Limitations and Exclusions   

Limitations  

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:
         - the effective date of the Agreement, or
         - 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

	cancer or tumor of all organs or malignancies of the blood or bone marrow
	endometriosis
	hemorrhoids
	diseased tonsils requiring surgery
	pathological abnormalities of nasal septum and turbinates
	hyperthyroidism/goiter
	cataracts
	sinus condition requiring surgery
	epilepsy
	asthma
	cirrhosis of the liver
	tuberculosis
	anal fistulae
	cholecystitis/cholelithiasis
	alculi of the urinary system
	gastric or duodenal ulcer
	hallux valgus
	diabetes mellitus
	hypertension
	collagen disease
	cardiovascular diseases
	hernia
	HIV/AIDS

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.

2. Maximum Limit For Dreaded Disease And / Or ICU Confinements Per Year

3. Lifetime Maximum Sum Per Dreaded Disease And / Or ICU Confinements

4. Permanent Exclusions

General Exclusions

• Care by Non-Affiliated Physician and/or in Non-Affiliated Hospitals, except in emergencies wherein the Emergency Provision shall apply.
  
  
• Additional hospital charges and Professional Fees resulting from taking a Room Category higher than that specified in the Member's Benefit Classification, additional personal comfort items (e.g. telephone and television, admission kit) and such other items of the same nature.
  
  
• All pregnancy related conditions requiring medical and surgical care
  
  
• 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. These pertain to care in a skilled affiliated facility or an institution that meets certain standards for medical care and includes nursing care and therapeutic services following hospital confinement.
  
  
• Cosmetic procedure and surgery and oral surgery solely for purpose of beautification, except reconstructive surgery to treat functional defects due to disease or accidental injury.
  
  
• 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 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.
  
  
• Procurement or use of corrective appliances, prosthesis, artificial aids and durable equipment such as but not limited to the following: (a) stents; (b) prolene mesh; (c) pins, screws, plates, wires; (d) VP shunt, clips; (e) hearing aids; (f) intraocular lens, eyeglasses, contact lenses; (g) balloons, valves; (h) braces, crutches; (a) pace maker.
  
  
• All expenses incurred by the Member in the process of donating organs.
  
  
• Injuries or illnesses resulting from hazardous activities in which a Member has engaged in leisure that may include but is not limited to: bungee jumping, scuba diving, hang-gliding, mountain climbing and all such other voluntary 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.
  
  
• 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.
  
  
• Injuries or illnesses due to military service or suffered under conditions of war
  
  
• Executive check-ups and confinement which are for purely diagnostic purposes except as specified in the Agreement;
  
  
• Injuries or illnesses wherein the care or reimbursement of services is provided by law or a government program, up to the stipulated limits;
  
  
• Injuries or illness 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 the violation of laws or ordinances.
  
  
• Take-home medicine, immunizing agents and out-patient medicines, with the exception of intravenous chemotherapy medicine and those administered during an emergency treatment.
  
  
• Vaccines, whether elective or administered during an emergency treatment are not covered.
  
  
• 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.” These are professional fees of medico-legal consultant to whom a patient is referred primarily for the issuance of a medical certificate for legal purposes.