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HMO Exclusions

  • Out of network services -Care by Non-Affiliated Physician in either Affiliated or Non-Affiliated Hospitals, or Care by Affiliated Physician in Non-Affiliated Hospital except ER cases
  • Any treatment which are not recommended and performed by a Physician as being medically necessary including any charges for non-medical services such as telephone, radio, television, extra bed, extra food, toilet articles and the like, private duty nurse or physician.
  • 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, Executive check-ups
  • All expenses incurred by the Member in the process of donating organs/organ transplants
  • Refusal to undergo recommended treatment or demanding treatment for which Intellicare doctors believe a professionally acceptable alternative exists
  • “Medico-Legal Fees” These are professional fees of a medico-legal consultant to whom a patient is referred primarily for the issuance of a medical certificate for legal purposes
  • Medical Certificates
  • Treatment of injuries/illnesses the direct and immediate cause of which is the engagement and participation of the Member in any (a) hazardous sport or activity i.e. scuba diving, mountain climbing, parachuting et. al. ,
  • Procurement or use of corrective appliances, prosthesis, artificial aids and durable equipment (e.g. stents, pins, screws, plates, wires, hearing aids; (f) intraocular lens, eyeglasses, contact lenses, braces, crutches, pace maker, etc.
  • All other government funded health-care entitlements as provided for by law.Infectious diseases (according to the local epidemiologic patterns) that may arise in times of epidemic (i.e. Avian Flu, Meningococcemia, etc.) as declared by the Department of Health
  • For Purposes of Beautification:
    • Cosmetic surgery, reconstructive surgery to treat a functional defect due to accidental injury within the initial confinement
    • Oral surgery following accidental injury to teeth for purposes of beautification
    • Weight reduction programs, surgical operation or procedure for treatment of obesity, including gastric stapling or balloon procedures and liposuctions.
  • Exposure to imminent danger or health hazards such as:
    • Serving in the military, navy, air force of any country or international authority
    • War-like or combat operations, government declared acts of rebellion, terrorism
    • Active participation in strikes, riots, demonstrations and labor disputes
    • Provoked criminal acts
    • Violation of a law / ordinance
    • Commission of a crime (whether consummated or not)
    • Setting off / Handling pyrotechnic materials
    • Attempted suicide, self-inflicted injuries
  • Determining / Ruling out PEC during the first 12 months of membership – if result is positive
  • Determining / Ruling out Hepatitis and Tuberculosis – if result is negative
  • Reproductive disorders, artificial insemination, circumcision, sex change
  • Laser eye surgery for myopia or error of refraction
  • Dental examination, extractions, fillings and general dental attention and conditions and all complications arising there from, except to the extent that are necessary for repair or alleviation of damage to the covered person caused solely by accidental injuries and those dental benefits as specified in the Agreement
  • All forms of behavioral disorders whether congenital or acquired; developmental or psychiatric disorder; psychosomatic illness
  • Alternative medical treatment / procedures such as:
    • Acupuncture
    • Chiropracty
    • Iridology
    • Chelation
    • Cell implant therapy
  • Sleep study not due to an organic illness
  • Fortuitous events/disasters such as:
    • Complete or partial destruction of hospital by fire, flood, or other perils
    • Acts of God
  • Air or sea travel other than a fare-paying passenger on a licensed aircraft/vessel
  • Take-home medicine, immunizing agents and out-patient medicines, with the exception of intravenous chemotherapy medicine and those administered during an emergency treatment
  • Human blood products; human anti-rabies or anti-tetanus vaccine and other vaccines;
  • Any treatment in connection to pregnancy or resulting childbirth or miscarriage or complications therefrom (except if maternity benefits are covered in the Policy as indicated in the Schedule of Benefits)
  • Congenital Abnormalities
  • Neuro-developmental disorders, genetic disorders which may result to mental retardation, and other conditions which may require speech/physical and other related therapies
  • Developmental delay
  • Sexually-transmitted diseases, AIDS and AIDS-related complex or condition



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