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proMediCare
(Individual)
Policy Wordings
Please read this insurance Policy carefully
to ensure that you understand the terms
and conditions and that this Policy meets
your requirements. If there are any changes
that may affect the insurance cover
provided, please notify us immediately.
Liberty Insurance Pte Ltd (Registration No. 199002791D) │ GST Registration No. M2-0093571-3
51 Club Street #03-00 Liberty House Singapore 069428 │ Tel: 1800-LIBERTY (542 3789)│ Fax: (+65) 6223 6434
03/2014
Page 1 of 14
1.
Cover
5.
Additions of Covered Persons
In consideration of the payment of the
Family members of the Insured who are
premiums, the Company agrees to indemnify
eligible to be covered shall from time to time
or compensate the Insured, details of which
be included into the policy if
are set out in the Proposal Form and Policy
a)
the Insured requests such inclusion
b)
upon evidence of insurability
Schedule, in the manner and extent of the
Schedule of Benefits selected for hospital
and surgical expenses in respect of illnesses
satisfactory to the terms and standards
or injuries incurred during the Period of
of acceptability by the Company
Insurance.
c)
payment of required premium
The Policy Schedule, Conditions, Exclusions
and Endorsements and Memoranda shall be
6.
Successor Insured
read together as one contract and any word
If the Insured dies while the Policy is in force,
or expression to which a specific meaning
the Insured's spouse who is a Covered
has been attached in any part shall bear the
Person shall automatically become the
same meaning wherever it appears.
Insured and all future references to the
Insured shall thereafter mean the spouse.
The Proposal made to the Company by the
in connection with this insurance shall be the
basis of and shall form part of this contract.
7.
Definitions
a)
“Accident” shall mean an event of
violent, accidental, external and visible
2.
3.
Geographical Cover
nature which shall independently of any
The benefits of the Policy (Scheme) are
other cause be the sole cause of bodily
worldwide, 24 hours.
injury
Policy Period
b)
“Illness” shall mean a physical
Insurance shall commence from the date
condition, marked by a pathological
specified on the Policy Schedule.
deviation from the normal healthy state
The Plan is an annual contract, renewable
c)
“lnjury” shall mean bodily injury
each year on the due date, subject to the
caused by force or violent, external and
option and renewal terms offered by the
visible means
Company.
d)
4.
“Hospital” shall mean only an
Eligible Persons
establishment duly constituted and
Persons eligible to be covered in the
registered as a hospital for the care and
Scheme are:
treatment of sick and injured persons,
a)
Insured and legal spouse below 65
as bed-paying patients, and which
years old
i)
Children (unmarried and unemployed)
ii)
has facilities for diagnosis and
major surgery
b)
between 15 days old and below 18
birthday
th
provides 24 hours a day nursing
services by registered graduate
nurses
iii) is under the supervision of a
physician, and
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iv) is not primarily a nature cure clinic,
based on normal medically accepted
a place for alcoholics or drugs
physical or pathological development of
addicts, a nursing, rest or
the illness or illnesses
convalescent home or similar
establishment, or home for the
j)
aged
“Waiting Period” shall mean the
duration of time between the beginning
of an insured person’s disability and the
e)
“Physician” or “Surgeon” shall mean
commencement of the insurance, and is
only a person qualified by degree in
applied only when the person is first
Western Medicine and legally licensed
insured. This shall not be applicable
and duly qualified to practice medicine
after the first year of insurance
and surgery authorised in the
geographical area of his practice
k)
“Maximum Each Injury or lllness”
shall mean all claims arising from the
f)
“Physician's Visit” shall mean a
same cause including any and all
physician's visit to the hospital bedside
complications therefrom except that if
of an Insured Person for treatment of a
the employee or dependant completely
non-surgical disability
recovers after a period of 14 clear days
continuously following the latest
g)
“Surgical Fees” shall mean all of the
discharge from hospital any subsequent
fees payable to Surgeon(s) for the
treatment shall be considered a new
operations performed including the
injury or illness
surgeon's visits to the patient, presurgical assessment and normal post
surgical care up to a maximum of 91
8.
Description of Benefits
a)
Hospital Room and Board-charges for
days from the date of operation or
room and board accommodation
discharge from hospital
inclusive of meals and general nursing
services for each day of confinement as
h)
“Dependants” shall mean the insured
a patient in the hospital
employee's legal spouse aged under 65
and all unmarried and unemployed
children who are aged between 15 days
th
b)
