PROVIDED BENEFITS UNDER THE PLAN
Pre-Existing Conditions - covered up to Maximum Limit of Benefit
DEFINITIONS AND CLARIFICATIONS OF IN-PATIENT SCHEDULE OF BENEFITS
TOTAL PAYABLE AMOUNT
In any case and for any reason the total payable amount should not exceed the Annual M.B.L. per member, per year of enrollment, removable any used amount of Out-patient M.B.L.
SPECIAL HOSPITAL SERVICES
This benefit covers the following
Operating room including anesthetics and oxygen and their administration;
X-rays examinations and echocardiography;
Laboratory examinations; and
Drugs, medicines, dressing and blood transfusions
Benefits for hospital services are to be allowed only when the individual is confined in the hospital as a registered bed patient. Charges for copies of hospital records, registration fees, newspapers, telephone calls, rent of radio or television and other similar charges are not covered.
This is the charge of the surgeon but not to exceed the amount corresponding to the particular surgery performed as determined by the SCHEDULE OF OPERATIONS
This benefit shall be payable even if no hospital confinement is involved, provided the surgery is performed by a legally qualified surgeon. Please see the Out-Patient Schedule of Benefits.
If two or more operative procedures are performed through a single incision, payment shall be made
only for that one operation for which the largest amount of benefit is payable.
If the surgical operation performed is not shown in the SCHEDULE OF OPERATIONS Polaris F.S. will determine the maximum benefit thereof.
Only one surgeon’s fee is payable, any other charges made by assistant surgeons are not payable.
If specialized procedures and treatment are required or provided, Polaris F.S. will pay up to the corresponding benefit or up to the limits stated in the SCHEDULE OF BENEFITS.
These are the daily charges of the attending physician for in-hospital visits or treatment calls to the individual during his confinement.
Doctor Calls benefit shall not be paid for
More than one treatment call on any calendar day; or
Treatment received for hospitalization which is not covered, according to the 'Limitation Schedule" or conditions resulting from any one of these; or
Treatment received on the day of any surgical operation and during convalescence there from the individual is entitled to receive benefit from such surgical operation, regardless of whether or not the benefit for the doctor calls is greater than the surgical benefit.
USE OF BENEFITS NOT IN ACCREDITED NETWORK
Use of the Benefits not in Accredited Network (hospitals, clinics, etc.) is reimbursed up to 75% of the actual cost and only if the member provides the medical bills and all the necessary documents, which the Administrator judges, within a period of 60 days.
Details-Terms & Conditions for Laboratories Tests
For scheduled laboratory test kindly first request for an approval by Polaris F.S. For Annual Physical Exam DOES NOT NEED APPROVAL by Polaris F.S.
Each batch of laboratory test can include more than one medical exam, under the strict condition that all the tests, in the same batch, are related with accredited doctor’s diagnosis.
Pre-Existing Conditions - covered up to Maximum Limit of Benefit
· ORAL EXAMINATION/DIAGNOSIS AS NEEDED
· ORAL PROPHYLAXIS EVERY SIX (6) MONTHS (TWICE A YEAR)
· GUM PROBLEM CONSULTATION AND TREATMENT PLANNING
· SIMPLE TOOTH EXTRACTION WHEN INDICATED (EXCLUDING IMPACTION)
· TEMPORARY FILLINGS WHEN INDICATED
· RE-CEMENTATION OF LOOSE JACKET CROWNS
· ADJUSTMENT OF DENTURES
· ORAL HYGIENE INSTRUCTION
· DENTAL HEALTH EDUCATION AND CONSULTATION
· ORTHODONTIC TREATMENT CONSULTATION
· TWO (2) SURFACES OF PERMANENT FILLINGS AND DENTAL SURGERY
· DESENSITIZATION OF HYPERSENSITIVE TEETH (2 TEETH ANNUALLY)
ANNUAL PHYSICAL EXAM (APE)
· PHYSICAL EXAMINATION
· CHEST X-RAY
· COMPLETE BLOOD COUNT (CBC)
· FECALYSIS (STOOL EXAM)
· ECG FOR 35 YEARS OLD AND ABOVVE
· PAPSMEAR FOR 35 YEARS OLD AND ABOVE
DEFINITIONS AND CLARIFICATIONS OF OUT-PATIENT SCHEDULE OF BENEFITS
TOTAL PAYABLE AMOUNT
In any case and for any reason the total payable amount should not exceed the Annual in-Patient M.B.L. which is Sub-amount of out-patient M.B.L. per member, per year of enrollment.
