Guidelines on the Approval of HMO Products and Forms

March 31, 2017

INSURANCE CIRCULAR LETTER NO. 19-2017

 

WHEREAS, Section 1, Executive Order (EO) No. 192, s. 2015, mandates that jurisdiction over Health Maintenance Organizations (HMOs) shall be transferred from the Department of Health (DOH) to the Insurance Commission (IC) in order to regulate and supervise the establishment, operations and financial activities of HMOs; HTcADC

WHEREAS, the IC shall have the authority to exercise the following functions, among others:

a. Issue rules and guidelines, with respect to the establishment of HMO minimum capitalization, net worth, reserve funds and security deposit requirements, as well as the criteria for qualification and disqualification of directors, officers and marketing personnel, and the procedure for the submission of reportorial and/or examination requirements, registration of contracts and plans, adjudication of claims, and other relevant matters, as necessary;

b. Fix, assess, collect, and utilize fees and/or charges as it may find reasonable in the exercise of regulatory powers;

c. Regulate, supervise, and monitor the operations and management of HMOs to ensure compliance with EO No. 192, s. 2015, existing laws, rules, regulations and such other directives and circulars issued by the Insurance Commissioner;

d. Prepare, approve or amend, rules, regulations, orders, and circulars, and issue opinions, provide guidance on and supervise compliance with such rules, regulations, orders, and circulars; and

e. Exercise such other powers as may be provided by law as well as those which may be implied from, or which are necessary or incidental to carry out the express powers granted to the IC to achieve the objectives and purposes of EO No. 192;

f. Pursuant to existing laws, rules, and regulations, impose sanctions, and/or appropriate penalties.

WHEREAS, pursuant to such functions there is a need to prescribe the key features of an HMO product, its minimum contract provisions and documentary requirements, that will regulate the products offered by HMOs to the public and streamline the process of product approval by the IC; CAIHTE

NOW THEREFORE, by the power vested in me by the provisions of EO No. 192, s. 2015, this Circular is hereby issued:

SECTION 1. Scope. —

This Circular shall apply to the approval of all HMO products and forms issued by HMOs licensed to do business in the Philippines by the IC.

SECTION 2. HMO Products. —

An HMO product refers to a pre-agreed or designated health care services to the enrolled members for a fixed pre-paid fee for a specified period of time through the use of selected network of health care providers.

An HMO product provides a wide array of medical, surgical and hospital services that include preventive care and wellness programs and generally has no cash-out transaction.

An HMO product shall be issued by an HMO duly licensed by the IC.

SECTION 3. Features of HMO Products. —

An HMO Product has the following key features:

a. TYPES OF HMO PRODUCT — An HMO product may be issued on individual/family or group basis.

b. PERIOD OF COVERAGE — Coverage is for a maximum of twelve (12) months subject to renewal.

c. PAYMENT PERIOD — Membership fees are guaranteed for a maximum of twelve (12) months.

d. PAYMENT OPTION — The fixed pre-paid fee may be in the form of (a) a pre-agreed membership fee or (b) a combination of the enrolment fee, administrative fee and a fund under an Administrative Services Only (ASO) agreement, or (c) a combination thereof.

e. BENEFITS — In addition to the preventive care and wellness programs that an HMO product must provide, an HMO product must have at least one (1) of the following benefits:

i. In-patient benefit

ii. Out-patient benefit

iii. Emergency care benefit

iv. Annual Physical Exam

v. Executive Check-up

vi. Dental benefit

vii. Maternity benefit aScITE

f. ANCILLARY BENEFITS — An HMO product may likewise provide the following benefits:

i. Point-of-Service

ii. Worldwide coverage

iii. Prescription drugs

iv. Alternative medicine

v. Clinic Management

vi. Other services related to health care

g. PRODUCT BUNDLING — An HMO product may be bundled with a Group Yearly Renewable Term insurance plan, Group Accident insurance plan or any similar product that has been duly approved by the IC. The HMO shall act as the group policyholder and shall endorse the benefit in the HMO Agreement. The HMO shall likewise act as the lead provider that will assume responsibility for the administration of the bundled products or services.

h. LIMITATIONS — An HMO product shall not have any savings or investment component, nor any mortality risk.

SECTION 4. Approval of HMO Products and Forms. —

An HMO product shall conform to the features referred to in the preceding section and its HMO Agreements shall contain in substance the minimum provisions prescribed in Annexes A and B of this Circular. The HMO Agreements shall not contain provisions or statements that are unjust, inequitable, misleading or encourage misrepresentation.

No HMO product shall be sold unless its Agreement and contract forms have been approved by the IC.

SECTION 5. Documentary Requirements for Product Approval. —

A covering letter duly signed by the President of the HMO or by any authorized senior officer, addressed to the Insurance Commissioner, shall be filed with the following documentary requirements:

a) HMO Agreement;

b) HMO Schedule of Benefits;

c) HMO Application Form;

d) Actuarial Notes

i. Product description DETACa

ii. Actuarial Assumptions

2.1 Morbidity/Incidence Rates (Per Benefit)

2.2 Expenses

2.2.1 Commission

2.2.2 Administrative Expense Allowance

2.3 Taxes

iii. Actuarial Formulations

3.1 Net and Gross Premiums Formulations

3.2 Reserves

3.2.1 Membership Fee Liability

3.2.2 Claims Liability (Outstanding claims and Incurred But Not Reported (IBNR) Claims)

3.2.3 Liabilities for Administrative Services Only (ASO)

iv. Table of Gross Membership Fees

v. Experience Refund Formulation, if applicable

e) Sworn certification of IC accredited actuary following prescribed IC format (Annex C);

f) Latest Audited Financial Statements prepared by IC-accredited external auditors;

g) Sample Sales Proposals/Marketing Materials;

h) Conforme Letter;

i) List of current affiliated hospitals, and other service providers;

j) Sample contract with service provider;

k) Administrative Services Only (ASO) Endorsement, if applicable, which includes the service fee and the fund requirements;

l) Any other documents as the IC may require.

SECTION 6. Contents of an HMO Agreement. —

An HMO Agreement shall contain in substance provisions of an individual or group contract as prescribed in Annexes A and B, respectively of this Circular:

a) Name and address of the Health Maintenance Organization;

b) In-Patient benefits and services; HEITAD

c) Emergency care benefits and services;

d) Out-Patient benefits and services;

e) Other benefits;

f) Pre-existing conditions;

g) Availment and Claims Procedure;

h) Exclusions and Limitations;

i) Eligibility Requirements;

j) PhilHealth/ECC provision;

k) Effective Date and Duration;

l) Membership Fees provision;

m) Membership provision; and

n) General Provisions.

In addition to the provisions required in the foregoing list, an HMO Agreement shall provide the Client with a ten-day period from its Effective Date, to cause its termination provided the ID cards and the Agreement are surrendered to the HMO within the same period. The HMO shall thereafter terminate the Membership and the termination provision of the Agreement shall apply.

SECTION 7. Schedule of Fees and Penalties. —

A filing fee plus Legal Research Fund (LRF), based on the schedule below, shall be imposed upon submission of products and forms for approval.

 

Products

Filing Fee

LRF *

A. New Products, Riders, Endorsements/Forms

1. Stand-alone product (per benefit) **	20,000.00	200.00
2. Rider (per benefit) ***	10,000.00	100.00
3. ASO Agreement	7,500.00	75.00
4. Endorsement or other forms	5,000.00	50.00

B. Revision of Products, Riders, Endorsements/Forms

1. Stand-alone product	10,000.00	100.00
2. Rider	5,000.00	50.00
3. HMO Agreement, ASO Agreement, Endorsement, other Forms or Actuarial Notes	5,000.00	50.00

*Legal Research Fund (LRF) is equivalent to 1% of the Filing fee but in no case lower than P10.00 as required by RA 3870 (An Act Defining the Functions of the UP Law Center, providing for its Financing and other purposes), as amended by PD 1856, dated December 26, 1982.

**refers to a product that may be sold on its own which may provide any of the benefits under Section 3.e hereof.

***refers to a benefit that may be attached to standalone product which may provide any of the benefits under Section 3.e and 3.f hereof.

 

A penalty amounting to fifty thousand pesos (PhP50,000.00) and five thousand pesos (Php5,000.00) shall be imposed for every HMO Agreement and contract form, respectively, issued without IC approval. aDSIHc

SECTION 8. Transitory Provision. —

HMOs shall be given one (1) year from effectivity of this Circular to amend their existing HMO products and corresponding Agreements and contract forms and submit to IC for approval, otherwise, the same shall no longer be sold after the said period.

SECTION 9. Separability Clause. —

If any provision of this Circular or any part hereof be declared invalid or unconstitutional, other provisions not otherwise affected shall remain valid and subsisting.

SECTION 10. Repealing Clause. —

All circulars, rules and regulations or parts thereof that are inconsistent with the provisions of this Circular are deemed repealed, superseded or modified accordingly.

SECTION 11. Effectivity. —

This Circular shall take effect immediately.

(SGD.) DENNIS B. FUNAInsurance Commissioner

ANNEX A

Individual Contract Provisions

<HMO> has offered and the Principal Member ("Client") has agreed to engage the services of <HMO> to extend healthcare and health maintenance services upon enrolment and payment of the appropriate Membership fees in such amount and manner as stated in this Agreement.

Parties to this Agreement include <HMO> and the Client only.

The Effective Date of this Agreement is on DD MM YYYY.

I. DEFINITION OF TERMS

1. ACCIDENT. A visible, external, sudden and violent event occasioned by a physical or natural cause and occurring entirely beyond the Member's control causing damage to the health of the Member. ATICcS

2. AFFILIATED HOSPITAL. A duly licensed hospital included in the list of affiliated hospitals of <HMO> with which the <HMO> has an existing and valid service agreement and where a Member can avail of medical services pursuant to this Agreement.

3. AFFILIATED MEDICAL CLINIC. A duly licensed medical health care facility included in the list of affiliated medical clinics of <HMO> which has an existing and valid affiliation agreement with <HMO> and where a Member can avail of medical services pursuant to this Agreement.

4. AFFILIATED PHYSICIAN. A duly licensed physician or specialist affiliated by <HMO> and named in the list of <HMO>'s affiliated physician with whom <HMO> has made arrangements to provide the required services under this Agreement.

5. ANESTHESIOLOGIST. A specialist duly licensed and registered to administer anesthetic agents and conduct other anesthesia procedures during medical operation.

6. ANNUAL BENEFIT LIMIT (ABL). The maximum liability that <HMO> shall assume for all covered services rendered to a Member within the one-year term of this Agreement. ABL is replenished upon renewal of this Agreement but not during extension.

7. ATTENDING PHYSICIAN. An Affiliated Physician who is part of the medical staff of an Affiliated Hospital or Affiliated Medical Clinic, and legally responsible for the care given to a Member while in the hospital or on out-patient basis.

8. AUTHORIZED REPRESENTATIVE. A person duly authorized by <HMO> to approve the provision of medical services or claims reimbursements to a Member.

9. CUSTODIAL OR MAINTENANCE CARE. Care which is primarily for the purpose of assisting the Member in the activities of daily living or in meeting personal rather than medical needs, which is not specific therapy for an Illness or Injury and is not skilled care.

10. DEVELOPMENTAL, CONGENITAL CONDITION, BIRTH DEFECT. A medical abnormality existing at the time of birth as well as neonatal physical or mental abnormalities developing thereafter because of causal factors or conditions present at the time of birth.

11. DISABILITY. An Illness or Injury and any symptoms, sequelae, or complication thereof requiring treatment. All injuries arising from the same event or series of continuous events are considered as one Disability.

12. DURABLE MEDICAL EQUIPMENT. As determined by the <HMO>, medically prescribed items of medical equipment for repeated use, owned or rented, such as but not limited to crutches and wheelchairs which are placed in the home of a Member to facilitate treatment and/or rehabilitation of Illness or Injury.

