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PRE-EXISTING CONDITION DEFINITION

MyCare is subject to a Pre-existing Condition Clause:

Any medical condition for which the Plan Member has experienced symptoms, received medication, advice or treatment in the 24 months prior the Effective Date of a Plan Member’s benefits, whether condition has been diagnosed or not and which in the opinion of Medical Director, is considered to be an underlying cause of, or directly related to, the medical condition which is the subject of the services.

 

Any medical condition which produced symptoms prior to the Plan Member’s Effective Date of any benefit that is added to existing benefits. These symptoms must be distinct and 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 a disorder; or

  • the symptoms would cause an ordinarily prudent person to seek medical diagnosis or treatment.

 

MyCare does not provide benefits for the following:

  • a Chronic or Congenital medical condition
  • a related medical condition
  • conditions relating to Alzheimer’s disease or severe burns

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