;
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Injuries or illness due to military service
or suffered under condition of war;
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Executive check-up and confinement which are
for purely diagnostic purposes;
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Diseases or injuries wherein the care or
reimbursement of services is provided by law or a government
program, up to the stipulated limits;
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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 laws or ordinances;
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Take-home medicines; out-patient medicines
except intravenous chemotherapy medicine and medicine administered
during an emergency treatment; vaccines except the first dose of
passive immunization for rabies, tetanus and snake bites if
medically prescribed;
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All hospital charges and professional fees
incurred after the day and time discharge from the hospital has
been duly authorized;
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Laser treatment for the purpose of
corrective eye refraction; and
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"Medico-Legal Fees". Medico-legal
fees refers to the professional fee of a medico legal consultant
to whom a patient is referred primarily for the issuance of a
medical certificate for legal purposes.