13. EFFECTIVE DATE. The date the Agreement commences as specified in the Agreement.

14. ELIGIBLE EXPENSES. Expenses incurred in the treatment of a covered Illness or Injury which are Medically Necessary and not exceeding the limits in Schedule A — Benefit Coverage. ETHIDa

15. EMERGENCY CONDITION. A life threatening or accidental Injury or a sudden and unexpected onset of a condition or Illness which at the time of the occurrence reasonably appears to have the potential of causing immediate Disability or death, or which requires the immediate action or alleviation of pain or discomfort. These Illnesses or injuries require urgent medical or surgical care and attention which the Member secures immediately after the onset or as soon as the care may be made available.

16. EXPIRY DATE. The date the Agreement is scheduled to terminate which is one (1) year from the Effective Date.

17. ID CARD. The identification card issued by <HMO> to a Member containing the latter's name and signature, ID reference number, and other matters pertaining to his Membership.

18. ILLNESS. A poor health or poor physical condition marked by a pathological deviation from the normal healthy state caused by disease or sickness.

19. INJURY. Physical damage or trauma arising wholly and exclusively from an Accident or other events of violent or external, and visible nature.

20. LETTER OF AUTHORIZATION (LOA). Letter of authorization duly issued by <HMO> to, and signed by, the Member which shall serve as the authority of the latter to avail of the medical services.

21. MATERIAL INFORMATION. An information is deemed material if its disclosure would have resulted in the (a) declination of the application for Membership of the applicant, (b) the assessment of a higher Membership Fee or (c) the inclusion of additional restrictions and exclusions to the benefits of the Member under this Agreement.

22. MAXIMUM BENEFIT LIMIT (MBL). The maximum liability that <HMO> shall cover and assume per covered Illness or Injury of a Member within the term of this Agreement. MBL is replenished upon renewal of the Agreement by Client but not during any extension thereof.

23. MEDICALLY NECESSARY. A medical service, as determined by <HMO>, which is (a) consistent with the diagnosis and customary medical treatment of the condition, (b) in accordance with the standards of managed care and good medical practice, (c) not for the convenience of the Member or the Affiliated Physician, (d) performed in the most cost effective manner required by the medical condition and (e) consistent with the terms and conditions of this Agreement.

24. MEDICINES AND DRUGS. Those for which a licensed medical practitioner has prescribed for dispensing, which are specifically required for the treatment of a covered Illness or Injury under this Agreement.

25. MEMBER. A Principal and/or Dependent who is eligible, has been accepted for Membership by <HMO> after complying with the Eligibility provision, and is currently enrolled under this Agreement.

26. MEMBERSHIP. Refers to membership in <HMO>, pursuant to this Agreement. TIADCc

27. MEMBERSHIP FEES. Refer to the fees for the enrollment of the Members, as specified in Schedule B — Membership Fees of this Agreement.

28. PHYSICIAN, SURGEON, SPECIALIST, OR DOCTOR: A person qualified by degree and duly licensed or registered to practice medicine in the geographical area in which he serves. This person must not be a relative of the Member up to the third degree of consanguinity and affinity.

29. PRIVATE NURSE. A licensed nurse providing close observation and performing special treatments, which are certified as Medically Necessary by the Attending Physician.

30. PROFESSIONAL FEES. As distinct from Surgeon and Anesthesiologist's Fees, fees paid to licensed medical professionals including but not limited to an Occupational Therapist, Physiotherapist, Attending Physician's visits or Pathologists.

31. ROOM AND BOARD ACCOMMODATION. The pre-assigned type of hospital room and board by <HMO> to the Member based on the benefit and coverage of the health care plan under this Agreement.

32. SURGERY. The branch of medicine dealing with manual or operative procedures for the correction of deformities and defects, repair of injuries, diagnosis and cure of certain diseases. This includes surgery performed in an out-patient setting for a covered Illness or Injury.

II. BENEFIT PROVISIONS

All the benefits provided for this Agreement are detailed in Schedule A — Benefit Coverage and subject to the following terms and conditions:

1. IN-PATIENT CARE. Coverage of in-patient benefits, except for Emergency Conditions, wherein the Emergency Care provision of this Agreement will apply, shall be subject to the following conditions:

a. The hospital confinement must be recommended by an Affiliated Physician and approved by the duly authorized representative of <HMO> in that Affiliated Hospital prior to confinement.

b. The confinement shall be in an Affiliated Hospital and in accordance with the Member's Room and Board Accommodation.

c. Professional services shall be provided only by Affiliated Physicians.

d. As proof of conditions a, b, and c above, <HMO> shall issue the requisite Letter of Authorization (LOA) and other necessary documents.

e. If a Member for whom discharge order has been issued by the Attending Physician refuses to be discharged, <HMO> shall no longer be responsible for all hospital expenses and professional fees incurred after the specific time or hour the Member should have been discharged. Such expenses shall be charged to the personal account of the Member.

2. EMERGENCY CARE

a. In Affiliated Hospital. If the emergency treatment has been administered in an Affiliated Hospital and the Member still requires confinement, <HMO> shall provide the in-patient benefits subject to the provisions of this Agreement. cSEDTC

If at the time of the confinement, the Affiliated Hospital has no available room in accordance with the Member's Room and Board Accommodation, the Member may opt to avail of a room accommodation which is higher than his Room and Board Accommodation but <HMO> will only cover the incremental rate differences for the room upgrade, professional fees, diagnostic and laboratory examinations, and other ancillary medical services for the first twenty-four (24) hours of confinement. The said charges and expenses shall be subject to the Member's MBL. All incremental costs incurred after the first twenty-four (24) hours shall be for the personal account of the Member except when the Affiliated Hospital issues a certification of non-availability of the Member's Room and Board Accommodation.

b. In Non-Affiliated Hospital. If emergency treatment has been administered in Non-Affiliated Hospital and the Member still requires confinement, he or his representative, as a pre-requisite for in-patient coverage, must notify <HMO> within a period of twenty-four (24) hours from admission. However, in case the Member, due to his medical condition, is unable to communicate directly or through a representative, the 24-hour notification period shall be extended for twenty-four (24) hours from the time he is clinically able to do so.

c. In all these circumstances, <HMO> reserves the right to validate whether the treatment received is emergency in nature and/or the Illness or condition is covered under the provisions of this Agreement.

3. OUT-PATIENT CARE

The Out-patient benefits can be availed by the Member immediately from the enrollment date of this Agreement, and every renewal date thereafter provided that the Membership Fees shall have been paid during the first billing. The benefits can be availed only through the Affiliated Hospital and Physician of <HMO>.

III. PRE-EXISTING CONDITIONS

An Illness, Injury or condition shall be considered pre-existing if it existed before the Effective Date of the Member's coverage, the natural history of which can be medically determined to have started prior to the effective date of coverage or at the time of processing of the Member's Application, whether or not the Member was aware of such Illness, Injury or condition.

Pre-Existing Conditions shall include the following Illnesses, Injuries or conditions, but not to the exclusion of all others including their complications and sequelae:

1. Tumor/Cyst of Internal Organs AIDSTE

2. Hemorrhoids/Anal Fistula

3. Diseased tonsils and sinus conditions requiring surgery

4. Cataract/Glaucoma

5. Pathological Abnormalities of nasal septum or turbinates

6. Goiter and other thyroid disorders

7. Hernia/Benign Prostatic Hypertrophy

8. Endometriosis

9. Asthma/Chronic Obstructive Lung disease

10. Epilepsy

11. Spinal column abnormalities

12. Tuberculosis

13. Cholecystitis

14. Gastric or Duodenal ulcer

15. Hallux valgus

16. Hypertension and other Cardiovascular diseases

17. Calculi

18. Tumors/Cyst on skin, muscular tissue, bone or any form of blood dyscrasias

19. Diabetes Mellitus

20. Cerebrovascular Accident/Transient Ischemic Attack

Diagnostic procedures undertaken to determine the existence of a Pre-existing Condition is a covered expense provided that the result of diagnostic procedure is negative for the existence of the pre-existing condition.

Pre-existing Condition shall only be covered after one year from Effective Date of the Member's coverage provided that there is no failure to disclose, misrepresent or conceal, Material Information in the original Application or Application for reactivation. Notwithstanding the disclosure by the Member of a pre-existing condition, the <HMO> may permanently exclude from cover a specific medical condition, Illness or Injury upon written notice to the Member.

IV. AVAILMENT AND CLAIMS PROCEDURE

1. CLAIMS SUBMISSION

a. Certification, Information and Evidence. All certificates, accounts, receipts, information and evidence required by <HMO> shall be furnished in such form as <HMO> may require.

b. Sufficiency of Notice. Written notice of any claim given by or on behalf of the Member or Beneficiary to <HMO> or to any authorized representative of <HMO>, with information sufficient to identify the Member, shall be deemed notice to <HMO>. SDAaTC

c. Notice of Claim

c.1. A Member shall first report his condition to <HMO> or designated plan coordinator during clinic hours for treatment unless the condition is emergency in nature. The Affiliated Physician shall, upon examining the Member, prescribe the necessary medical procedure. If hospitalization is needed, the Affiliated Physician shall provide the required hospital referral in the prescribed form. Before being discharged from the Hospital, a Member must fill up the prescribed claim form and settle that portion of the medical bill not covered by the Agreement. That portion of the bill covered by the Agreement shall be settled directly by the HMO with the hospital and/or Attending Physician(s).

c.2. In case of emergency, the Emergency Care provision specified in the Agreement shall apply.

c.3. In cases wherein <HMO> covered costs were not deducted from the medical bills and a Member is made to pay for the health care cost, a Member may request reimbursement of such costs which are covered under the Agreement. The request must be made on the prescribed claim form to which shall be attached official receipts, together with supporting charge slips, detailed itemized accounts and other necessary documents. No reimbursement shall be made to the Member unless such original documents are submitted by the Member or if the Member has otherwise been fully indemnified or reimbursed of the medical bills or costs incurred under any other health care coverage or insurance policy or any other similar contracts or Agreements. Such request for benefits must be presented within thirty (30) days after the expiration of the period of confinement for which claim for benefits is being made. Failure to submit within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time.

c.4. <HMO> will process the payment of all claims within thirty (30) days upon receipt of complete documents and in accordance with the terms of the Agreement. All benefits that pertain to a Member will be paid by check to the order of Principal Member, unless the Principal Member requests otherwise, or <HMO>, in its discretion, considers it preferable to make the payment in another manner. In case of death of a Member, any benefit due but remaining unpaid shall be paid to the first surviving class of the following classes of successive preference of beneficiaries: the Member's (a) widow or widower; (b) surviving children; (c) surviving parents; (d) surviving brothers and sisters; and, (e) executors or administrators.

d. Fraudulent Claims. If any claim under this Agreement is in any respect fraudulent, all benefits payable and/or paid in relation to that claim shall be forfeited and if deemed appropriate, recoverable respectively. AaCTcI

e. Physical Examination and Autopsy. <HMO> shall have the right and opportunity to examine the Member when and as often as it may reasonably require during the pendency of claim hereunder, and the right and opportunity to make an autopsy in case of death, where it is not forbidden by law.

2. BENEFIT PAYMENT

All benefits payment shall be in PHILIPPINE PESO.

a. Payment of Benefits. If a Member incurs Eligible Expenses during the effectivity of this Agreement, <HMO> will pay benefits in accordance with Schedule A — Benefit Coverage of this Agreement. <HMO> will pay the Eligible Expenses after application of any stipulated co-payment or other deductions that may apply.

b. Coordination of Benefits. Benefits will not exceed the total medical expenses when combined with other health care or medical coverage in force or organizations or which are provided free of charge in government or private facilities.

3. REIMBURSEMENT CLAIMS FOR EMERGENCY CASES

a. Limitation. The claims for reimbursement shall apply only in emergency treatments, whether out-patient or in-patient, rendered in non-Affiliated Hospitals.

b. Filing of Claims. All claims for reimbursement must be filed using the prescribed claim form and submitted to <HMO> Offices within thirty (30) days from the date of availment for out-patient or from date of discharge for in-patient.

