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Delivers a package of comprehensive health services
for its actively enrolled members where the
primary thrust is to prevent, detect & treat
an illness.
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Limitations
and Exclusions:
1. Non-Coverage of
Pre-Existing Conditions
Whether known or unknown, disclosed
or undisclosed,
an illness or condition shall be considered
as Pre-existing if during the period
prior to:
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the effective date of the Agreement,
or
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The approval date of re-application
in case of lapsation;
a. any professional advise or treatment
was given for such illness or condition,
b. such illness or condition was in
any way evident to the member,
c. the pathogenesis of such illness
or condition has started
Pre-Existing
Conditions
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All tumors and
cancer (malignancies) |
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Endometriosis and other gynecologic
diseases |
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Hemorrhoids and anal fistulae |
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Chronic ENT diseases such
as tonsillitis, sinusitis requiring
surgery |
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Cataracts and other chronic
eye diseases |
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Epilepsy and other neurological
diseases |
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Asthma, tuberculosis and other
chronic pulmonary diseases |
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Cirrhosis of the liver |
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Calculi of the urinary system
– calculi (stones) of
the biliary & urinary systems. |
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Gastric or duodenal ulcer
and other gastrointestinal disorder
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Hallux valgus & other
musculo-skeletal diseases |
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Diabetes mellitus, goiter
and other endocrine diseases |
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Hypertension –cardiovascular
diseases |
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Collagen and auto-immune diseases |
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Hernia |
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Blood dyscracias |
All new members
of PrudentialifeCare will be subject
to the pre-existing condition clause
on the first year of coverage. If
a pre-existing illness comes out on
the first year, it will not be covered
by PrudentialifeCare and shall be
automatically excluded from an enrollee’s
coverage upon renewal.
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Pre-existing condition
clause can only be waived for
group accounts with 100 or more
enrollees AND if said number
represents at least 75% of the
total number of eligible employees. |
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No waiver of pre-existing
condition clause for Baby Groups |
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If there are two or more companies
to be covered under one agreement,
a certification or any business
document is required as a proof
of their affiliation. |
General
Exclusions
No Health Care Benefits
shall be provided for the following
services, procedures or conditions:
- Care by non-affiliated
physician or in non-accredited
hospitals
- Additional hospital
charges and professional fees;
upgrading of room
- All pregnancy-related
conditions, if not specified in
the plan
- Circumcision,
sterilization of either sex or
reversal of such, artificial insemination,
sex transformation or diagnosis
and treatment of infertility
- Rest cures, custodial,
domiciliary and convalescent care.
- Cosmetic procedure
- Dental services,
if not specified in the plan
- All forms of
behavioral disorders
- Drug-related
and/or alcohol-related injuries
and illnesses
- Experimental
medical and surgical procedures
- Allergens
- Corrective Appliances
- All expenses
incurred by the member in the
process of donating organs.
- Injuries or
illnesses resulting from hazardous
activities
- Physical examinations
not related to the health maintenance
of the client.
- Injuries and
illnesses due to military service
or suffered under the conditions
of war.
- Executive check-ups,
if not specified in the plan
- Injuries or
illnesses wherein the care or
reimbursement of services is provided
by law or a government program
up to the stipulated limits.
- Self-inflicted
injuries and illnesses
- Out-patient
medicines
- Vaccines
- All hospital
charges and professional fees
incurred after the day and time
the discharge from the hospital
has been duly authorized.
- Laser treatment
for the purpose of corrective
eye refraction.
- Medico-Legal
Fees
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