Intensive Care Unit-payable when
necessitated by an intensive care phase
old and below 18 birthday. For those in
of critical illness or injury subject to a
full-time tertiary institutions, the age limit
maximum of 20 continuous days per
th
will be extended to their 24 birthday
any one disability. The number of days
for which charges incurred are payable
i)
“Pre-Existing lllness” shall mean any
in respect of daily room and board and
condition which existed or have
ward charges for intensive care unit
developed symptoms or there exist
shall not in the aggregate exceed the
manifestation of illness or medical
maximum number of days provided
treatment have been sought on drugs
under hospital room and board benefits
and medicine have been prescribed
before the effective date of cover in
respect of any Insured Person of which
the Insured Person was aware or
should reasonably have been aware or
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c)
Hospital Miscellaneous Services-
e)
Anesthetist Fees-charges will be
hospital charges for operating room x-
reimbursed at up to 25% of the surgical
ray examinations medicines dressings
reimbursement. Eligible anesthetist fees
ordinary splints and plaster casts
of less than S$75 are covered in full
electrocardiograms basal metabolism
tests laboratory tests intravenous
f)
Diagnostic Services-charges for
infusions blood transfusions
specialist's opinion or advice or for
physiotherapy and other customary
diagnostic x-rays and laboratory
services rendered or supplied during the
examinations or tests which are
confinement period
recommended by a licensed physician
because of illness or injury incurred
d)
Surgical Fees-fees actually charged for
within 91 days prior to hospital
the operation by the surgeon including
confinement or surgical operation.
the surgeon's hospital visit to the patient
Payment will not be made for clinical
and post operative care up to a
treatments (including medications and
maximum of 91 days from the date of
subsequent consultations after an
operation. The maximum level payable
illness is diagnosed), or if the insured
as benefit is assessed according to the
employee or dependant is not
amount provided by the chosen Plan in
subsequently hospitalized or surgically
relation to the Schedule of Surgical
treated after such consultations or
Benefits, depending on the nature of
examinations
operation performed. Day surgery is
also subject to the usual interpretation
g)
In-Hospital Physician's Visits-fees
charged by the physician for treatment
If two or more procedures are
or visits made to a patient, for whom a
performed through a single incision,
full day's room charge is made by the
reimbursement for charges for all such
hospital for non-surgical treatment
procedures shall not exceed the amount
specified for the one surgical procedure
h)
Post-Hospitalization Treatment-
performed for which the largest amount
expenses for follow-up treatment of the
is payable.
specific medical condition for which the
Insured Person received in-hospital
If surgery for a disability is performed in
treatment by the same physician up to a
various stages over a period of time,
period of 91 days immediately following
then all surgical fees charged in the
discharge from hospital
various stages will be aggregated in
computing the maximum amount
i)
Emergency Outpatient Accidental
payable under the Schedule of Surgical
Treatment-charges for services and
Benefits.
medical supplies provided by the
hospital or clinic for emergency
Eligible surgical fees below S$500 are
treatment of an injury as a result of an
covered in full.
accident and received as an outpatient
within 24 hours after the accident. When
such emergency treatment for an injury
is obtained from Registered Chinese
bone-setter, charges up to S$250 are
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covered. Eligible expenses incurred
HIV positive, and any communicable
thereafter for follow-up treatment by the
diseases requiring isolation or
same medical practitioner, will be
quarantine by law
reimbursed up to 31 days from the date
of the accident
f)
treatment for injuries or diseases arising
from or consequent upon war (whether
j)
Ambulance Fees-charges for
declared or undeclared), riot, civil
ambulance services (inclusive of
commotion, civil war, invasion, acts of
charges for attending medical personnel)
foreign enemies, hostilities, rebellion,
to and/or fro from the hospital. Payment
mutiny, revolution, insurrection or
will not be made if the insured employee
military or usurped power confiscation
or dependant is not hospitalized
or nationalization by or under the order
of any government or public or local
9.
Exclusions
authority nuclear energy (nuclear
The following treatments directly or indirectly,
reactions radiation contamination) illegal
conditions, activities, items, and their related
act and full-time service in any of the
expenses and any complications relating
uniform groups except reservist duty or
thereto are excluded from this insurance and