Failure to submit within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time.

c. Payment of Claims. All benefits that pertain to a Member will be paid by check to the order of Principal Member, unless the Principal Member requests otherwise, or HMO, in its discretion, considers it preferable to make the payment in another manner. In case of death of a Member, any benefit due but remaining unpaid shall be paid to the first surviving class of the following classes of successive preference of beneficiaries: the Member's (a) widow or widower; (b) surviving children; (c) surviving parents; (d) surviving brothers and sisters; and, (e) executors or administrators.

d. Request for Reconsideration. If a claim for reimbursement is denied, or the Member is not satisfied/agreeable to the reimbursement paid by <HMO>, a written request for reconsideration must be filed with the <HMO> Head Office not later than ten (10) days from receipt of such denial or questioned reimbursement. Otherwise, the claim shall be deemed satisfied or terminated. The request for reconsideration shall contain all the reasons upon which reconsideration is sought and shall be decided upon by an authorized personnel of <HMO>, whose decision shall be final. <HMO> reserves the right to deny Claims for Reimbursement if the procedures and requirements have not been strictly complied with. acEHCD

V. EXCLUSIONS AND LIMITATIONS

<All HMOs have a list of exclusions and benefit limitations. These exclusions and limitations would impact the HMO's pricing/membership fee calculation, and could define their pricing strategies.>

1. Long-term rehabilitation and psychiatric care and/or psychological illnesses and conditions including neurotic and psychotic behavior disorders; anxiety disorders.

2. Developmental disorders including functional disorders of the mind, such as but not limited to Attention-Deficit Disorder (ADD) or Attention-Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Bipolar Disorders, Central Auditory Processing Disorder (CAPD), Cerebral Palsy, Down Syndrome, Neural Tube Defects, and Mental Retardation.

3. Congenital, genetic and hereditary diseases and their complications affecting functions of individuals.

4. Sexually transmitted diseases including genital warts.

5. Injuries resulting from direct participation in riots, strikes, and other civil disturbances.

6. Infectious diseases (i.e., Avian Flu, Meningococcemia, etc.) that are declared epidemic or pandemic by the Department of Health, World Health Organization or any recognized health authority.

7. Aesthetic, cosmetic and reconstructive surgery or any consultation or treatment for any beautification purposes except if necessary to treat a functional defect due to accidental injury within the initial confinement.

8. Maternity care and all other conditions, including pre and post natal consultations, related to and/or resulting from pregnancy and/or delivery which affect the conditions of the principal Member and the unborn child.

9. Circumcision (except for treatment of urological conditions), sex transformation, diagnosis, treatment and procedures related to fertility or infertility, artificial insemination, sterilization or reversal of such procedures and their complications.

10. Experimental medical procedures and its complications.

11. Acupuncture, acupressure, chirotherapy and other forms of alternative medicine and their complications.

12. Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance, government licensing, health permit and other similar purposes. EcTCAD

13. All screening tests.

14. Treatment for injury and its complications resulting from self-inflicted injuries including infections as a result of tattoos, piercing of the ear or in any body part, whether self-inflicted or done by a third party or attempted suicide or self-destruction, whether sane or insane.

15. Treatment of any injury received wherein there is negligence, unauthorized use of prohibited or regulated drugs, alcoholic liquor intake, direct or indirect participation in the commission of a crime whether consummated or not, violation of a law or ordinance or unnecessary exposure to imminent danger, knowingly or unknowingly, or hazard to health, by the Member.

16. Treatment of injuries or illnesses caused directly or indirectly by engaging in any professional sport or hazardous activity such as but not limited to scuba diving, surfing, water skiing, mountain climbing, rock climbing, mountaineering, parachuting, airsoft, drag racing, paintballing, wakeboarding and bungee jumping.

17. Treatment of injuries or illnesses resulting from war and any combat-related activities while in military service.

18. Treatment for Chronic Dermatoses.

19. Services obtained for non-emergency conditions from physicians and hospitals in any of the following circumstances:

a. non-Affiliated Physicians in non-Affiliated Hospitals or non-Affiliated Clinics

b. non-Affiliated Physicians in Affiliated Hospitals or Affiliated Clinics

c. Affiliated Physicians in non-Affiliated Hospitals or non-affiliated Clinics or other healthcare facility.

20. Additional hospital charges and physician's professional fees resulting from:

a. room-upgrading beyond twenty-four (24) hours during Emergency Conditions;

b. extension of hospital stay despite release of discharge order from Member's Attending Physician;

c. fees of the assistant surgeons for surgeries with less than 250 RUV units/resident doctors who assisted the Attending Physician in the process of rendering the medical services shall not be chargeable to the Member and/or <HMO> except for hospitals that do not have resident physicians to assist during surgeries subject to the prior approval of <HMO>;

d. use of extra bed, TV, electric fan, DVD/VCD, and other similar items unless such appliances and items are necessarily and ordinarily included in the Member's Room and Board Accommodation;

e. extra food; toilet articles like face towel, soap, toothbrush and the like; SDHTEC

f. difference in Room and Board Accommodation, the incremental rate differences for professional fees, diagnostic and laboratory examinations, and other ancillary medical services brought about by obtaining a room and board accommodation higher than the Member's Room and Board Accommodation limit;

g. services of a private or a special nurse;

h. all other items not medically necessary in the medical management of the Member.

21. Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance/travel or government licensing, health permit and other similar purposes.

22. Custodial, Domiciliary, Convalescent and Intermediate care.

23. Medical certificates.

24. Professional fees of medico-legal officer/s.

25. All expenses incurred in the process of organ donation and transplantation if the Member is the donor, and its complications.

26. Benefits covered by PhilHealth and all other government funded healthcare entitlements as provided for by law.

27. Cost of the medical services and professional fees in excess of the MBL.

28. Purchase of lease of any Durable Medical Equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care.

VI. ELIGIBILITY

1. Principal Member. Principal Member is a person who has attained the age of eighteen (18) years old but not more than XX years old. Attained age is defined as the age last birthday. [Enrollment to this Agreement is subject further to the prevailing Underwriting Guidelines of the HMO.]

2. Dependents. Persons designated by a Principal Member under this Agreement must be enrolled simultaneously or within thirty (30) days from enrollment of the Principal Member except for cases involving marriage or the birth of a child wherein enrollment must be made within thirty (30) days after the date of marriage or birth.

a. For Married Principal Member — The legal spouse, not more than sixty-five (65) years old and his natural born or legally-adopted children who have attained the age of fifteen (15) days and not more than twenty-one (21) years old, unmarried and not gainfully employed or earning an income and fully dependent upon the Principal Member for support are eligible.

b. For Single Principal Member — Parents who are not more than sixty-five (65) years old provided neither is employed for monetary gain and siblings who have attained the age of fifteen (15) days old and not more than twenty-one (21) years old, unmarried and not gainfully employed or earning an income and fully dependent upon the Principal Member for support are eligible. HSAcaE

c. For Single Parent Principal Member — Children who have attained the age of fifteen (15) days and not more than twenty-one (21) years old, unmarried, not gainfully employed or earning an income and fully dependent upon the Principal Member for support; or parents who are not more than sixty-five (65) years old provided neither is employed for monetary gain are eligible.

3. Hierarchy Rule for Selecting Qualified Dependents. For married Principal Members, the spouse must be enrolled first followed by children applying their birth rank. For single Principal Members, the parents must be enrolled first followed by the siblings applying also their birth rank.

<HMO> reserves the right to require at any time the submission of such documents which <HMO> may deem appropriate for the purpose of validating the eligibility of Principal Members and their Dependents.

VII. PHILHEALTH/ECC PROVISION

This Agreement is integrated with benefits under the PhilHealth and/or Employee Compensation Commission (ECC). The <HMO> will deduct these entitlements from the amount otherwise payable. <HMO> will not pay or advance the costs of such benefits, nor be responsible for filing any claims under PhilHealth or ECC.

VIII. EFFECTIVE DATE AND DURATION

1. EFFECTIVE DATE OF THE AGREEMENT. This Agreement shall commence on the Effective Date upon payment in full of the due Membership Fee.

2. TERMINATION OF AGREEMENT BY CLIENT.

a. By giving a written notice within [ten (10) days] from Effective Date of the Agreement, Client may cause the termination of this Agreement provided the ID Cards and this Agreement are surrendered to <HMO> within the same period. <HMO> shall thereafter terminate the Membership and the termination provision of this Agreement shall apply. <HMO> shall return any Membership Fee paid. Failure to terminate this Agreement within the period set or any availment of a Member within the [10-day period] shall be understood as an acceptance of all terms and conditions provided hereunder.

b. The Client may terminate this Agreement for justifiable reasons at any time by giving a written notice to the <HMO> at least [thirty (30) days] prior to the intended termination date. Client may only terminate this Agreement if he/she is not in default in the performance of his/her obligations or he/she has not violated any of his/her warranties and representations. Starting on the termination date, <HMO> shall be free from all liabilities to Client, Members and their dependents. This shall be without prejudice to the right of <HMO> to collect Client's obligations which have become due and demandable.

c. Client shall be entitled to a refund in accordance with Refund/Credit of Membership Fee provision. AScHCD

3. TERMINATION OF AGREEMENT BY HMO. <HMO> shall have the right to immediately terminate this Agreement in the event that:

a. Any material representation or warranty made by Client is false or untrue when made; or if Client commits any act with the intent to defraud <HMO>;

b. Non-payment of Membership Fees and other obligations subject to agreed payment terms;

All medical services and coverage under this Agreement shall terminate on the termination date, without prejudice to any claim for covered medical services rendered to a Member prior to the termination date.

Termination under this provision shall be without prejudice to the right of <HMO> to collect the Client's obligations which have become due and demandable.

4. RENEWAL OF AGREEMENT. This Agreement may be kept in force by payment of the Membership Fee on the due date. The renewal Membership Fee for each year of coverage is based on the age of each Member on the first day of the renewal year of coverage, the Membership Fee Rate Table then in effect, and other factors which materially affect the risk of the Member. <HMO> has the right to change the Membership Fee Rates Table on a class basis for all similar Agreements on this form. The renewal Membership Fee may be subject to adjustment based on claims experience of the Member.

5. CHANGE IN PLAN. Changes in plan, including upgrading or downgrading of plan and addition or deletion of benefits are allowable during the renewal of this Agreement subject to the approval of <HMO>.

6. TERMINATION OF MEMBER'S COVERAGE. Coverage shall automatically terminate on the earliest of the following:

a. Expiry date;

b. The date a Member ceases to be eligible for coverage. However, when the Member's age exceeds the maximum permissible age, coverage will continue until Expiry Date.

c. When the Membership Fee and/or other obligations are not paid within the grace period;

d. Effective immediately, when the Member has fraudulent availment or material misrepresentation or misstatements for the purpose of availing the benefits;

e. Effective immediately, when the Member enters military, naval or air service of any country or international authority;

f. For a Dependent Member: HESIcT

f.1. On the date a dependent ceases to be eligible;

f.2. on the separation or termination of coverage of the Principal Member;

g. Effective immediately, when the Member fails to observe the terms and conditions of this Agreement or fails to act with utmost good faith.

All medical expenses incurred after the date of termination of the Member's coverage shall be charged to the Client.

If the Membership Fees are unpaid prior to cancellation or termination of Membership, Client shall settle the pro-rata Membership Fee, inclusive of penalty charges, if applicable.

7. INVALIDATION OF AGREEMENT. Failure to disclose or misrepresent any material information by the Member in the application form or medical examination, whether intentional or unintentional, shall automatically invalidate this Agreement from the very beginning, and liability of <HMO> shall be limited to the return of all Membership Fees paid less cost of previous services rendered or amount already refunded plus administration fee.

IX. MEMBERSHIP FEES

1. AMOUNT OF MEMBERSHIP FEES. Client shall pay <HMO> the amounts stipulated in the attached Schedule B — Membership Fees for the services covered under this Agreement.

2. PAYMENT OF MEMBERSHIP FEES. The Membership Fees are due on the Effective Date of this Agreement and every month thereafter for monthly mode of payment, every quarter thereafter for quarterly mode of payment and every semester thereafter for semi-annual mode of payment. The Membership Fee due on any due date shall be the aggregate of the Membership Fees for all Members enrolled under this Agreement.

The Membership Fee shall be payable in advance and is subject to modification upon prior notice to the Member. Membership Fee may be paid at <HMO> Head Office or at such other places as may be designated by <HMO>.

