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The Pre-Existing Condition (PEC) for illnesses coverage given on the first year of health card membership is one of the advantages of
Maxicare. And if I remember correctly, they are one of the first who offered this benefit of including dreaded and non-dreaded disease
coverage in the HMO industry. After my review against another popular health card company like the VIP Program of Medicard
compared to MyMaxicare brand of Maxicare which are both for Individual and Family membership, the latter has less limitations. If
Medicard limits you up to ten out-patient consultations for P300 per consultation and out-patient laboratory and diagnostic tests up to
eighty percent or a maximum of P10,000 per year, Maxicare allows to avail of the same services without any similar cap provided you
do not exceed the maximum benefit limit of your plan. Also, MaxiPlus a brand of Maxicare that caters to corporate accounts
immediately covers pre-existing conditions on the first year for a minimum ten members/employees of compared to Medicard Classic
and Prime variants of their SME Plan which requires at least above fifty members.
Such Dreaded Conditions are as follows, but not limited to:
All malignancies (including indicated chemotheraphy or radiotheraphy)
Arthritis
Blood Dyscrasias such as but not limited to Leukemia, Idiopathic Thrombocytopenic Purpura
Chronic Cardiovascular Diseases and its complications such as but not limited to Uncontrolled Hypertension of whatever
etiology, Aortic Dissection, Abdominal Aortic Aneurysm, Myocardial infarction, Cardiac Arrest, Congestive Heart Failure, Cardiac
Arrhythmia, Cardiac Tamponade, Coronary Artery Disease, Cardiomyopathies and Valvular Heart Disease, Aortic Dissection,
Abdominal Aortic Aneurysm and Peripheral Vascular Disease and its complications such as but not limited to Buergers Disease
Cataract and Glaucoma
Cerebrovascular Diseases such as but not limited to Stroke, Cerebral, Cerebellar, Thrombosis, Embolism and Ruptured
aneurysm and all Intracranial Hemorrhage and related conditions
Cholecystolithiasis and Choledocholithiasis
Chronic Endocrine Disorders and its complications such as but not limited to Dyslipidemia, Obesity, Diabetes Mellitus,
Hormonal Dysfunctions excluding surgical treatment/procedures for obesity
Chronic Gastrointestinal Diseases such as but not limited to Irritable Bowel Syndrome, Crohns disease
Chronic Genito-urinary Disorders
Chronic Kidney Disease/Failure & its complications
Chronic Liver Parenchymal Diseases such as but not limited to Liver Cirrhosis, Chronic hepatitis, Non-alcoholic Fatty Liver
Disease/Steatohepatisis (NASH)
Chronic Pulmonary Diseases such as but not limited to Bronchial Asthma, Chronic Obstructive Pulmonary Disease (COPD),
emphysema, and other chronic lung disease
Collagen Vascular/Connective Tissue/Immunologic Disorders such as but not limited to Systemic Lupus Erythematosus and its
complications
Complications of immuno-compromised clinical conditions except HIV/AIDS
Extrapulmonary Tuberculosis including Potts disease and Multi-Drug Resistance Case (MDR) case
Multiple Organ Failure
Muscular Dystrophies such as but not limited to Duchenne, Becker, limb girdle, facioscapulohumeral, myotonic,
oculopharyngeal, distal, and Emery-Dreifuss
Neuro-surgical interventions and/or major neurological diseases such as but not limited to
Poliomyelitis/Meningitis/Encephalitides, Demyelinating Neurologic diseases and its complications/sequelae and Peripheral Nervous
System Disorders/Diseases
Thyroid Dysfunctions due to disease of thyroid such as but not limited to Hypothyroidism and Hyperthyroidism
Any illness other than above which would require Critical Care/Intensive Care Unit (ICU) Confinement
All complications resulting from above list of conditions
Such Non-Dreaded Conditions are as follows, but not limited to:
All benign tumors
Anal Fistulae
Cervical Polyps (if benign biopsy)
Conjunctivitis (except chemical, complicated)
Endometrioses/Controlled Dysfunctional Uterine Bleeding (except if caused by uterine malignancies)
Hemorrhoids
Hepatitis A
Gastritis, Duodenitis or Uncomplicated Gastric / Duodenal Ulcer
Inactive Pulmonary Tuberculosis
Migraine
Non-surgical Ear-Nose-Throat conditions such as but not limited to Sinusitis, Rhinitis, Tonsillopharyngitis, Laryngitis, Parotitis,
Otitis Media, Otitis Externa and Surgical Ear-Nose-Throat conditions such as but not limited to Tonsillectomy, Nasal Polypectomy,
Tympanoplasty, Sialolithotomy, Sialodochoplasty.
Non-Toxic Goiter (if uncomplicated)
Ovarian cysts Uncomplicated Cholecystitis, Cholelithiasis
Uncomplicated Hernias (Congenital Hernia will have coverage as listed in the Congenital Clause)
Uncomplicated Hypertension
Uncomplicated Urinary Tract Infection, Stones/Calculi
Urinary Incontinence

PRE-EXISTING CONDITION EXPLAINED

Examples of PECs are, but not limited to:

Pre-existing condition (PEC) - an illness or condition shall be

considered pre-existing if before the Effective Date of the
Agreement:

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1. Any professional advice or treatment was given for such

illness or condition prior to effective date of coverage.