training
the Company shall not be liable for:
a)
pre-existing illness or injuries contracted
g)
before the inception date of this Policy
routine medical examination (including
vaccinations, the issue of medical
certificates and attestations), routine
b)
illnesses which commence within a
eye and ear examinations, refractive
period of 30 days, except for accidental
errors of the eyes, cosmetic or plastic
injuries (this waiting period is applied
surgery and the provision of appliances
the first time the person is insured)
including spectacles, special braces,
hearing aids, lenses, wheelchairs and
c)
charges which are not for actual,
any prosthetic devices
necessary and reasonable expenses
incurred in the treatment of the illness or
h)
injury
dental care and treatment (including
oral surgeries) except emergency
treatment to sound natural teeth
d)
outpatient treatment not related to in-
damaged during an accident
patient treatment or day surgery, except
as a result of an accident
i)
pregnancy including childbirth,
caesarean operation, abortion, ectopic
e)
costs resulting from abuse of drugs or
pregnancy, hydatidiform mole,
alcohol, self-inflicted injuries, criminal
miscarriage (except as a result of an
act of the Insured Person and sexually
accident), treatments against infertility,
transmitted diseases, or treatment
sterilization and contraception
which in anyway arises from, is
attributable to, or is consequential upon
j)
treatments relating to birth defects,
Acquired Immune Deficiency Syndrome
congenital abnormalities and hereditary
(AIDS), AIDS related Complex
conditions
Syndrome (ARCS) and all diseases
caused by and/or related to the virus
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k)
charges for private nursing, consultation
The liability of this policy shall cease on the
with a general practitioner, routine
last day of the cover for the insured person
health checks, precautionary services,
or dependant.
acupuncture and inoculation and
charges for telephone, television,
11. Cancelation
newspapers and other ineligible non-
This policy may be cancelled by either the
medical items whilst as an in-patient
Company or the Insured by giving 30 days
notice in writing. No premium will be
l)
services or treatment of any institution
refunded if claims have already been made
that is mainly long term care facility like
by the Insured.
convalescent and nursing homes,
nature cure clinics, spa, hydro-clinic or
Pro-rata refund of premium will be made to
sanatorium and establishments that
the Insured if the policy is canceled by the
provides only incidental or limited
Company during its currency.
hospital services
Cancelation shall be without prejudice to any
m) treatments arising from any geriatric,
psycho-geriatric, psychiatric conditions
claim originating prior to the effective date of
cancelation.
or physiotherapy
If the Insured terminates the policy, the
n)
acquisition of any organ itself and all
premium charged will be based on the
expenses incurred by the donor
following:
o)
treatment by a family member
1 month
3 months rate
p)
treatment that is not scientifically/
2 months
4 months rate
medically recognized
3 months
6 months rate
4 & 5 months
7 months rate
expenses recoverable from a third party,
6 & 7 months
9 months rate
including Workmen's Compensation
8 months
q)
Period of Cover
Premium Charged
1 full year premium
Insurance or Social Security
Organization
12. Premium Payment
This policy is deemed to have lapsed
r)
treatment for obesity, weight reduction
automatically if no premium is received
and weight improvement
within 30 days from the commencement or
renewal date of the policy. Notwithstanding
10. Termination of Cover
the termination of the policy, the Insured
Cover ceases for the insured persons:
shall be liable for the payment of all
a)
on the date of termination of the policy
premiums due while the policy has been in
b)
on the renewal date of this Policy next
force including the grace period.
occurring after a insured person ceases
to be eligible as defined herein
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13. Notice and Proof of Claim
17. Alterations
Written notice of claim must be given to the
No alteration to this Policy shall be valid
Company within 31 days after occurrence of
unless authorized and endorsed by the
any hospitalization or surgery covered by the
Company.
Scheme.
18. Contracts (Rights of Third Parties) Act
The Company upon receipt of such notice
2001
shall furnish the Insured such forms as are
A person who is not a party to this Policy
usually required for the filing of proof of
Contract shall have no right under the
illness or injury. Affirmative proof of illness or
Contracts (Rights of Third Parties) Act 2001
injury must be submitted to the Company at
to enforce any of its terms.
the expense of the Claimant.
19. Non-Guaranteed Premium
14. Currency Exchange Rates
Premiums payable for this coverage are not
In the event of hospitalization outside
guaranteed and may be revised at policy
Singapore, bills rendered in terms of