3. GRACE PERIOD FOR PAYMENT OF MEMBERSHIP FEES. Client is given thirty (30) days grace period from Effective Date or due date, whichever is applicable, within which to pay the amount due. All claims incurred during the grace period shall be paid to the Member only after the due Membership Fee is paid.

4. EFFECTS OF NON-PAYMENT OF MEMBERSHIP FEES. Non-payment of the Membership Fees due after the grace period shall entitle <HMO> to:

a. Suspend all services under this Agreement or services to Members whose Membership Fees have not yet been received, until full payment of all Membership Fees due, including penalty charges equivalent to X% a month or a fraction thereof on the unpaid Membership Fees due, computed from due date; and

b. Terminate this Agreement without prejudice to collect the amount due and the corresponding penalty charges that have accrued thereon. AcICHD

5. REACTIVATION OF AGREEMENT. A Member whose coverage has lapsed may apply to reactivate his or her coverage within fifteen (15) calendar days from the end of the grace period by (a) submitting a written request for reactivation; (b) paying the Membership Fee due with arrears, including the penalty charge per Member; (c) for modes of payment other than annual, paying in advance the Membership fee due for the next period.

Suspension of benefits under this Agreement shall be in force until such time the Member shall have paid in full all fees required in reinstatement of his or her coverage and within thirty (30) calendar days from the effective date of reactivation.

After fifteen (15) days from end of grace period and all fees required in reactivation of coverage is not yet paid and settled, <HMO> reserves the right to disapprove reactivation. However, Member may re-apply subject to approval of <HMO>.

6. REFUND/CREDIT OF MEMBERSHIP FEE. If a Member's coverage is terminated or cancelled, the unused pro rata Membership Fee paid shall be refunded to the Client only if no availment has been made by the Member prior to the termination or cancellation. Refund is available only if the Client has fully paid its annual or semi-annual Membership Fees.

There shall be no refund of Membership Fees in the event that:

a. Membership Fee is payable on a quarterly or monthly mode;

b. Remaining coverage of the Member is six (6) months or less;

c. The Member has availed of any benefits under this Agreement.

If the Membership Fees are unpaid prior to cancellation or termination of Membership, Client shall settle the pro rata Membership Fee, inclusive of penalty charges if applicable.

X. GENERAL PROVISION

1. ENTIRE AGREEMENT. This Agreement, the application form, rider clauses or warranties and/or any stipulation or endorsement attached or posted to this Agreement or application form, shall constitute the entire contract between <HMO>, and Client. All statements and information contained in the Member's Application Form shall be deemed representations and warranties made by the Member himself for purposes of applying the provisions of this Agreement.

Any change to this Agreement must be approved by an authorized officer of <HMO> and such approval must be endorsed or attached to this Agreement. Unless applied for by the Client, no such alteration or endorsement shall affect any Agreement issued prior to the alteration or Endorsement without the written consent of the Client. The written consent shall be taken as his agreement to the contents of such alteration or Endorsement.

2. AREAS WITHOUT AFFILIATED HOSPITALS. In areas without Affiliated Hospitals, <HMO> will reimburse the following:

a. 100% on room and board charges according to the Member's Room and Board Accommodation.

b. 100% on other hospital bills according to the Member's Room entitlement. caITAC

c. Professional Fees based on <HMO> rates for an Affiliated Physician rendering the service in an Affiliated Hospital according to the PF of the Member's Room entitlement.

3. DOWNGRADING OF ROOM ACCOMMODATION. Availment of a room accommodation lower than the Member's Room and Board Accommodation can be done at the option of the Member but there shall be no refund or offsetting for the cost difference in room accommodation and other related medical benefits.

4. ROOM UPGRADING AND INCREMENTAL RATE DIFFERENCES. If a Member is confined in a hospital room of higher category than his Room and Board Accommodation within the <HMO> network for whatever reasons except during Emergency Care referred to under Benefit provisions, incremental rate difference and excess charges due to voluntary or involuntary room upgrading shall be charged to the Member, in accordance with the following:

a. For covered hospital charges or ancillaries, the Member shall pay the amount equivalent to XXX percent (X%) of such charges.

b. For Professional Fees, the Member shall pay the difference between the allowable Professional Fees (PF) of the occupied or upgraded room and allowable PF of Member's room entitlement based on <HMO>'s Schedule of Fees.

c. For Room and Board charges, the Member shall pay the difference between the actual rate of the room occupied and the allowable room rate.

d. PhilHealth portion for which the Member is eligible shall be applied to or deducted from allowable charges.

5. EXCESS CHARGE. Any availment that is not covered but is advanced by <HMO> shall be charged to the Member and the Member shall be liable to pay such advances. These shall include but not limited to the following:

a. Benefit availment of lapsed or cancelled Members even if approved by <HMO>.

b. Hospital bills and professional fees that are in excess of <HMO> rates.

c. Amount in excess of the MBL and other inner limitations.

d. Availment that is not intended to be covered by <HMO>, such as exclusions, fraudulent availments, uncoverable items, telephone calls, additional beds, etc.

If the excess charges are not paid after the due date, <HMO> reserves the right to suspend all services to the Member until the excess charges due, including penalty charge, have been paid and settled. TAIaHE

6. NON-TRANSFERABILITY. All benefits in this Agreement are not transferable or assignable. Client may not assign any of its rights or delegate any of its obligations under this Agreement without the prior written consent of <HMO>. <HMO> may assign any of its rights or delegate any of its obligations upon written notice to Client. Any purported assignment or delegation in violation of this Agreement is null and void.

7. AUTHORITY TO EXAMINE MEDICAL RECORDS. Client hereby represents and warrants that, at the time of the effectivity of this Agreement and effectivity of coverage of each Member and his dependents, it has obtained from the Member and his dependents the required consents authorizing <HMO> and any of its authorized representatives to: (a) obtain, examine and process the Member's personal information, including the medical records of their hospitalization, consultation, treatment or any other medical advice in connection with the benefit/claim availed under this Agreement; and (b) disclose such information to Client and his/her representatives.

It is hereby agreed that it is the sole responsibility of Client to obtain from the Members the consent herein specified and that <HMO>shall have all the right to rely on the representation by Client that this consent shall have been duly and timely obtained. Client shall hold <HMO> free and harmless from and against any and all suits or claims, actions, or proceedings, damages, costs and expenses, including attorney's fees, which may be filed, charged or adjudged against <HMO> or any of its directors, stockholders, officers, employees, agents, or representatives in connection with or arising from the use by <HMO> of the Member's medical records and other personal information pursuant to this Agreement and disclosure of such information to Client pursuant to <HMO>'s reliance on Client's representation and warranty that <HMO> has the authority to examine, use or disclose, as the case may be, said medical records or personal information.

8. CONFIDENTIALITY. Client, agents or representatives, shall not use or reproduce, directly or indirectly any Confidential Information for the benefit of any person, or disclose to anyone such Confidential Information without the written authorization of <HMO>, whether during or after the term of this Agreement, for as long as such information retains the characteristics of Confidential Information.

"Confidential Information" means any data or information, that is proprietary to <HMO> and not generally known to the public, whether in tangible or intangible form, whenever and however disclosed, including, without limitation, (i) personal information, treatments or operations undergone by its Members, (ii) trade secrets, confidential or secret formulae, special medical equipment and procedures, (iii) medical utilization reports, directly or indirectly useful in any aspect of the business of <HMO>, (iv) any vendor names, Member and supplier lists, (v) marketing strategies, plans, financial information, or projections, operations, sales estimates, business plans and performance results relating to the past, present or future business activities of <HMO>, (vi) all intellectual or other proprietary information or material of <HMO>; (vii) all forms of Confidential Information including, but not limited to, loose notes, diaries, memoranda, drawings, photographs, electronic storage and computer print outs; (viii) any other information that should reasonably be recognized as confidential information of <HMO>. All information which Client acquires or becomes acquainted with during the period of this Agreement, whether developed by <HMO> or by others, which Client has a reasonable basis to believe to be Confidential Information, or which is treated, designated and/or identified by <HMO> as being Confidential Information, shall be presumed to be Confidential Information. Confidential Information need not be novel, unique, patentable, copyrightable or constitute a trade secret in order to be designated Confidential Information. ICHDca

9. FUTURE TAXES, LEVIES AND GOVERNMENT IMPOSITION. If during the effectivity of this Agreement, the fees and benefits are made subject to new taxes, levies or fees, or such law, regulation or its equivalent resulted to changes in the formula or manner of computing taxes thereby resulting in additional obligations on the part of <HMO>, any additional amount due shall automatically be charged to the Client/Member in addition to the fees stated therein. Future taxes, levies or fees referred herein are only those that affect the quoting of Membership Fees (Ex. 12% VAT), other future taxes, levies or government impositions that do not affect the quoting of Membership fees are therefore excluded.

10. GOVERNING LAW. This Agreement shall be governed by and construed in accordance with the laws of the Republic of the Philippines.

11. ARBITRATION. Any difference arising between the Client or any Member and <HMO> shall be referred to an arbitrator to be appointed by the parties to the dispute. If the parties are unable to agree on a single arbitrator, two (2) arbitrators shall be appointed (one by each party). In the event of further disagreement, the arbitrators shall select an umpire. If the difference between the parties requires medical knowledge (including any question regarding the appropriate maximum indemnity for any medical service or an operation not listed in the schedule of surgical fees) the arbitrators at the discretion of <HMO>, may be a registered medical practitioners and the umpire in such an instance, shall be a consultant Specialist, Surgeon, or Physician. Determination of an award shall be a Condition Precedent to Any Liability or right of action against <HMO>.

12. SEPARABILITY. If any term or provision of this Agreement is declared invalid, illegal or unenforceable under Philippine laws, such invalidity, illegality or unenforceability shall not affect or render unenforceable any other term or provision of this Agreement.

13. NOTICES. All notices, demands and other communications required or permitted hereunder shall be made in writing and sent to Client at the address indicated in the Conforme Letter.

14. RIGHT OF SUBROGATION. The coverage under this Agreement is extended to cover injuries of the Member caused by third party(ies) whether liability is determinable or not as in cases of vehicular accidents and other similar instances or related incidents including but not limited to all the claims, losses, damages which may be recovered by the Member or which may have been paid to or due him as a result of the Illness or Disability which have been paid by <HMO> pursuant to the Terms and Conditions of the Agreement and that the Member will subrogate his rights of recovery from any other party to <HMO> and will undertake to assist <HMO> in the successful recovery of the losses.

15. CIVIL CODE ARTICLE 1250 WAIVER. The provisions of Article 1250 of the Civil Code of the Republic of the Philippines (Republic Act No. 386) which reads, "In case an extraordinary inflation or deflation of the currency stipulated should supervene, the value of the currency at the time of establishment of the obligation shall be the basis of payment," shall not apply in determining the extent of liability under the provisions of this Agreement. cDHAES

16. IMPORTANT NOTICE. The Insurance Commission, with offices in Manila, Cebu and Davao, is the government officer in charge of the enforcement of all laws related to Health Maintenance Organization (HMO), and has supervision over HMOs. It is ready at all times to assist the general public in matters pertaining to HMO, pre-need and insurance. For any inquiries or complaints, please contact the Public Assistance and Mediation Division (PAMD) of the Insurance Commission at 1071 United Nations Avenue, Manila with telephone numbers +632-5238461 to 70 and email address [email protected]. The official website of the Insurance Commission is www.insurance.gov.ph.

