MEDICAL & DENTAL HMO EXCLUSIONS

  • Pre-existing and Congenital Illnesses or conditions (An illness or condition shall be considered pre-existing if before the Effective Date of the Agreement:
    - Any professional advice or treatment was given for such illness or condition
    - Such illness or condition was in any way evident to the member
    - The pathogenesis of such illness or condition has already started (which the member may not be aware of))
  • Infectious diseases (i.e. Avian Flu, Meningococcemia, etc.) that are declared epidemic or pandemic by the Department of Health, World Health Organization or any recognized health authority
  • Sexually transmitted disease, AIDS, HIV, rehabilitative treatment for alcoholism and drug abuse
  • Psychiatric disorders, psychosomatic conditions, treatment for any mental or nervous disorders, illness/injury / condition/complication arising from the plan member’s excessive alcohol intake and/or use of regulated/prohibited drugs, mind-altering drugs
  • Neuro-surgical / neurological conditions
  • Circumcision, cosmetic / aesthetic procedures except re-constructive surgery to treat functional defects due to a covered disease and/or accidental injury
  • Maternity and any maternity related conditions and/or complications, treatment, consultations, and procedures
  • Sterilization of either sex or reversal of such, artificial insemination, sex change, consultation/confinement regarding fertility
  • Medical/surgical procedures and/or diagnostic tests that are experimental in nature and/or not generally accepted by the medical profession such as, but not limited to, iridology, chiropractic services, and acupuncture
  • Organ transplant – expenses to organ donation, both as donating or receiving party
  • Chemotherapy
  • Dialysis
  • Physical and Speech Therapy
  • Executive check-ups and Annual Physical Exam
  • Illnesses/injuries resulting from the plan member’s active participation in hazardous activities such as, but not limited to, bungee jumping, hang-gliding, scuba diving, mountain/wall climbing, and professional sports
  • Illnesses/injuries resulting from conditions of war or sustained from combat-related activities
  • Illnesses and/or injuries arising from the plan member’s participation in brawls, riots, commission of a crime, violation of ordinances, or the like
  • Illnesses/injuries attributable to the plan member’s own misconduct / gross negligence / immoral habits, and willful and unnecessary exposure to danger or health hazards
  • Blood and blood elements
  • Additional hospital charges and/or professional fees resulting from a plan member taking a room accommodation more than his R&B limit (excesses and/or incremental costs)
  • Services rendered or supplies provided free of charge
  • Acquisition of prosthetic appliances, artificial aids, durable equipment, surgically implanted devices and external prosthetic devices
  • Take-home medicines and vaccines, except for the first doses of either anti-venom, anti-rabies or anti-tetanus used for emergency treatment
  • Non-recommended confinement, convalescent / domiciliary / custodial care, rest cures
  • Medico-legal fees including the cost of Medical Certificates that a plan member may require for any purpose it may serve him or her
  • Reimbursements for Dental Consultations and ALL Dental procedures in non-accredited Dental Clinics and Dentists
  • Reimbursements for Medical Consultations and ALL Medical procedures in non-accredited Hospitals, Clinics, and Physicians
  • Dental-related cases except those that may be provided by the Dental Benefits
  • Laser Therapy, including correction of vision
  • ALL Optical related treatment, illness including but not limited to Consultation, laboratories, Appliance
  • Ambulance Services