renewal at the full discretion of the Company.
currency other than Singapore dollars, will
be converted to the currency of Singapore
20. Change of Occupations/Country of
dollars on the basis of quoted exchange rate
Residence
(open market rate if a free market, official
In the event of a change in
rate if not a free market) in effect on the date
occupation/country of residence of the
of discharge from hospital of the Claimant.
Insured, the Insured shall notify the
Company in writing of the new occupation/
15. Other Insurance
country of residence. The Company shall
If an employee or dependant included in this
increase or reduce the premium rates
Scheme carries other insurance covering
according to the risk classification for the
injury or illness that is also covered by this
new occupation/country of residence.
policy, the Claimant must inform the
Company of such duplicate cover at the time
21. Right to Return Policy
of claiming. The total benefit payable for
In the event that the Insured is not satisfied
each claim, for which more than one
with the Policy for any reason, it may be
insurance policy is applicable, shall not
returned to the Company for cancelation
exceed the total of eligible expenses
within fourteen days of receipt and
incurred.
a)
any premium paid or billed will be
refunded in full
16. Legal Proceedings
The parties hereto agree that the Laws of
b)
Singapore shall govern and control in the
this Policy is deem to be voided from
inception and
event of any conflict or dispute between the
parties with regard to the Plan and that the
c)
the Company shall not be liable for any
parties submit themselves to the exclusive
claims occurring prior to the return of
venue and jurisdiction of the courts of
the Policy
Singapore for the resolution of any conflict or
dispute.
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This condition shall however only apply to
first instalment and thereafter from
policies issued in the name of the Insured
the agreed dates on which the
Person. This Policy document is deemed to
subsequent instalments become
have been received by the Insured 3 days
payable and
after the Company has dispatched it.
ii)
EFFECTIVE date of coverage of
any Endorsement issued under
22. Premium Warranty Clause
such Policy for the first instalment
Notwithstanding anything herein contained to
and thereafter from the agreed
the contrary and subject only and without
dates on which the subsequent
prejudice to Clause 2 hereinafter set out it is
instalments become payable
hereby declared and agreed that it is a
OR
condition precedent to liability under this
c)
when the period of insurance is LESS
Policy, Renewal Certificate Endorsement or
than SIXTY (60) days, within the period
Cover Note that any premium due must be
of insurance specified in the Policy
paid and actually received in full by the
Endorsement Renewal Certificate or
Company, the registered broker or registered
Cover Note
agent through whom this policy was effected
a)
When the period of insurance is 60 days
In the event any of the abovementioned
or more within SIXTY (60) days from the
premium is not paid in full to the company,
i)
INCEPTION date of the coverage
registered broker or registered agent as
under the Policy Renewal
described above in the manner and within
Certificate or Cover Note or
the time stipulated above (the premium
EFFECTIVE date of the coverage
warranty period) the cover under this Policy
stated on each Endorsement if any
Renewal Endorsement or Cover note shall
issued under the Policy Renewal
deemed to have terminated from the expiry
Certificate or Cover Note when the
of the premium warranty period and the
effective date of coverage stated
company shall be discharged from all liability
on the Endorsement is on or after
therefrom but without prejudice to any
the issuance date of the
liability incurred before that date and the
Endorsement or
company will be entitled to a pro-rata time on
ii)
iii) ISSUANCE date of each
risk premium subject to a minimum of S$25.
Endorsement if any issued under
the Policy Renewal Certificate or
The limits for any surgical procedure will be
date of coverage under the
determined by the amounts shown herein. If
Endorsement is before the
the operation is not shown in this table, the
issuance date
Company reserves the right to determine the
OR
b)
23. Schedule of Surgical Benefits
Cover Note where the effective
limit for such operation which is consistent
where the total premium under any
with the amounts listed herein; taking into
single Policy exceeds S$50,000 and the
account the nature and complexity of the
Company has allowed payment of that
procedure involved and the policy exclusions
premium by instalments within SIXTY
and/or other restrictions applicable.
(60) days from the
i)
INCEPTION date of the cover
under the Policy Renewal
Certificate or Cover Note for the
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Description of Surgical
Surg %
Description of Surgical
Benefits
Benefits
1.
2.
Abdomen
Abscess