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2. Such illness or condition was in any way evident to the

member prior to effective date of coverage.
3. The pathogenesis of such illness or condition has
already started prior to effective date of coverage.
After the member has been continuously covered for 12
months and the agreement is renewed, the provision on
PEC excluded from I-Care coverage shall be waived,
provided that such PEC is not considered part of the
"Permanent Exclusions to Health Care Coverage" and
that such PEC was disclosed by the member in the
original application.
Explanation:
Any illness, disease, or adverse health condition which a member
has upon enrollment, whether he is aware of it or not, is not
covered during the first year of membership. Upon renewal with ICare the same may be covered subject to evaluation.

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Hernias
All tumors and malignancies involving any body organ or
system
Endometriosis, Dysfunctional Uterine Bleeding
Hemorrhoids
Diseased tonsils requiring surgery
Pathological abnormalities of the nasal septum and
turbinates
Thyroid Dysfunction /Goiter
Cataract
Sinus condition requiring surgery
Asthma /Chronic Obstructive Pulmonary Disease
Liver Cirrhosis
Tuberculosis
Anal Fistula
Cholelithiasis /Cholecystitis
Calculi of the urinary system
Gastric or Duodenal Ulcer
Hallux Valgus
Diabetes Mellitus
Hypertension
Collagen Disease /Auto Immune Disease
Cardiovascular Disease
Hormonal Dysfunction
Seizure Disorder /Cerebral Insufficiency /Stroke

What are covered and not covered for PhilCares prepaid consultation cards?
Pre-existing conditions is covered. The only exceptions are maternity-related cases and cases related to all forms of behavioural
disorders, developmental or psychiatric disorders and psychosomatic illnesses whether acquired or congenital.
What are the non-covered illnesses and diseases for emergency and hospitalization health cards?
The following are the diseases and conditions in which the emergency and hospitalization health cards cannot be used. No health care
benefits shall be paid for the following services, procedures or conditions. This is not a complete list of non-covered illnesses and
diseases. PhilCare reserves the right to have the final interpretation of all definition, provisions and articles relating to the health cards.
A. List of diseases not covered but not limited to:
Anal fistulae / Asthma / Auto immune conditions / Cardiovascular diseases / Calculi of the urinary system / Cataracts / Sinus conditions
requiring surgery / Cerebrovascular diseases / Cholecystitis/cholelithiasis / Chronic skin conditions / Cirrhosis of the liver / Collagen
disease / Degenerative conditions / Diabetes mellitus / Diseased tonsils requiring surgery / Endometriosis / Epilepsy / Gastric or
duodenal ulcer / Hallux valgus / Hemorrhoids / Hernia / HIV/AIDS / Hypertension / Neurologic conditions / Obesity, dyslipidemia and
other metabolic conditions / Pathological abnormalities of nasal septum and turbinates / Thyroid conditions / Tuberculosis / Tumors,
whether benign or malignant of all organs and organ systems, including malignancies of the blood or bone marrow / Non-emergency
case during point of availment / Pre-existing and congenital conditions Pre-existing and congenital conditions An illness or condition
shall be considered pre-existing if, prior to the effective date of health coverage the pathogenesis of such illness or condition has
started, whether or not the member is aware of such illness or condition.
B. General exclusions applicable to health care coverage.
Care by Non-Accredited Physician in either Accredited or Non-Accredited Hospitals
Care by an Accredited Physician in Non-Accredited Hospital
Additional hospital charges and professional fees resulting from taking a room category higher than that specified in the
members benefit schedule
Additional personal comfort items (e.g., telephone and television, additional food trays, admission kit and such other items of
the same nature)
Procurement or use of corrective appliances, prosthesis, artificial aids and durable equipment such as but not limited to the
following: stents, prolene mesh, pins, screws, plates, wires, VP shunt, clips, hearing aids, intraocular lens, eyeglasses, contact
lenses, balloons, valves; braces, crutches , pace maker
All pregnancy-related conditions and complications relating to mother and unborn child, requiring medical and surgical care,
regardless of time/date of occurrence (during the actual time of pregnancy or thereafter)
All sexually transmitted diseases
Blood screening, blood typing, cross-matching for potential donors in relation to blood donation and transfusion
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 those that are not generally accepted as standard medical
treatment by the medical profession, that may include but is not limited to Chiropractic Services, Acupuncture, and
Reflexology;
Allergens used for hypersensitivity testing regardless if administered as an out patient or in patient procedure
Treatment of injuries or illnesses resulting from the voluntary participation of a member in any hazardous sport or activity that
may include but is not limited to: bungee jumping, scuba diving, hang-gliding, mountain climbing, parachuting, surfing, rock
climbing, airsoft, paintballing, boxing, wrestling, martial arts (such as taekwondo, judo, karate, etc.), gymnastics, motor sports
(drag racing, jet skiing), wakeboarding, water skiing and all such other voluntary activities which pose a grave danger to life
and limb.
Treatment of injuries or illnesses due to military service or suffered under conditions of war
Treatment of injuries or illnesses wherein the care or reimbursement of services is provided by law or a government program,
up to the stipulated limits
Treatment of any injury which is proven to be attributable to the members own misconduct such as negligence, intemperate
use of drugs or alcoholic liquor, direct or indirect participation in the commission of a crime, whether consummated or not,
violation of a law or ordinance, unnecessary exposure to imminent danger or hazard to health, including fireworks related
injuries, infections or complications as a result of tattoos and piercing of the ear or any body part, whether self-inflicted or done
by a third party, or attempted suicide or self-destruction, whether sane or insane
All cases of assault perpetrated by the Member including domestic violence which result in harm or injury to the Member
perpetrator
Vaccines, whether elective or administered during an emergency treatment are not covered
In-patient pain management necessitating specialized pain management team and/or the use of specialize equipments
All diseases declared as epidemic by the Department of Health (DOH) and any other recognized health agencies
All hospital charges and professional fees incurred after the day and time the discharge from hospital has been duly
authorized
All procedures and/ or services considered screening
Pre-existing and congenital anomalies and conditions, and their complications
Cosmetic procedure and surgery and oral surgery solely for the purpose of beautification except reconstructive surgery to treat
functional defects due to disease or accidental injury

