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,
         - the approval date of  re-instatement

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

	All tumors and cancer (malignancies)
	Endometriosis and other gynecologic diseases
	Hemorrhoids and anal fistulae
	Chronic ENT diseases such as tonsillitis, sinusitis requiring surgery
	Cataracts and other chronic eye diseases
	Epilepsy and other neurological diseases
	Asthma, tuberculosis and other chronic pulmonary diseases
	Cirrhosis of the liver
	Calculi of the urinary system - calculi (stones) of the biliary & urinarysystems
	Gastric or duodenal ulcer and other gastrointestinal disorder
	Hallux valgus & other musculo-skeletal diseases
	Diabetes mellitus, goiter and other endocrine diseases
	Hypertension –cardiovascular diseases
	Collagen and auto-immune diseases
	cardiovascular diseases
	Hernia
	Blood dyscracias

General Exclusions

No Health Care Benefits shall be paid for the following services, products or conditions:

• Care by non-affiliated physicians or in non-affiliated hospitals except in emergencies wherein the Emergency Care Provision of this Agreement shall apply.
  
  
• Additional hospital charges and professional fees resulting from taking a room accommodation at a rate in excess of the maximum daily room rate or additional personal comfort items e.g. telephone, television, admission kit and/or other such items of the same nature.
  
  
• All pregnancy related conditions during paying and paid up period.
  
  
• Circumcision, sterilization of either sex or reversal of such, artificial insemination, sex transformation or diagnosis and treatment of infertility.
  
  
• Rest cures, custodial, domiciliary or convalescent care.
  
  
• Cosmetic procedure/surgery and oral surgery solely for the purpose of beautification except reconstructive surgery to treat function defects due to disease or accidental injury.
  
  
• Psychotherapy, counseling and treatment and of mental or psychiatric disorder or psychosomatic illness.
  
  
• Any injury or illness or condition which the Member may suffer after he has taken intoxicating drugs or alcoholic beverages as evidenced by alcoholic breath and/or as determined by examining physician and/or conditions or illnesses resulting from Alcoholism and /or intake of prohibited drugs.
  
  
• Congenital anomalies or conditions and their complications.
  
  
• 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 not limited to chiropractic services and acupuncture.
  
  
• Allergens used for hypersensitivity testing regardless if administered as an outpatient or inpatient 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 and wires (d) VP shunt (e) hearing aids (f) intraocular lens, eyeglasses, contact lens (g) balloons, valves (h) braces, crutches (i) pace maker (j) artificial joints & limbs.
  
  
• All expenses incurred in the process of organ donation.
  
  
• Self-inflicted or induced injury or illness, or caused by an attempt at suicide or in connection with the commission of a crime or violation of law or due to unnecessary hazardous activities.
  
  
• Physical examination for insurance, employment and the like, and medical services not incident to the treatment of an illness or injury, including medico legal fees.
  
  
• Diseases or injuries wherein the care or reimbursement of services is provided by law or a government program, up to the stipulated limits.
  
  
• Take-home medicine, vaccines, outpatient medicines except medicine administered during an emergency treatment.
  
  
• 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.
  
  
• Sexually transmitted diseases and HIV/AIDS.
  
  
• Open heart surgery, coronary angiography, percutaneous transcoronary angioplasty, pacemaker insertion, uncontrolled hypertension, organ transplant or hyperalimentation during paying and paid up period.