*These exclusions should not in any way prevent a member from undergoing whatever treatment procedures deemed necessary by the attending physician.
A. Confinement without the official recommendation of the Carewell Medical Director, Accredited Outpatient Physician Coordinator or their representatives including confinement after effectivity of discharge order issued by attending or Carewell Physician Coordinator.
B. Extra services not directly related to the member’s health management such as, but not limited to, service of private nurse, extra food, bed, TV, electric fan, DVD players, telephones, ID bracelet, thermometer and others.
C. Hospitalization and treatment abroad.
D. Prescribed medicines for outpatient cases including vaccines.
E. X-ray, laboratory and procedures not prescribed or approved in writing by the Carewell Medical Director, accredited outpatient physician coordinator or attending physician.
F. Congenital defects, slipped disc, spinal stenosis and hearing impairment.
G. Correction of all physical deformities.
H. Guillian-Barre Syndrome, Multiple Sclerosis, Epilepsy and other autoimmune neurological diseases.
I. Psoriasis and Vitiligo.
J. Plastic and reconstructive surgery for cosmetic purposes or congenital deformities and abnormalities.
K. Physical examination required for obtaining or continuing employment, insurance or government licensing.
L. Experimental medical procedures and other alternative forms of medicine such as acupuncture or cupping.
M. Services related to reproductive capacity i.e. abortion, sterilization, ligation, male/female fertility treatments etc.
N. Purchase or lease of durable medical equipment, oxygen-dispensing equipment and oxygen except during covered inpatient care.
O. Corrective appliances, artificial aids and prosthetic devices.
P. Human blood products like platelets, packed red blood cells (PRBC), plasma, etc.
Q. Psychiatric care, rehabilitation treatment, physiotherapy and speech therapy.
R. Open heart surgery, organ transplant and craniotomy sequelae.
S. Injury or illness resulting from participation in war-like or combat operation, brawls, riots and civil disturbances except those resulting from unprovoked assaults.
T. Hazardous job-related illness or injury.
U. Injuries that are self-inflicted or attributable to member’s own misconduct, gross negligence, mental state, drug and/or alcohol use, vicious or immoral/promiscuous habits, participation in crime, any conduct in violation of law or ordinance, and unnecessary exposure to imminent danger or hazards to health including treatment for alcoholism and drug addiction/abuse.
V. Any injury sustained whenever the member is determined by attending physician to have taken alcohol.
W. Maternity care and other conditions as a result of pregnancy and its origin (unless otherwise specified in the healthcare service contract).
X. Custodial, domiciliary, convalescent, and intermediate care.
Y. Sexually transmitted diseases and origin including gonorrhea, herpes and AIDS.
Z. Adverse medical conditions arising from treatment by non-accredited physicians, clinics, and hospitals.
EXCLUSIONS (CONDITIONS NOT COVERED)
1. Availments / hospital expenses coursed through non-affiliated doctors/clinics/hospitals except in emergencies wherein the emergency provisions of the contract shall apply.
2. Surcharges resulting from additional personal amenities/request or services (i.e. telephone, television and other incurred charges after the Carewell physician has authorized the discharge of the member).
3. Physical examination required for obtaining employment, insurance, government license, entrance for school or military purposes, executive check-ups and annual physical examination (APE) not authorized by Carewell, medical clearance for physical workouts, etc.
4. Availments / disease relative to epidemics as declared by the national or local government except for those disease / availments within limits set forth in the contract for local epidemics.
5. All expenses related to the actual bloodletting, screening and cross-matching of blood, in cases when blood for transfusion will be from the voluntary blood donor (provided for in the National Voluntary Blood Donation Program of the government).
6. Diseases or injuries wherein the care or reimbursement is provided by law or a government program up to the stipulated limits (e.g. PhilHealth / Medicare / ECC benefits); program thrusts of the Department of Health (DOH) and other national agencies where medication / care / treatment is provided (e.g. Leprosy Control Program).
7. Rest, custodial, domiciliary or convalescent cures, long-term rehabilitation care, psychiatric care.
8. Medical and surgical procedures that are not generally accepted as standard medical treatments by the medical professions (e.g. hilot, herbal medicines, acupuncture, reflexology, chiropractic treatment, etc).
9. Take-home medicines in case of hospitalizations.
10. Conditions / illnesses resulting from research experiments (e.g. AIDS – vaccination).
11. Hepatitis screening and all diagnostic exams for employment purposes.
12. Any complications resulting from dental conditions, except for those covered under the Dental Benefit Rider.
13. Prescribed medications for Hormonal Replacement Therapy (HRT).
14. Procurement or use of corrective appliance, artificial aids and orthopedic hardware used in nailing, pinning, and bracing metals plates during craniotomy, wheelchair, cervical collar, abdominal braces, clutches, hearing aids, contact lens, intraocular lens, etc. Purchase or lease of durable medical equipment, oxygen dispensing equipment and oxygen except during covered inpatient care.