MAXICARE PRE EXISTING NON DREADED AND DREADED CONDITIONS

PRE EXISTING NON DREADED AND DREADED CONDITIONS*
* Applies to Family and Individual Accounts
* These conditions are waived under Maxicare's Corporate Plans
NON DREADED CONDITIONS are as follows, but not
limited to:
1. All tumors (benign masses)
2. Anal Fistulae
3. Arthritis
4. Bronchial Asthma
5. Buerghers Disease
6. Cataract and Glaucoma
7. Cholecystitis, Cholelithiasis, Cholecystolithiasis and
Choledocholithiasis
8. Ear-Nose-Throat conditions requiring surgery (except
cancers which are considered dreaded conditions)
9. Endometrioses/Dysfunctional Uterine Bleeding (except
if caused by uterine malignancies)
10. Gastric or Duodenal Ulcers
11. Hallux valgus
12. Hemorrhoids
13. Hernias (Congenital Hernia will have coverage as
listed in the Congenital Clause)
14. Migraine
15. Muscular Dystrophies (Duchenne, Becker, limb girdle,
facioscapsulohumeral, myotonic, oculopharyngeal,
distal, and Emery-Dreifuss)
16. Ovarian cysts (except Ovarian Malignancies)
17. Peripheral Nervous System Diseases (except Multiple
Sclerosis and GBS)
18. Tuberculosis (Pulmonary or Extrapulmonary including
Potts disease)
19. Uncomplicated Hypertension

20. Urinary Tract Stones/Calculi

21. All complications resulting from above list of
conditions

DREADED CONDITIONS are as follows, but not limited

to:
1. All cancers (malignant masses) including carcinoma in
situ and related conditions
2. Blood Dyscrasias (Leukemia, Idiopathic
Thrombocytopenic Purpura, etc)
3. Central Nervous System Infections
(Poliomyelitis/Meningitis/Encephalitis)
4. Cerebrovascular Accident (Stroke, Cerebral, Cerebellar
and all Intracranial Hemorrhage) and related
conditions
5. Chronic Cardiovascular Diseases (Complicated
Hypertension and related conditions, Aortic
Dissection, Abdominal Aortic Aneurysm, etc.)
6. Chronic Endocrine Disorders and their complications
(Dyslipidemia, Impaired Fasting Glucose, Impaired
Glucose Tolerance, Obesity, Diabetes Mellitus,
Hormonal Dysfunctions, etc.) Excluding surgical
treatment/procedures for obesity-exclusion
7. Chronic Gastrointestinal Diseases (ex. Irritable Bowel
Syndrome, Crohns disease)

8. Chronic Genito-urinary Disorders

9. Chronic Kidney Disease/Failure
10. Chronic Liver Parenchymal Diseases (Liver Cirrhosis,
Chronic hepatitis, etc)
11. Chronic Pulmonary Diseases except asthma (COPD,
emphysema, and other chronic lung disease)
12. Collagen-Vascular/Connective Tissue/ Immunologic
Disorders
13. Complications of immuno-compromised state (except
HIV/AIDS)
14. Injuries incurred prior to and up to one year from date
of effectivity and their subsequent complications

15. Systemic Lupus Erythematosus including Lupus

Nephritis
16. Thyroid conditions (Hypothyroidism, Hyperthyroidism)
except Thyroid masses
17. Valvular Heart Diseases (except for surgeries for
valve correction, ie valvuloplasty)
18. Any illness other than above which would require
Intensive Care Unit Confinement
19. All complications resulting from above list of
conditions