Schedule A — Benefit Coverage

I. In-Patient Care Benefits

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Room and Board Accommodation	Subject to the Member's Room and Board limit
2	Use of operating room, Intensive Care Unit (ICU), isolation room (if prescribed by Attending Affiliated Physician) and recovery room.	Subject to Maximum Benefit Limit (MBL)/Annual Benefit Limit (ABL)
3	Professional fees in accordance with HMO schedule of rates per physician/specialist.	Subject to MBL/ABL
	a. Attending Physicians
	b. Surgeons
	c. Anesthesiologists
	d. Cardio-pulmonary clearances before surgery and cardiac monitoring during surgery except CP clearances for all elective surgical cases including OB and Gynecology.
4	Standard Nursing Services	Subject to MBL/ABL
5	Medicines for in-patient use	Subject to MBL/ABL
6	Blood products transfusions and intravenous fluids, including blood screening and cross matching if the Member patient is the recipient excluding expenses for donor screening services	Subject to MBL/ABL
7	X-Ray, laboratory examinations, routine, diagnostic and therapeutic procedures incidental to confinement	Subject to MBL/ABL
8	Dressings, conventional casts (plaster of Paris) and sutures	Subject to MBL/ABL
9	Anesthesia and its administration	Subject to MBL/ABL
10	Oxygen and its administration	Subject to MBL/ABL
11	Standard Admission kit	Subject to MBL/ABL
12	All other items directly related in the medical management of the patient, as deemed medically necessary by the Attending Affiliated Physician	Subject to MBL/ABL

 

II. Emergency Care Benefits TCAScE

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	In Affiliated Hospitals
	a. Physician's services	Affiliated Physician Non-Affiliated Physician
	b. Emergency Room Fees	Subject to MBL/ABL
	c. Medicines used for immediate relief during treatment	Subject to MBL/ABL
	d. Oxygen, Intravenous fluids and blood products	Subject to MBL/ABL
	e. Dressings, conventional casts (plaster of Paris) and sutures	Subject to MBL/ABL
	f. X-Rays, laboratory and diagnostic examinations, and other medical services related to the emergency treatment of the patient	Subject to MBL/ABL
2	In Non-Affiliated Hospitals	Reimbursable up to x% of hospital bills & professional fees based on rates incurred during the first 24 hours of treatment up to XX/availment/Member/year
3	Outside the Philippines	Reimbursable up to 100% of actual cost subject to the inner limits and MBL/ABL
4	Areas without Affiliated Hospital	a. 100% on room and board charges according to the Member's Room and Board accommodation. b. 100% on other hospital bills. c. Professional fees based on rates for an Affiliated Physician rendering the service in an Affiliated Hospital.
5	Ambulance Land Transfer (Affiliated Hospital/Clinic to Affiliated Hospital/Clinic)	Up to MBL/ABL
6	Ambulance Land Transfer (Non-Affiliated Hospital/Clinic to Affiliated Hospital/Clinic)	Reimbursable up to Pxx per ambulance conduction

Note: The ambulance service provided herein shall be available regardless of the location within the Philippines.

7

Initial treatment of Animal bites except cost of vaccines

Covered for the first 24 hrs. from the time of bite subject to MBL

 

III. Out-Patient Care Benefits ASEcHI

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Consultations and treatment prescribed by an affiliated physician or specialist.	Subject to Maximum Benefit Limit (MBL)/Annual Benefit Limit (ABL)
2	Pre and Post Natal consultations.	Subject to MBL/ABL
3	Treatment for minor injuries and minor surgery except out-patient medicines.	Subject to MBL/ABL
4	Dressings, conventional casts (plaster of Paris) and sutures.	Subject to MBL/ABL
5	Routine diagnostic examinations and therapeutic procedures prescribed by an Affiliated Physician/Specialist provided however that the cost of diagnostic and therapeutic procedures covered shall be limited to a specific amount.	Subject to MBL/ABL
6	Laser Eye therapy only for retinal tear, retinal hole, retinal detachment and glaucoma prescribed by an Affiliated Physician/Specialist.	Up to xx/eye/Member/year
7	Electrocauterization of skin lesions such as plantar warts, flat warts, periungual warts, filiform warts and molluscum contagiosum, in any part of the body prescribed by an Affiliated Physician/Specialist.	Up to xx/Member/year
8	Sclerotherapy for varicose veins (except medicines and for cosmetic purposes) as prescribed by an Affiliated Physician, to be availed through affiliated vascular surgeons.	Up to xx/leg/Member/year
9	Allergy Testing/allergy screening and other related examinations prescribed by an Affiliated Physician.	Up to xx/Member/year
10	Speech therapy for stroke patients only. Note: Consultations shall be part of the limit and treated as sessions.	Actual charge up to xx/Member/year
11	Tuberculin test	Up to xx/Member/year

 

IV. Preventive Care Benefits

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Passive and active vaccines including anti-venom for tetanus, animal bites as well as snake bites; and its administration	Up to xxx/Member/year
2	Health-education and counseling on diets or exercise	Covered
3	Health habits and Family Planning counseling	Covered

 

V. Benefits Covered Whether Out-Patient or In-Patient

1. ROUTINE PROCEDURES (whether OP or IP)

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Blood Chemistries	Actual Cost subject to MBL/ABL
2	Chest X-Ray	Actual Cost subject to MBL/ABL
3	Complete Blood Count (CBC)	Actual Cost subject to MBL/ABL
4	Fecalysis	Actual Cost subject to MBL/ABL
5	Urinalysis	Actual Cost subject to MBL/ABL

 

2. DIAGNOSTIC PROCEDURES (whether out-patient or in-patient)

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	12-Lead Electrocardiogram (ECG)	Actual Cost subject to MBL/ABL
2	24-hour Electroencephalogram (EEG) Monitoring	Actual Cost subject to MBL/ABL
3	24-hour Holter Monitoring	Actual Cost subject to MBL/ABL
4	Adrenocortical Function	Actual Cost subject to MBL/ABL
5	Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam	Actual Cost subject to MBL/ABL
6	Arterial Blood Gas	Actual Cost subject to MBL/ABL
7	Arthroscopic Procedures, Orthopedic Arthroscopy	Actual Cost subject to MBL/ABL
8	Audiograms and Tympanograms	Actual Cost subject to MBL/ABL
9	Bone Densitometry Scan (Dexascan)	Actual Cost subject to MBL/ABL
10	Bone Mineral Density Studies	Actual Cost subject to MBL/ABL
11	Cardiac Stress Tests (Thallium and Dipyridamole Stress Tests)	Actual Cost subject to MBL/ABL
12	Computed Tomography (CT) Scans	Actual Cost subject to MBL/ABL
13	Diagnostic Radiographs:	Actual Cost subject to MBL/ABL
	a. Biliary tract: Cholecystogram and Cholangiogram	Actual Cost subject to MBL/ABL
	b. Chest, ribs, sternum and clavicle	Actual Cost subject to MBL/ABL
	c. Digestive: Plain film of the abdomen, Barium Enema, Upper Gastrointestinal (GI) Series, Lower GI Series, Small Bowel series	Actual Cost subject to MBL/ABL
	d. Face (including sinuses), Head and Neck	Actual Cost subject to MBL/ABL
	e. Urinary: Kidney, Ureter and Bladder (KUB) Pyelograms and Cystograms	Actual Cost subject to MBL/ABL
	f. X-ray of the extremities and pelvis	Actual Cost subject to MBL/ABL
	g. X-ray of the spine (cervical, thoracic, lumbo-sacral)	Actual Cost subject to MBL/ABL
14	Diagnostic Ultrasounds:	Actual Cost subject to MBL/ABL
	a. 2D-Echo with Doppler	Actual Cost subject to MBL/ABL
	b. Abdomen	Actual Cost subject to MBL/ABL
	c. Duplex Scan	Actual Cost subject to MBL/ABL
	d. Digestive and Urinary Systems	Actual Cost subject to MBL/ABL
	e. Ultrasound of the Lungs	Actual Cost subject to MBL/ABL
15	Electroencephalogram (EEG) Monitoring	Actual Cost subject to MBL/ABL
16	Electromyelography and Nerve Conduction Studies	Actual Cost subject to MBL/ABL
17	Endoscopic Procedures	Actual Cost subject to MBL/ABL
18	Fluorescein Angiography	Actual Cost subject to MBL/ABL
19	Impedance Plethysmography	Actual Cost subject to MBL/ABL
20	Magnetic Resonance Angiography (MRA)	Actual Cost subject to MBL/ABL
21	Magnetic Resonance Imaging (MRI)	Actual Cost subject to MBL/ABL
22	Mammogram and Sonomammogram	Actual Cost subject to MBL/ABL
23	Myelogram	Actual Cost subject to MBL/ABL
24	Nuclear Radioactive Isotope Scan	Actual Cost subject to MBL/ABL
25	Pap's Smear	Actual Cost subject to MBL/ABL
26	Perfusion Scan	Actual Cost subject to MBL/ABL
27	Plasma Urinary Cortisol, Plasma Aldosterone	Actual Cost subject to MBL/ABL
28	Polysomnograms (Sleep Recording)	Actual Cost subject to MBL/ABL
29	Pulmonary Function Tests	Actual Cost subject to MBL/ABL
30	Radioisotope Scans and Function Studies:	Actual Cost subject to MBL/ABL
	a. Cardiac	Actual Cost subject to MBL/ABL
	b. Gastrointestinal	Actual Cost subject to MBL/ABL
	c. Liver	Actual Cost subject to MBL/ABL
	d. Parathyroid Bone, Pulmonary (Perfusion/Ventilation Lung Scans)	Actual Cost subject to MBL/ABL
	e. Renal	Actual Cost subject to MBL/ABL
	f. Thyroid Scans	Actual Cost subject to MBL/ABL
	g. Total Body Scans	Actual Cost subject to MBL/ABL
31	Radionuclide Ventriculography	Actual Cost subject to MBL/ABL
32	Surface Electromyography (SEMG)	Actual Cost subject to MBL/ABL
33	Thallium Scintigraphy	Actual Cost subject to MBL/ABL
34	Treadmill Stress Test (TMST)	Actual Cost subject to MBL/ABL

 

3. THERAPEUTIC PROCEDURES CAIHTE

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Anti-neoplastic Chemotherapy	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
2	Arthrocentesis	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
3	Continuous Positive Airway Pressure (CPAP) titration for sleep study	Up to Px shared limit for OP and IP
4	Dialysis	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
5	Oral anti-neoplastic chemotherapy	Up to x shared limit for OP and IP
6	Physical therapy	Shared limit of up to x sessions/Member/year subject to MBL/ABL for OP; Up to MBL/ABL for IP *Define session
7	Therapeutic Radiology:
	a. Brachytherapy	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
	b. Cobalt	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
	c. Linear Accelerator Therapy	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
	d. Radioactive Cesium	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
	e. Radioactive Iodine	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
8	Thoracentesis	Up to MBL/ABL shared limit for OP and IP

 

4. ADDITIONAL PROCEDURES AND MODALITIES (shared limit for OP and IP; Professional Fees, Hospital Bills and other incidental expenses relative to the procedure shall form part of the limit).

The following procedures and modalities are subject to the inner limits when specified, otherwise Actual Cost, subject to MBL/ABL.

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Angiography (gastrointestinal, brain, retinal and peripheral vascular)	Actual Cost subject to MBL/ABL
2	Coronary Angiogram and/or Angioplasty/Coronary Artery Bypass Graft
3	Cryosurgery	Actual Cost subject to MBL/ABL
4	Gamma Knife Surgery	Actual Cost subject to MBL/ABL
5	Hysteroscopic Myoma Resection	Actual Cost subject to MBL/ABL
6	Hysteroscopically-guided D&C	Actual Cost subject to MBL/ABL
7	Laparoscopy	Actual Cost subject to MBL/ABL
8	Lithotripsy	Actual Cost subject to MBL/ABL
9	Percutaneous Ultrasonic Nephrolithotomy	Actual Cost subject to MBL/ABL
10	Stereotactic Brain Biopsy	Actual Cost subject to MBL/ABL
11	Conventional Hemorrhoidectomy	Actual Cost subject to MBL/ABL
12	Scalpel Hemorrhoidectomy	Up to Pxxx
13	Stapled Hemorrhoidectomy	Up to x/Member/year
14	Mammotome/Vaccum Assisted Breast Biopsy	Up to x/Member/year
15	4D Ultrasound except for maternity-related cases	Up to x/Member/year
16	Esophageal Manometry	Up to x/Member/year
17	Intensified Modulated Radiotherapy	Up to x/Member/year
18	Botox which is not cosmetic in nature nor for beautification purpose	Up to x/Member/year
19	Positron Emission Tomography (PET) Scan	Up to x/Member/year
20	CT Pulmonary Angiography	Up to x/Member/year
21	Photodynamic Therapy	Up to x/Member/year
22	Other medically necessary modalities not mentioned above and those for which there are no comparable, conventional or traditional counterparts	Up to x/procedure/Member/year
23	Transurethral Microwave Therapy of Prostate	Up to x/Member/year

 

VI. Additional Benefits CHTAIc

The following procedures and modalities are subject to the inner limits when specified, otherwise Actual Cost, subject to MBL/ABL.