15. All congenital abnormalities (for example Kyrphoscoliosis, Spinal Stenosis, Coarctation of the Aorta, Tetralogy of Fallot, Patent Ductus Arteriosus, Ventricular Septal Defect, Ebstein Anomaly of the Great Vessel, AV malformations, etc.) and inborn errors of metabolism, physical deformities prior to enrollment, Spinal Stenosis, Inguinal and Umbilical hernia, and other related conditions. Conditions / Illnesses arising from Perinatal / Natal complications like Cerebral Palsy & other related conditions; Metabolic Disorders that are congenital in nature.
16. Blood Dyscrasia (Hemophilia, Sickle Cell Anemia, Leukemia, etc).
17. All types of Aneurysm and Angiography
18. All cases requiring Craniotomy and Burr holing.
19. Severe autoimmune disease e.g. Systemic Lupus Erythematosus (SLE); Vitiligo, Psoriasis and its complications, etc.
20. Functional disorders of the mind (psychiatric disorders) including mental retardation.
21. Sterilization of either sex or reversal of such, artificial insemination, sex transformation or tubal ligation, in-vitro fertilization, circumcision, IUD insertion and complications arising from these procedures.
22. All pregnancy-related conditions requiring medical or surgical care, except if with Maternity Benefit Rider.
23. Cardiovascular Diseases:
a. Cardiac Valvular Diseases, Aortic Stenosis, Mitral Regurgitation, Tricuspid Regurgitation, Mitral Stenosis, Mitral Valve Prolapse (MVP).
c. Arrythmias, Sick Sinus Syndrome, Stroke Adam Syndrome, Ventricular Tachycardia, Supraventricular Trachycardia, Second and Third Degree AV Block
d. Congestive heart failure Class III-IV
e. Malignant / Uncontrolled Hypertension with complications (such as Hemorrhagic cases that may or may not require craniotomy or burr holing)
f. RHD (Rheumatic Heart Disease)
24. Organ transplants, open heart surgery (coronary artery bypass) or any diagnostic procedures / tests related thereto (i.e. 2D Echo, coronary angiogram, cardiac catheterization, etc.); pacemaker incision; valve replacements.
25. Chronic Renal Disease (e.g. Chronic Glomerulonephritis, Chronic Renal Failure due to primary serial renal failure or other secondary causes, Nephrotic Syndrome, Chronic Pyelonephritis, Staghorn Calculi resulting to Renal Failure, Chronic Renal Failure secondary to Diabetes) except for acute renal disease with acute renal failure.
26. Neurocirculatory Asthenia; Anorexia Nervosa and its complications.
27. Human anti-rabies and other vaccines (except for the first does of anti-tetanus vaccine in case of emergency), Immunoglobulins and other biological products.
28. Cosmetic surgery including vein stripping, oral surgery, dermatological procedures for purposes of beautification except reconstructive surgery to treat a dysfunctional defect due to disease or accidental injury, warts, acne and moles not infected and no malignant tendencies (excluded for cosmetic purposes).
29. Sexually Transmitted Diseases, AIDS, AIDS-related (SY, CC, Herpes, Yaws, NGU, Monilia classified as STD) and other tests to diagnose these diseases.
30. Work-related injuries / illnesses for those working under hazardous conditions / occupations.
31. Injuries and illnesses due to military, paramilitary, police service or war (e.g. Army, Navy, Barangay Tanod, etc.).
32. Injuries sustained as a result of domestic fights and problems, hazardous sports (e.g. scuba diving, skydiving, mountain climbing, etc.) and professions (e.g. athletes, aerobatics, racecar drivers, professional entertainers, mining, underground workers, secret service, explosives factory workers, martial arts practitioners, etc.), avocation and other sports-related activities.
33. Injuries or illnesses due to attempted suicide; use of alcohol and/or drugs, vicious or immoral habits, participation or involvement in acts of war, terrorism, crime, riot or brawl, violation of law or ordinance, and unnecessary exposure to imminent danger to health – including complications of such conditions (e.g. alcoholic hepatitis).
34. Hospital confinement for purely diagnostic purposes except when covered under a special provision of the contract such as executive check-up.
35. Death related to motorcycle accident.
36. Professional fee medico-legal officer called for medico-legal cases.
37. Determining / ruling out of PEC during the first 12 months of membership.
38. Motorcycle vehicular accident cases.
39. PHIC uncompensable cases.
40. HEPA B and its complications.
41. All other illnesses, medications and diagnostic procedures that are not covered by your contract.