Appendectomy
50
Incision and drainage of

Biopsy of pancreas
45
abscess, boil, furuncle or

Cholecystotomy,
60
carbuncles; one or more

drainage or removal of
calculus/gall stones

Cholecystotomy,
Colon resection, partial

65
50
3.

Colon resection, total
100

Gastric or duodenal
75

closure of
single, including
75
closure
15

Hip joints
100

Leg, through tibia and
55
diagnostic
fibula

30
duodenoscopy,

60
exploration or foreign
4.

Gut, resection of
100

Gastrectomy, total or
100
Wrist, distal to
Biopsy of breasts,
Excision of cyst, fibro-
75
breast tissue, duct
lobectomy
lesion or nipple lesions
100
acute

Mastectomy, simple
50

Mastectomy, radical,
75
Laparotomy, exploratory
55
including breast,

Liver Biopsy
20
pectoral muscles and

Pancreatectomy, total
75
axilliary lymph nodes,
or sub-total
of spleen
25
benign tumor, aberrant
of liver) partial
Splenectomy, removal
20
adenoma or other


30
incisional

stomach
Intestinal obstruction,
75
Breasts

partial resection of

Thigh, between hip and
metacarpals
body removal)
Hepatectomy (resection
100
knee

into the stomach/with

Shoulder joint or blade
(interscapula-thoracic)
operative
Gastrostomy (opening
20
neurectomies with direct
duodenoscopy,

Fingers, thumbs or toes;
any joint or phalanx,
Gastroscopy and/or
55
primary or secondary,
Gastro jejunostomy

Arm, upper, forearm,
ulcer, perforation,
Gastroscopy and/or
20
entire hand or foot


Requiring
Amputation of
colostomy
Gastro-enterostmy/
5
hospitalization
with or without

Simple, not requiring
hospitalization
removal of gall bladder

Surg %
unilateral
65
5.
Chest

Artificial pneumothorax,
12
induction of Initial
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Description of Surgical
Surg %
Benefits

Description of Surgical
Refills, each but not

5
more than six

Bronchoscopy,
20
7.
Dislocations and Joints

30
100

Arthroscopy
20

Hip dislocation, closed
65
portion of chest walls)


Cardiac heart, requiring
or open, reduction

100
with uncomplicated soft
with bypass
tissue closure,
100
Lobectomy, total or sub-

90
Hepatectomy partial
75
tissue closure,
manipulative reduction

resection or enacleation
closed or open
multiple
reduction with or without
90
Pericardium, opening

75
and draining
Pneumonectomy, total
100

Thoracoplasty,
100

Thoracotomy,

Thoracotomy, removal

12
of pus, tapping
6.
Circulatory System

Intra-abdominal aortic
o
simple
50
o
radical
80

Myringotomy for otitis
15
media
Removal of adenoids
10
alone
ilea-femoral)
aneurysm-transverse
Mastoidectomy
65

of aorta/with or without
Intrathoracic aortic
100
Myringoplasty
(circumscribed dilation

Fenestration, one or

100
aneurysm
20
both sides

excepted
Ear operation for
epithelioma of
50
exploratory
35
Ear

complete
Wrist dislocation, closed
or open reduction
8.