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

2 *	Motor Vehicular Accidents	Subject to MBL/ABL and exclusions and limitations
3	Unprovoked Assault, including domestic violence, whether initiated by the Member or by a known or unknown third party	Up to MBL/ABL
4	Scoliosis including necessary procedures, except physical therapy sessions, whether congenital, pre-existing, developmental or acquired. Note: Physical Therapy sessions shall form part of the Physical therapy/Occupational therapy limits.	Up to xx/Member/year (shared limit for OP and IP)
5	Congenital Conditions except physical therapy sessions and developmental disorders. Note: Physical Therapy sessions shall form part of the Physical therapy/Occupational therapy limits.	Up to xx/Member/year (shared limit for OP and IP)
5 *	Congenital Hernia	Up to MBL
6	Chronic Dermatoses (Consultations only)	Up to MBL
7	Scabies (consultations and treatments)	Up to MBL
8	Valvular heart disease (congenital and/or acquired) including Cardiomyopathies, Chronic Glomerulonephritis, previous craniotomy sequelae/hearing impairment/Neurologic disease and Spinal Stenosis (if pre-existing)/Poliomyelitis/Slipped disc (if pre-existing) and Guillain-Barre Syndrome, Diabetes and its complications (if pre-existing), Complicated Hypertension (e.g., those with history of stroke, myocardial ischemia or infarction and poor kidney function), and all malignant tumors (if pre-existing)	Up to MBL (if acquired) and subject to Dreaded Pre-existing provision (if Pre-existing)
9	Hepatitis B except vaccines and screening	Up to MBL/ABL (if acquired)

 

VII. Optional Benefits

1. ANNUAL CHECK-UP (ACU)

 

1	Physical Examination	Covered
2	Complete Blood Count	Covered
3	Urinalysis	Covered
4	Fecalysis	Covered
5	Chest X-Ray	Covered
6	Electrocardiogram (ECG)	(Optional) For Members 35 years old and above
7	Pap's Smear	(Optional) For female Members 35 years old and above

 

2. EXECUTIVE CHECK-UP (ECU)

 

1	Executive Check-up (IP)	Covered
2	Executive Check-up (OP)	Covered
3	Semi-Executive Check-up (OP)	Covered

 

3. DENTAL CARE

The following procedures and modalities are subject to the inner limits when specified, otherwise Actual Cost, subject to MBL/ABL.

 

1	Annual Dental examination and consultation	Covered
2	Emergency out-patient dental treatment — to be availed at affiliated dental clinics only	Covered
3	Oral Prophylaxis	Covered*
4	Simple tooth extractions	Covered
5	Restorative and prosthodontic treatment planning	Covered
6	Temporary fillings.	Covered*
7	Desensitization of hypersensitive teeth.	Covered*
8	Simple adjustment and repair of dentures.	Covered
9	Re-cementation of loose crowns, bridges, inlays and onlays.	Covered
10	Dental nutrition and dietary counseling.	Covered
11	Dental health education.	Covered
12	Permanent fillings (not applicable for basic dental package)	Covered*
13	Palliative treatment for simple mouth sores and blisters	Covered
14	Open incision and drainage (intraoral)	Covered
15	Pre-natal check of teeth and gums	Covered
16	Temporo Mandibular Joint Consultation (Initial consult only, referral to specialist not covered)	Covered
17	Gum Treatment for cases like inflammation or bleeding	Covered

 

4. MATERNITY ASSISTANCE — Optional

 

1

Covered Members

Female Employees (Married or Single/Married only) and Spouse of Male Employees

2	The HMO shall cover the hospital bills and professional fees incurred by covered Member for maternity services/procedures, up to the following limit:

	Normal Delivery	(Specify Limit)
	Caesarian	(Specify Limit)
	Miscarriage and Abortion	(Specify Limit)
	Ectopic Pregnancy	(Specify Limit)
	H.Mole Pregnancy	(Specify Limit)
	Home Delivery	(Specify Limit)
	Other Complications	(Specify Limit)
3	Type of Availment	LOA-facilitated if availed within the network; and shall be on reimbursement basis based on actual amount and subject to above mentioned limits if availed outside the network
4	280 days Waiting Period	Waived/Applicable
5	Laboratory procedures/work-ups (limited to nine (9) procedures only)	Covered/Not Covered

6	For availments in Affiliated Hospitals but with Non-Affiliated Physicians, the HMO shall provide outright coverage for the hospitals bills and the professional fees of Non-Affiliated Physicians shall be on a reimbursement.

 

Schedule B — Membership Fees

ANNEX B

Corporate Contract Provisions

<HMO> shall extend, during the effectivity of this Agreement, healthcare and health maintenance services and programs to <Client Company/Association Name>'s ("Client") employees/members who would qualify as bona fide Members of <HMO> upon enrolment and payment of the appropriate Membership Fees by Client. EATCcI

Parties to this Agreement include <HMO> and the Client only.

The Effective Date of this Agreement is on DD MM YYYY.

I. DEFINITION OF TERMS

1. ACCIDENT. A visible, external, sudden and violent event occasioned by a physical or natural cause and occurring entirely beyond the Member's control causing damage to the health of the Member.

2. ACTIVELY AT WORK. An employee who: (i) is on a regular paid vacation leave as certified by the Client or on paid non-working day; (ii) is not absent from work due to sickness, Injury or other form of Disability; (iii) was actively at work on the last preceding regular working day prior to the Effective Date of this Agreement.

3. AFFILIATED HOSPITAL. A duly licensed hospital included in the list of affiliated hospitals of <HMO> with which the <HMO> has an existing and valid service agreement and where a Member can avail of medical services pursuant to this Agreement.

4. AFFILIATED MEDICAL CLINIC. A duly licensed medical health care facility included in the list of affiliated medical clinics of <HMO> which has an existing and valid affiliation agreement with <HMO> and where a Member can avail of medical services pursuant to this Agreement.

5. AFFILIATED PHYSICIAN. A duly licensed physician or specialist affiliated by <HMO> and named in the list of <HMO>'s affiliated physician with whom <HMO> has made arrangements to provide the required services under this Agreement.

6. ANESTHESIOLOGIST. A specialist duly licensed and registered to administer anesthetic agents and conduct other anesthesia procedures during medical operation.

7. ANNUAL BENEFIT LIMIT (ABL). The maximum liability that <HMO> shall assume for all covered services rendered to a Member within the one-year term of this Agreement. ABL is replenished upon renewal of this Agreement but not during extension.

8. ATTENDING PHYSICIAN. An Affiliated Physician who is part of the medical staff of an Affiliated Hospital or Affiliated Medical Clinic, and legally responsible for the care given to a Member while in the hospital or on out-patient basis.

9. AUTHORIZED REPRESENTATIVE. A person duly authorized by <HMO> to approve the provision of medical services or claims reimbursements to a Member.

10. CONTRIBUTORY MEMBER. A Member whose Membership Fee is fully or partially paid for by the Member.

11. CUSTODIAL OR MAINTENANCE CARE. Care which is primarily for the purpose of assisting the Member in the activities of daily living or in meeting personal rather than medical needs, which is not specific therapy for an Illness or Injury and is not skilled care.

12. DEVELOPMENTAL, CONGENITAL CONDITION, BIRTH DEFECT. A medical abnormality existing at the time of birth as well as neonatal physical or mental abnormalities developing thereafter because of causal factors or conditions present at the time of birth.

13. DISABILITY. An Illness or Injury and any symptoms, sequelae, or complication thereof requiring treatment. All injuries arising from the same event or series of continuous events are considered as one Disability.

14. DURABLE MEDICAL EQUIPMENT. As determined by the <HMO>, medically prescribed items of medical equipment for repeated use, owned or rented, such as but not limited to crutches and wheelchairs which are placed in the home of a Member to facilitate treatment and/or rehabilitation of Illness or Injury.

15. EFFECTIVE DATE. The date the Agreement commences as specified in the Agreement.

16. ELIGIBLE EXPENSES. Expenses incurred in the treatment of a covered Illness or Injury which are Medically Necessary and not exceeding the limits in Schedule A — Benefit Coverage.

17. EMERGENCY CONDITION. A life threatening or accidental Injury or a sudden and unexpected onset of a condition or Illness which at the time of the occurrence reasonably appears to have the potential of causing immediate Disability or death, or which requires the immediate action or alleviation of pain or discomfort. These Illnesses or injuries require urgent medical or surgical care and attention which the Member secures immediately after the onset or as soon as the care may be made available.

18. EXPIRY DATE. The date the Agreement is scheduled to terminate which is one (1) year from the Effective Date. ISHCcT

19. ID CARD. The identification card issued by <HMO> to a Member containing the latter's name and signature, ID reference number, and other matters pertaining to his Membership.

20. ILLNESS. A poor health or poor physical condition marked by a pathological deviation from the normal healthy state caused by disease or sickness.

21. INJURY. Physical damage or trauma arising wholly and exclusively from an Accident or other events of violent or external, and visible nature.

22. LETTER OF AUTHORIZATION (LOA). Letter of authorization duly issued by <HMO> to, and signed by, the Member which shall serve as the authority of the latter to avail of the medical services.

23. MATERIAL INFORMATION. An information is deemed material if its disclosure would have resulted in the (a) declination of the application for Membership of the applicant, (b) the assessment of a higher Membership Fee or (c) the inclusion of additional restrictions and exclusions to the benefits of the Member under this Agreement.

24. MAXIMUM BENEFIT LIMIT (MBL). The maximum liability that <HMO> shall cover and assume per covered Illness or Injury of a Member within the term of this Agreement. MBL is replenished upon renewal of the Agreement by Client but not during any extension thereof.

25. MEDICALLY NECESSARY. A medical service, as determined by <HMO>, which is (a) consistent with the diagnosis and customary medical treatment of the condition, (b) in accordance with the standards of managed care and good medical practice, (c) not for the convenience of the Member or the Affiliated Physician, (d) performed in the most cost effective manner required by the medical condition and (e) consistent with the terms and conditions of this Agreement.

26. MEDICINES AND DRUGS. Those for which a licensed medical practitioner has prescribed for dispensing, which are specifically required for the treatment of a covered Illness or Injury under this Agreement.

27. MEMBER. A Principal and/or Dependent who is eligible, has been accepted for Membership by <HMO> after complying with the Eligibility provision, and is currently enrolled under this Agreement.

28. MEMBERSHIP. Refers to membership in <HMO>, pursuant to this Agreement.

29. NON-CONTRIBUTORY MEMBER. A Member whose Membership Fee is fully paid for by the Client.

30. PHYSICIAN, SURGEON, SPECIALIST, OR DOCTOR: A person qualified by degree and duly licensed or registered to practice medicine in the geographical area in which he serves. This person must not be a relative of the Member up to the third degree of consanguinity and affinity. DHITCc

31. PRIVATE NURSE. A licensed nurse providing close observation and performing special treatments, which are certified as Medically Necessary by the Attending Physician.

32. PROFESSIONAL FEES. As distinct from Surgeon and Anesthesiologist's Fees, fees paid to licensed medical professionals including but not limited to an Occupational Therapist, Physiotherapist, Attending Physician's visits or Pathologists.

33. ROOM AND BOARD ACCOMMODATION. The pre-assigned type of hospital room and board by <HMO> to the Member based on the benefit and coverage of the health care plan under this Agreement.

34. STATEMENT OF ACCOUNT or "SOA". The statement of account duly issued by <HMO> on or before the due date of payment reflecting Membership Fees and other monetary obligations, if any, payable by Client.

35. SURGERY. The branch of medicine dealing with manual or operative procedures for the correction of deformities and defects, repair of injuries, diagnosis and cure of certain diseases. This includes surgery performed in an out-patient setting for a covered Illness or Injury.

