Pre-Existing Conditions (PECs) for Corporate Accounts
A. An illness or condition shall be considered pre-existing if before the Effective Date of the Agreement:
- Any professional advice or treatment was given for such illness or condition
- Such illness or condition was in any way evident to the member
- The pathogenesis of such illness or condition has already started (which the member may not be aware of).
B. PECs are not covered in the first year of coverage.
C. After the member has been continuously covered with Insular Health Care for 12 months and the agreement is renewed, the following provisions on PECs shall apply:
- PECs are covered provided that the PECs are not considered part of the “Permanent Exclusions to Health Care Coverage”, and that
- such PECs were declared by the member in the original application;
- such PECs are unknown to the member (without established medical history);
- Undeclared PECs with established medical history are excluded from coverage. However, said PECs may be evaluated for possible future consideration.
- In case an application is disapproved due to an adverse medical condition, an applicant may still avail of the Insular Health Care program by executing a “waiver” relinquishing or limiting coverage for the particular adverse condition/s (as stated in the provision on Enrollment / Approval of Application).
D. Examples of PECs: (inclusive of complications)
- All tumors and malignancies involving any body organ or system
- Endometriosis, Dysfunctional Uterine Bleeding
- Diseased tonsils requiring surgery
- Pathological abnormalities of the nasal septum and turbinates
- Thyroid Dysfunction/Goiter
- Sinus condition requiring surgery
- Asthma / Chronic Obstructive Pulmonary Disease
- Cirrhosis of the liver
- Anal Fistula
- Cholelithiasis / Cholecystitis
- Calculi of the urinary system
- Gastric or Duodenal Ulcer
- Hallux Valgus
- Diabetes Mellitus
- Collagen Disease / Auto Immune Disease
- Cardiovascular Disease
- Hormonal Dysfunction
- Seizure Disorder / Cerebral Insufficiency / Stroke
E. The following health conditions may be covered (either fully or up to certain amounts) provided pre-existing conditions of an account are likewise covered:
- Organ transplants and/or open-heart surgery / angioplasty and all services (e.g., coronary angiogram) related thereto (except organ donor services)
- AIDS and AIDS-related diseases except when sexually transmitted
- Congenital abnormalities and conditions are covered up to Php 25,000.
- Chronic glomerulonephritis, gullain-barre syndrome
- Scoliosis, Spinal Stenosis and Kyphosis are covered up to Php 25,000. For all other physical deformities, only consultations are covered.
- For Vitiligo and Psoriasis, only consultations are covered.
- Confirmatory Tests are covered up to the MBL provided the tests are done for valid diagnoses. Coverage shall be extended only up to the time the condition in question has been ruled in/out. Confirmatory tests are not applicable to health conditions listed under Permanent Exclusions.