LIMITATIONS (CONCERNING INPATIENT AND/OR OUTPATIENT)
Expenses for any hospital confinement brought about by a cause or causes enumerated hereunder shall not be reimbursed
1. The hospital confinement and the charges and operation, if any, treatment, therapy, laboratory tests, etc. upon which a claim is based the continuation of such confinement during the entire period thereof not recommended and/or approved by a legally qualified physician or surgeon (M.D.).
Any outpatient care not recommended and/or approved by a legally qualified physician or surgeon (M.D.).
2. Charges, fees or expenses not mentioned in the Schedule of Benefits and the other provisions of this Policy.
3. Charges for room, board general nursing care and special hospital services which are not related to the diagnosis and treatment of the condition for which hospital confinement is required by the attending physician or surgeon.
4. Any doctor's fee except fees of the surgeon for performing any operation mentioned in the provisions of this group Policy.
5. Hospital confinement or for charges or surgical fees incurred which result from
a. Any bodily injury sustained by the insured which he is in or about any airplane or aerial device except while traveling as a fare-paying passenger in a passenger airplane which is
Operated by a regular passenger airline;
Operated by a duly licensed pilot; and
Traveling on a scheduled passenger trip over an established passenger route.
b. Any form disability, injury, sickness, sustained or contracted in riot, civil commotion, insurrection, or war, or service in any military, naval or air force of any country while such country is engaged in war, or police duty and a member of any military, naval or air organization.
c. Any bodily injury self-inflicted intentionally whether the insured is sane or insane at the time of commission.
d. Any dental treatment or surgery unless it is mentioned in the “Dental Benefits” of this Policy and except] dental operation resulting from an injury sustained by the member in an accident.
e. Treatment of any mental and nervous disease or disorder.
f. Any treatment, which is purely for physical therapy [(except of cases mentioned on outpatient benefits in this policy),] or for recuperative purposes or confinement in a hospital or sanatorium or convalescent home for rest cure.
g. Any treatment for tuberculosis, except surgical operations for removal of diseased portions of organs afflicted with tuberculosis, e.g. caecum, kidney, spine.
h. Any treatment or surgical operations for congenital deformities or defects, such as harelip, clubfoot, heart defect, birthmark, abnormal bone or muscular growth, cerebral palsy, and others.
i. Any confinement for physical checkup or diagnostic purposes.
j. Any communicable disease in epidemic proportion as declared by the government and any form of venereal disease.
k. Any cosmetic and/or plastic surgery except for treatment of injury sustained because of an accident, which is absolutely necessary in accordance with the opinion of the physician.
l. Sterilization of either sex, such as castration, vasectomy, tubectomy, and tubal ligation.
m. Any process in determining the refractive errors of the eyes and their correction by glasses.
n. Sex change surgery and all the charges/expenses that may be incurred by this.
6. Hospital confinement for charges or surgical fees incurred which result from pregnancy, resulting childbirth, miscarriage or caesarian section, prenatal or postnatal care.
7. Any charges and or expenses which have been already reimbursed by any insurer, private or public.
8. Any hospital confinement or charges incurred for the treatment of Acquired immuno Deficiency Syndrome (AIDS) or charges incurred for the examination immunization, and detection of human deficiency of human immuno deficiency virus and other related viruses.
9. Any hospital confinement for sickness or injuries incurred in the commission of criminal acts.
10. Use of Benefits not in Accredited Network
Use of the Benefits not in Accredited Network (Doctors, Specialists, laboratories, etc.) is reimbursed up to 75% of the actual cost and only if the member provides the medical bills and all the necessary documents, which the Administrator judges, within a period of 60 days