II. BENEFIT PROVISIONS

All the benefits provided for this Agreement are detailed in Schedule A — Benefit Coverage and subject to the following terms and conditions:

1. IN-PATIENT CARE. Coverage of in-patient benefits, except for Emergency Conditions, wherein the Emergency Care provision of this Agreement will apply, shall be subject to the following conditions:

a. The hospital confinement must be recommended by an Affiliated Physician and approved by the duly authorized representative of <HMO> in that Affiliated Hospital prior to confinement.

b. The confinement shall be in an Affiliated Hospital and in accordance with the Member's Room and Board Accommodation.

c. Professional services shall be provided only by Affiliated Physicians.

d. As proof of conditions a, b, and c above, <HMO> shall issue the requisite Letter of Authorization (LOA) and other necessary documents.

e. If a Member for whom discharge order has been issued by the Attending Physician refuses to be discharged, <HMO> shall no longer be responsible for all hospital expenses and professional fees incurred after the specific time or hour the Member should have been discharged. Such expenses shall be charged to the personal account of the Member.

2. EMERGENCY CARE

a. In Affiliated Hospital. If the emergency treatment has been administered in an Affiliated Hospital and the Member still requires confinement, <HMO> shall provide the in-patient benefits subject to the provisions of this Agreement. CAacTH

If at the time of the confinement, the Affiliated Hospital has no available room in accordance with the Member's Room and Board Accommodation, the Member may opt to avail of a room accommodation which is higher than his Room and Board Accommodation but <HMO> will only cover the incremental rate differences for the room upgrade, professional fees, diagnostic and laboratory examinations, and other ancillary medical services for the first twenty-four (24) hours of confinement. The said charges and expenses shall be subject to the Member's MBL. All incremental costs incurred after the first twenty-four (24) hours shall be for the personal account of the Member except when the Affiliated Hospital issues a certification of non-availability of the Member's Room and Board Accommodation.

b. In Non-Affiliated Hospital. If emergency treatment has been administered in Non-Affiliated Hospital and the Member still requires confinement, he or his representative, as a pre-requisite for in-patient coverage, must notify <HMO> within a period of twenty-four (24) hours from admission. However, in case the Member, due to his medical condition, is unable to communicate directly or through a representative, the 24-hour notification period shall be extended for twenty-four (24) hours from the time he is clinically able to do so.

c. In all these circumstances, <HMO> reserves the right to validate whether the treatment received is emergency in nature and/or the Illness or condition is covered under the provisions of this Agreement.

3. OUT-PATIENT CARE

The Out-patient benefits can be availed by the Member immediately from the effective date of Member's coverage, and every renewal date thereafter provided that the Membership Fees shall have been paid during the first billing. The benefits can be availed only through the Affiliated Hospital/Clinics and Physician of <HMO>.

III. PRE-EXISTING CONDITIONS

An Illness, Injury or condition shall be considered pre-existing if it existed before the Effective Date of the Member's coverage, the natural history of which can be medically determined to have started prior to the effective date of coverage or at the time of processing of the Member's Application, whether or not the Member was aware of such Illness, Injury or condition.

Pre-Existing Conditions shall include the following Illnesses, Injuries or conditions, but not to the exclusion of all others including their complications and sequelae: cEaSHC

1. Tumor/Cyst of Internal Organs

2. Hemorrhoids/Anal Fistula

3. Diseased tonsils and sinus conditions requiring surgery

4. Cataract/Glaucoma

5. Pathological Abnormalities of nasal septum or turbinates

6. Goiter and other thyroid disorders

7. Hernia/Benign Prostatic Hypertrophy

8. Endometriosis

9. Asthma/Chronic Obstructive Lung disease

10. Epilepsy

11. Spinal column abnormalities

12. Tuberculosis

13. Cholecystitis

14. Gastric or Duodenal ulcer

15. Hallux valgus

16. Hypertension and other Cardiovascular diseases

17. Calculi

18. Tumors/Cyst on skin, muscular tissue, bone or any form of blood dyscrasias

19. Diabetes Mellitus

20. Cerebrovascular Accident/Transient Ischemic Attack

Diagnostic procedures undertaken to determine the existence of a Pre-existing Condition is a covered expense provided that the result of diagnostic procedure is negative for the existence of the pre-existing condition.

Pre-existing Condition shall only be covered after one year from Effective Date of the Member's coverage provided that there is no failure to disclose, misrepresent or conceal, Material Information in the original Application or Application for reactivation. Notwithstanding the disclosure by the Member of a pre-existing condition, the <HMO> may permanently exclude from cover or limit coverage a specific medical condition, Illness or Injury upon written notice to the Member.

IV. AVAILMENT AND CLAIMS PROCEDURE

1. CLAIMS SUBMISSION

a. Certification, Information and Evidence. All certificates, accounts, receipts, information and evidence required by <HMO> shall be furnished in such form as <HMO> may require.

b. Sufficiency of Notice. Written notice of any claim given by or on behalf of the Member or Beneficiary to <HMO> or to any authorized representative of <HMO>, with information sufficient to identify the Member, shall be deemed notice to <HMO>. IAETDc

c. Notice of Claim

c.1. A Member shall first report his condition to <HMO> or designated plan coordinator during clinic hours for treatment unless the condition is emergency in nature. The Affiliated Physician shall, upon examining the Member, prescribe the necessary medical procedure. If hospitalization is needed, the Affiliated Physician shall provide the required hospital referral in the prescribed form. Before being discharged from the Hospital, a Member must fill up the prescribed claim form and settle that portion of the medical bill not covered by the Agreement. That portion of the bill covered by the Agreement shall be settled directly by the HMO with the hospital and/or Attending Physician(s).

c.2. In case of emergency, the Emergency Care provision specified in the Agreement shall apply.

c.3. In cases wherein <HMO> covered costs were not deducted from the medical bills and a Member is made to pay for the health care cost, a Member may request reimbursement of such costs which are covered under the Agreement. The request must be made on the prescribed claim form to which shall be attached official receipts, together with supporting charge slips, detailed itemized accounts and other necessary documents. No reimbursement shall be made to the Member unless such original documents are submitted by the Member or if the Member has otherwise been fully indemnified or reimbursed of the medical bills or costs incurred under any other health care coverage or insurance policy or any other similar contracts or Agreements. Such request for benefits must be presented within thirty (30) days after the expiration of the period of confinement for which claim for benefits is being made. Failure to submit within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time.

c.4. <HMO> will process the payment of all claims within thirty (30) days upon receipt of complete documents and in accordance with the terms of the Agreement. All benefits that pertain to a Member will be paid by check to the order of Principal Member, unless the Principal Member requests otherwise, or <HMO>, in its discretion, considers it preferable to make the payment in another manner. In case of death of a Member, any benefit due but remaining unpaid shall be paid to the first surviving class of the following classes of successive preference of beneficiaries: the Member's (a) widow or widower; (b) surviving children; (c) surviving parents; (d) surviving brothers and sisters; and, (e) executors or administrators.

d. Fraudulent Claims. If any claim under this Agreement is in any respect fraudulent, all benefits payable and/or paid in relation to that claim shall be forfeited and if deemed appropriate, recoverable respectively. CTIEac

e. Physical Examination and Autopsy. <HMO> shall have the right and opportunity to examine the Member when and as often as it may reasonably require during the pendency of claim hereunder, and the right and opportunity to make an autopsy in case of death, where it is not forbidden by law.

2. BENEFIT PAYMENT

All benefits payment shall be in PHILIPPINE PESO.

a. Payment of Benefits. If a Member incurs Eligible Expenses during the effectivity of this Agreement, <HMO> will pay benefits in accordance with Schedule A — Benefit Coverage of this Agreement. <HMO> will pay the Eligible Expenses after application of any stipulated co-payment or other deductions that may apply.

b. Coordination of Benefits. Benefits will not exceed the total medical expenses when combined with other health care or medical coverage in force or organizations or which are provided free of charge in government or private facilities.

3. REIMBURSEMENT CLAIMS FOR EMERGENCY CASES

a. Limitation. The claims for reimbursement shall apply only in emergency treatments, whether out-patient or in-patient, rendered in non-Affiliated Hospitals.

b. Filing of Claims. All claims for reimbursement must be filed using the prescribed claim form and submitted to <HMO> Offices within thirty (30) days from the date of availment for out-patient or from date of discharge for in-patient.

Failure to submit within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time.

c. Payment of Claims. All benefits that pertain to a Member will be paid by check to the order of Principal Member, unless the Principal Member requests otherwise, or HMO, in its discretion, considers it preferable to make the payment in another manner. In case of death of a Member, any benefit due but remaining unpaid shall be paid to the first surviving class of the following classes of successive preference of beneficiaries: the Member's (a) widow or widower; (b) surviving children; (c) surviving parents; (d) surviving brothers and sisters; and, (e) executors or administrators.

d. Request for Reconsideration. If a claim for reimbursement is denied, or the Member is not satisfied/agreeable to the reimbursement paid by <HMO>, a written request for reconsideration must be filed with the <HMO> Head Office not later than ten (10) days from receipt of such denial or questioned reimbursement. Otherwise, the claim shall be deemed satisfied or terminated. The request for reconsideration shall contain all the reasons upon which reconsideration is sought and shall be decided upon by an authorized personnel of <HMO>, whose decision shall be final. <HMO> reserves the right to deny Claims for Reimbursement if the procedures and requirements have not been strictly complied with. DcHSEa

V. EXCLUSIONS AND LIMITATIONS

<All HMOs have a list of exclusions and benefit limitations. These exclusions and limitations would impact the HMO's pricing/membership fee calculation, and could define their pricing strategies.>

1. Services obtained for non-emergency conditions from physicians and hospitals in any of the following circumstances:

a. non-Affiliated Physicians in non-Affiliated Hospitals or non-Affiliated Clinics

b. non-Affiliated Physicians in Affiliated Hospitals or Affiliated Clinics

c. Affiliated Physicians in non-Affiliated Hospitals or non-affiliated Clinics or other healthcare facility.

2. Additional hospital charges and physician's professional fees resulting from:

a. room-upgrading beyond twenty-four (24) hours during Emergency Conditions;

b. extension of hospital stay despite release of discharge order from Member's Attending Physician;

c. fees of the assistant surgeons for surgeries with less than 250 RUV units/resident doctors who assisted the Attending Physician in the process of rendering the medical services shall not be chargeable to the Member and/or <HMO> except for hospitals that do not have resident physicians to assist during surgeries subject to the prior approval of <HMO>;

d. use of extra bed, TV, electric fan, DVD/VCD, and other similar items unless such appliances and items are necessarily and ordinarily included in the Member's Room and Board Accommodation;

e. extra food; toilet articles like face towel, soap, toothbrush and the like;

f. difference in Room and Board Accommodation, the incremental rate differences for professional fees, diagnostic and laboratory examinations, and other ancillary medical services brought about by obtaining a room and board accommodation higher than the Member's Room and Board Accommodation limit;

g. services of a private or a special nurse;

h. all other items not medically necessary in the medical management of the Member. SaCIDT

3. Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance/travel or government licensing, health permit and other similar purposes.

4. Custodial, Domiciliary, Convalescent and Intermediate care.

5. Medical certificates.

6. Professional fees of medico-legal officer/s.

7. All expenses incurred in the process of organ donation and transplantation if the Member is the donor, and its complications.

8. Benefits covered by PhilHealth and all other government funded healthcare entitlements as provided for by law.

9. Cost of the medical services and professional fees in excess of the MBL.

10. Purchase of lease of any Durable Medical Equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care.

VI. ELIGIBILITY

1. Principal Member. Principal Member is an employee who actively works full time and meets the requirement of the Client as an eligible member. [For associations: Principal Member is a person who meets the requirement of the Client as an eligible member.] The names of the Members must be in the list submitted by the Client to <HMO>.

Minimum and Maximum Enrollment Ages. A person who has attained the age of eighteen (18) years old but not more than XX years old. Attained age is defined as the age last birthday. [Enrollment to this Agreement is subject further to the prevailing Underwriting Guidelines of the HMO.]