35
skeletal fixation
or portion of

Tarsal bone dislocation,
of lesion, single or
Lung, complete removal
30
uncomplicated soft
Lobectomy, wedge

Shoulder dislocation,
open, with
total/segmental

40
manipulative reduction
abdominal aneurysm

Knee dislocation, open
sutures of wall/repair
Intrathoracic or intra-
60
reduction
biopsy
Cardiolysis (removal of
Ankle dislocation,
closed or open,
operative, excluding

30
pacemaker
bronchoscope
Bronchoscopy,
Transvenous placement
of endocardial
diagnostic, rigid

Surg %
Benefits
100

Removal of aural polypi
5

Stapes, mobilisation
60

Tympanoplasty, with
100
mastoidectomy
arch graft
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Description of Surgical
Surg %
Benefits

9.
Description of Surgical

Radius & ulna
20
ossicular chain

Shoulder, knee
50
reconstruction

Thoracic or lumbar
95
Tympanoplasty, with
100
spine (closed or open)
Esophagus

Esophagoscopy

Esphagus, operation for
20

Tibia and Fibula
20
37.5

Wrist
15

Compound fracture -the
stricture

Esophagus, resection of
limit is twice the amount
100
closed reduction subject
10. Excision or Fixation by
to a max of 100%
Cutting


Ankle dislocation,
Hallux Valgus (Bunion),
50
closed or open,
operation for
reduction
o
Single
25
o
Bilateral
50
Bone, removal of,
40

diseased position of


of semilunar cartilage of
fibula
knee)
Hip joint, shoulder or
75

Lesser bones
Synovectomies of ankle
Osteomyelitis of long
20
o
Acute
75
40
o
Chronic
60

Release of carpal tunnel
Cataract, removal of
Detached retina,
60

Cystorrhaphy: suture of
75
rupture, simple

Eyeball, removal of
45

Foreign body, removal
5

Bladder
o
removal of growths
of, from cornea
Glaucoma or trauma
45

Pterygium, excision or
15
surgery
o
removal of growths
o
of
7

removal of stone
75
Circumcision, surgical
15
incision of
excision other than
12. Fractures, Treatment of
clamp or dorsal slit,
except newborn
Simple, closed reduction:
Ankle, carpal bone,
20

Curettage or
12.5
cauterization of cevix,
metacarpal, phalanges,
non-puerperal
tarsal bone


Elbow
15

Hip
65
ureteroileal conduit or

Lower jaw or patella
15
sigmoid with bilateral
proMediCare (Individual)
40
by diathermy
transposition or removal

60
by abdominal

Style or chalazion,
60
bladder wound, injury or
operation of

30
13. Genito – Urinary Tract
11. Eye

50
bones
and toes

Menisectomy (removal
femur, tibia, humerus or
spine

Surg %
Benefits
Cystectomy-with
100
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Description of Surgical
Surg %
Benefits
pelvic
growth or
lymphadenectomy
tuberculosis of
Cystoscopy–Diagnostic
5

with minor endoscopic
10
Dilation and curettage,


30
Ureter, removal of stone
85
unilateral,

Urethra, Stricture of,
30
Evacuation of foreign
25
Hydrocele, radical care
open operation

30
Hysterectomy, radical
with complete removal
with or without
Kidney hemorrhage due
Intra-Urethral cutting
15
operation

65
Varicocele,
epididymectomy
75
o
Excision of Single
25
o
Bilateral
35
14. Goitre
65
appendectomy

Endoscopic means –

of tubes and ovaries

75
partial removal
for cancer

Transurethral resection
undescended testis
of

10
of prostate
40
bodies from the bladder

Open testicular
biopsy
25
non-puerperal
Exploration for
o

procedure (e.g. biopsy)

Surg %
Benefits


Description of Surgical

Hemithyroidectomy

Lymphatic glands
o
75
to accident
Removal of
40
100
malignant tumors

Fixation of
75

Removal of, with total
85
of
o
Removal of tumors
urecterectomy &
for diagnosis or
bladder cuff
adenoma of thyroid
50

Removal of stone
50

Laparascopy
20
o
Sub-total
50

Myomectomy, single or
60
o
Total
65
multiple, excision of
abdominal approach
Orchidectomy, simple,
30
unilateral

Renal

Herniorhapy
35

Herniotomy
50

Strangulated hernia
75
16. Ligaments and Tendons
100

homotransplantations

20
shorting

Repair and suture
25
neprectomy

Transplantation
50

Extensive grafting
50

Deep suppuration in
30
Salpingectomy or
55
unilateral or bilateral,
palm, forearm, arm
independent procedure
sole, leg or thigh
Testicles
involving multiple
o
12 of 14
Tendon, lengthening or
with unilateral recipient
oophorectomy or both,

