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PRE-EXISTING CONDITION DEFINITION

A Pre-Existing Condition means:

  • Any medical condition for which a MyCare member is given medical care, treatment, services, medication, diagnosis, diagnostic services or consultation Twenty Four (24) months prior to the member’s effective date of coverage under the MyCare program or prior to the effective date of any benefit that is added to existing coverage; or
  • Any medical condition which produced symptoms Twenty Four (24) months prior to the member’s effective date of coverage under the program or prior to the effective date of any Benefit that is added to existing coverage. These symptoms must be distinct and significant enough to establish onset or manifestation by one of the following tests:
    • The symptoms would allow one learned in medicine to make a diagnosis of the disorder; or
    • The symptoms would cause an ordinarily prudent person to seek medical diagnosis or treatment.

 

MyCare does not provide benefits for the following:

  • chronic or congenital medical condition
  • conditions relating to Alzheimer’s disease or severe burns

 

Diagnosis: The identification of the nature of an Illness or other problem by examination of the symptoms as provided by a Physician, Specialist or Surgeon.

Diagnostic Services: Any kind of medical test performed to aid in the diagnosis or detection of disease or Injury to measure the progress or recovery from disease or Injury and to confirm the Member is free from disease.

Chronic Medical Condition: A disease, Sickness or Injury resulting in the Member having a medical condition which has at least one of the following characteristics: the condition continues indefinitely and has no known cure; the condition returns or is likely to return; the condition is permanent; the condition results in the Member needing to be rehabilitated or specially trained to cope with it; the condition results in the Member needing long term medical care which includes regular monitoring, consultation, check-ups, examinations or tests.

Congenital Medical Condition: A disease or defect existing from birth whether diagnosed or not.

Illness: Any unexpected and unforeseen condition or disease manifesting itself while this Program is in force.

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