Thyroidectomy
15. Hernia
fibroid tumor of uterus

Castration for
33
proMediCare (Individual)
03/2014
Description of Surgical
Surg %
Benefits

Repair of the
40
17. Nail


Antrum puncture
5

Extranasal sinus
17.5

25

abscess
Intranasal sinus
100
70

Sigmoidectomy
20
10
22. Skull
60

Nose, reconstruction of

or more
40
Toilet and suture
5

Turbinectomy
10

hemorrhage
7.5

23. Spine or Spinal Cord
30

20

Division of posterior

Fissure-in-ano, cutting
75
Ontevetebral disc,
excision of
operation for:
Independent
Gasserian ganglion,
resection of
without biopsy
o
40
Without spinal
75
fusion
Procedure

100
spinal tracts or roots
Colonoscopy with or
o
100
cerebellar tumor
21. Rectum

Tumor or abscess of the
brain, cerebral of
5
20. Pilonidal Cyst or Sinus

100
other intercranial
12.5
joints or spine
Removal of
Trephning for fracture
middle miningeal or
cauterization excepted
Ear drum, Hydrocele,
40
decompression
19. Paracentesis
Chest or bladder,
Removal of bone
trephning or


100
tapping excepted

nasal septurn, classic
Tapping of – Abdomen
Cutting into cranial
cavity, trephning and
60
or epithelioma of nose

25
Rectum, excision of
Mastoid, radical cue for
Submucous resection,
Other cutting operation


Sarcoma, operation for,
7.5
of rectum
operation
Polypus, removal, one
Papillectomy, single or
multiple procedure
operation

15
perirectal/perianal
18. Nose

Incision & Drainage of
ischiorectal and/or
nail)

60
fistulectomy
complete (e.g. ingrown

Hemorrhoidectomy and
fistulotomy or
15
matrix, partial or

55
complex or extensive

Excision of nail and nail
Hemorrhoidectomy,
internal & external,
tendoachilles

Surg %
Benefits
incisions or drainage

Description of Surgical
o
Fistulotomy or
With spinal fusion
100
fistulectomy

Laminectomy
100
o
Simple
35

Nerve grafting
50
o
Multiple
45

Spinal cord tumor,
100
proMediCare (Individual)
13 of 14
03/2014
Description of Surgical
Surg %
Description of Surgical
Benefits
operation for
ganglion) foot or toe

24. Throat

Adenoidectomy,
Excision of tumor of

Malignant tumors of the
tissue

100
Malignant tumors,

Partial excision
50
except those of the

Laryngectomy, without
75
mucous membrane skin
and subcutaneous
neck dissection
Laryngoscopy, direct
tissue
25

operative with biopsy

Parotidectomy
60

Removal of lower lip
50
Tongue, total excision

Tonsillectomy with or

100
Tracheotomy,
20

20
independent procedure

Turbinectomy
10
o
One leg
25
o
Both legs
40
Injection treatment,
20
Ligation of small
10
arteries, smaller
20
aneurysms
testicles

Cutting operation,
or both legs

Benign tumors of the
50
complete procedure one
25. Tumors

Aneurysm in large
complete procedure
without adenoidectomy

5
arteries
of for cancer

Warts or moles
26. Varicose Veins
cancer

50
surgical removal of,
upper or lower

25
skin and subcutaneous
stripping of vocal cords
Jaw, total excision of
20
mucous membrane,
35
cords & epiglottis/or

Lesion of tendon sheath
– wrist
15
independent procedure

Surg %
Benefits

Benign tumors one or
Stripping of varicose
30
vein, one leg
more, except as
otherwise herein
provided;
o
Requiring hospital
1.
20
confinement
o
Not requiring
5
hospital
confinement

Excision of Bartholin’s
25
tumor or cyst

Incision or drainage of
5
cyst

Lesion of tendon or
20
fibrous sheath or
capsule (e.g. cyst or
14 of 14
proMediCare (Individual)
03/2014