2. Dependents. Persons designated by a Principal Member under this Agreement must be enrolled simultaneously or within thirty (30) days from enrollment of the Principal Member except for cases involving marriage or the birth of a child wherein enrollment must be made within thirty (30) days after the date of marriage or birth.

a. For Married Principal Member — The legal spouse, not more than sixty-five (65) years old and his natural born or legally-adopted children who have attained the age of fifteen (15) days and not more than twenty-one (21) years old, unmarried and not gainfully employed or earning an income and fully dependent upon the Principal Member for support are eligible.

b. For Single Principal Member — Parents who are not more than sixty-five (65) years old provided neither is employed for monetary gain and siblings who have attained the age of fifteen (15) days old and not more than twenty-one (21) years old, unmarried and not gainfully employed or earning an income and fully dependent upon the Principal Member for support are eligible.

c. For Single Parent Principal Member — Children who have attained the age of fifteen (15) days and not more than twenty-one (21) years old, unmarried, not gainfully employed or earning an income and fully dependent upon the Principal Member for support; or parents who are not more than sixty-five (65) years old provided neither is employed for monetary gain are eligible. SCaITA

3. Hierarchy Rule for Selecting Qualified Dependents. For married Principal Members, the spouse must be enrolled first followed by children applying their birth rank. For single Principal Members, the parents must be enrolled first followed by the siblings applying also their birth rank.

<HMO> reserves the right to require at any time the submission of such documents which <HMO> may deem appropriate for the purpose of validating the eligibility of Principal Members and their Dependents.

VII. PHILHEALTH/ECC PROVISION

This Agreement is integrated with benefits under the PhilHealth and/or Employee Compensation Commission (ECC). The <HMO> will deduct these entitlements from the amount otherwise payable. <HMO> will not pay or advance the costs of such benefits, nor be responsible for filing any claims under PhilHealth or ECC.

VIII. EFFECTIVE DATE AND DURATION

1. EFFECTIVE DATE OF THE AGREEMENT. This Agreement takes effect on ____________________.

2. TERMINATION OF AGREEMENT BY CLIENT.

a. By giving a written notice within [ten (10) days] from Effective Date of the Agreement, Client may cause the termination of this Agreement provided the ID Cards and this Agreement are surrendered to <HMO> within the same period. <HMO> shall thereafter terminate the Membership and the termination provision of this Agreement shall apply. Failure to terminate this Agreement within the period set shall be understood as an acceptance of all terms and conditions provided hereunder. Any availment of a Member within the [10-day period] shall also mean acceptance by Client of all the terms and conditions of this Agreement.

b. The Client may terminate this Agreement for justifiable reasons at any time by giving a written notice to the <HMO> at least [thirty (30) days] prior to the intended termination date. Client may only terminate this Agreement if it is not in default in the performance of its obligations or it has not violated any of its warranties and representations. Starting on the termination date, <HMO> shall be free from all liabilities to Client, Members and their dependents. This shall be without prejudice to the right of <HMO> to collect Client's obligations which have become due and demandable.

c. Client shall be entitled to a refund in accordance with Refund/Credit of Membership Fee provision.

3. TERMINATION OF AGREEMENT BY HMO. <HMO> shall have the right to immediately terminate this Agreement in the event that:

a. Any material representation or warranty made by Client is false or untrue when made; or if Client commits any act with the intent to defraud <HMO>;

b. Non-payment of Membership Fees and other obligations subject to agreed payment terms; cHECAS

All medical services and coverage under this Agreement shall terminate on the termination date, without prejudice to any claim for covered medical services rendered to a Member prior to the termination date.

Termination under this provision shall be without prejudice to the right of <HMO> to collect the Client's obligations which have become due and demandable.

4. RENEWAL OF AGREEMENT. This Agreement may be renewed for another year subject to negotiation.

5. TERMINATION OF MEMBER'S COVERAGE. Coverage shall automatically terminate on the earliest of the following:

a. Expiry date;

b. The date a member ceases to be eligible for coverage. However, when the Member's age exceeds the maximum permissible age, coverage will continue until Expiry Date.

c. If the Client is an employer and a member is an employee of said employer, the date a member retires, is pensioned, leaves voluntarily, or is dismissed from employment, or the date the member otherwise ceases active work for the Client, except that, in the event of Disability, temporary layoff or approved leave of absence, payment of the membership fee will continue the coverage for a limited period commencing from the date a member ceases active work and automatically terminating:

c.1. In the event of Disability, the end of the period of Disability; or

c.2. in the event of temporary layoff or approved leave of absence, the end of the month; or

d. When the Membership Fee and/or other obligations are not paid within the grace period;

e. Effective immediately, when the member has fraudulent availment or material misrepresentation or misstatements for the purpose of availing the benefits;

f. Effective immediately, when the member enters military, naval or air service of any country or international authority;

g. For a Dependent member:

g.1. on the date a dependent ceases to be eligible;

g.2. on the separation or termination of coverage of the principal member;

h. Effective immediately, when the member fails to observe the terms and conditions of this Agreement or fails to act with utmost good faith. aTHCSE

All medical expenses incurred after the date of termination of the member's coverage shall be charged to the Client.

If the Membership Fees are unpaid prior to cancellation or termination of Membership, Client shall settle the pro rata Membership Fee, inclusive of penalty charges if applicable.

IX. MEMBERSHIP FEES

1. AMOUNT OF MEMBERSHIP FEES. Client shall pay <HMO> the amounts stipulated in the attached Schedule B — Membership Fees for the services covered under this Agreement.

2. PAYMENT OF MEMBERSHIP FEES. The Membership Fees are due on the effective date of this Agreement and every month thereafter for monthly mode of payment, every quarter thereafter for quarterly mode of payment and every semester thereafter for semi-annual mode of payment. The Membership Fee due on any due date shall be the aggregate of the Membership Fees for all Members enrolled under this Agreement.

The Membership Fees of members added after any due date and any adjustments in the Statement of Account (SOA), such as addition or deletion of members, upgrading or downgrading of plan, errors and changes still under process, shall be reflected in another SOA to be given within thirty (30) days from the date the advice from Client is received by <HMO>.

Should there be any dispute, contest or conflict regarding the SOA on any substantial matter appertaining thereto, Client shall pay (X%) percent of the sum demanded on or before the due date, notwithstanding such dispute, contest or conflict, unless Client shows proof of significant error on any substantial matter stated in the SOA. For this purpose, significant error means an error that would affect at least 25% of the total amount due. Upon resolution of the dispute, contest or conflict, the adjustment, if any, shall be reflected in another statement of account to be given within seven (7) days from the date of dispute, contest or conflict was settled by Client and <HMO>. In this regard, a full payment of such adjusted SOA shall be made fifteen (15) days from the time of receipt of such adjusted SOA.

The absence of any written notice to <HMO> regarding dispute, contest or disagreement in the details contained in the SOA seven (7) days from receipt thereof shall constitute Client absolute agreement thereof.

3. GRACE PERIOD FOR PAYMENT OF MEMBERSHIP FEES. Client is given thirty (30) days grace period from Effective Date or due date, whichever is applicable, within which to pay the amount due.

4. APPLICATION OF PAYMENT. All payments received by <HMO> from Client shall be applied to the SOAs, in the order of respective due dates, starting from the earliest.

5. EFFECTS OF NON-PAYMENT OF MEMBERSHIP FEES. Non-payment of the Membership Fees due after the grace period shall entitle <HMO> to: AHDacC

a. Suspend all services under this Agreement or services to members whose Membership Fees have not yet been received, until full payment of all Membership Fees due, including penalty charges equivalent to X% a month or a fraction thereof on the unpaid Membership Fees due, computed from due date; and

b. Terminate this Agreement without prejudice to collect the amount due and the corresponding penalty charges that have accrued thereon.

6. LIFTING OF SUSPENSION. Suspension shall be lifted upon receipt of payment for the Membership Fees due plus penalty charges, subject to clearing of checks. Claims incurred during the Suspension shall not be reimbursed even after the lifting of suspension.

7. REACTIVATION OF AGREEMENT. Upon lifting of the suspension, <HMO> shall initiate the reactivation of this Agreement to the effect that members can access the <HMO>'s network of healthcare providers.

8. REFUND/CREDIT OF MEMBERSHIP FEE. If a Member's coverage is terminated or cancelled, the unused pro rata Membership Fee paid shall be refunded to the Client, only if no availment has been made by the Member prior to the termination or cancellation. Refund which shall be computed in accordance with the Short Period Rate Scale indicated below is available only if the Client has fully paid its annual or semi-annual Membership Fee.

 

SHORT PERIOD RATE SCALE

 

There shall be no refund of Membership Fees in the event that:

a. Membership Fee is payable on a quarterly or monthly mode;

b. Remaining coverage of the member is six (6) months or less;

c. The member has availed of any benefits under this Agreement; or

d. In the event that the total number of principal members falls below the minimum membership requirement.

9. MEMBERSHIP FEE OF MEMBERS ADDED AFTER THE EFFECTIVE DATE OF THE AGREEMENT. The Membership Fee of members added after the effective date of this Agreement shall be computed on a pro rata basis from the effective date of the Member's coverage until the Expiry Date.

10. MINIMUM NUMBER OF ENROLLEES. Client shall be required to pay the Membership Fees corresponding to the minimum principal Membership requirement of _____ persons in the event that the number of enrolled principal members falls below the minimum requirements at any time during the effectivity of this Agreement. cAaDHT

11. PARTICIPATION REQUIREMENT. When payment of Membership Fees is non-contributory, 100% enrollment of all eligible employees is required. On the other hand, when payment of Membership Fees is contributory, at least 75% of eligible employees must enroll. If the Agreement provides coverage for the dependents then all eligible dependents should be enrolled under the program or the number of dependents should reach at least 75% of the total number of principal Members.

X. MEMBERSHIP

1. INDIVIDUAL EFFECTIVE DATE OF A MEMBER'S COVERAGE.

a. If membership is non-contributory, coverage shall become effective on the Effective Date of this Agreement or the date on which the person first becomes eligible, whichever is later.

b. If membership is contributory, coverage shall become effective on the Effective Date of this Agreement, the date of enrollment provided that it is not more than one (1) month from effective date of this Agreement, or the date on which the person becomes eligible, whichever is latest.

2. ADDITION AND CANCELLATION OF MEMBERSHIP. The procedure on addition and cancellation of Members shall be subject to the following conditions:

a. Client shall submit all the required information of additional enrollees to <HMO>.

b. The Client's authorized representative shall duly endorsed the list of enrollees to ensure accuracy and security of data.

c. The Effective Date of Member's coverage shall be subject to the following conditions:

c.1. Change of Effective Date within the coverage period shall not be allowed.

c.2. <HMO> reserves the right to accommodate requests for late enrollment.

c.3. Effective date of an enrollee's coverage shall be based on the completion and receipt by <HMO> of all requirements.

c.4. Should the effective date of coverage depend on the date of regularization of the employee, Client shall ensure that the endorsement is made prior to the date of regularization or within thirty (30) days thereafter. The Effective Date of coverage shall then follow the date of regularization or the date of endorsement, whichever is later.

d. All additional enrollees/dependents must be endorsed within thirty (30) days from the Effective Date and they shall follow the original/renewal Effective Date of coverage. Additional enrollees beyond this period shall be considered in the next renewal period except for newly regularized employees, newly-wed spouse and newly-born dependents whose coverage is effective from the date of eligibility or the date of endorsement, whichever is later. IDSEAH

e. In case of a member's resignation, termination, separation or retirement, Client shall notify <HMO> in writing prior to the cancellation of membership. The cancellation shall be based on the Member's cancellation date as advised by the Client or the date of receipt of notice by <HMO>, whichever is later. Client shall also cause the return and surrender of the ID card to avoid fraudulent claims.

3. UPGRADING/DOWNGRADING OF PLAN. Upgrading or downgrading a Member's plan due to change in Member's classification (rank, position, assignment) shall be subject to the following conditions:

a. Client notifies the <HMO> in writing.

b. The Effective Date of the upgrading/downgrading of the plan shall be the date as endorsed by the Client.

c. In case of upgrade of plan, Client shall pay the additional Membership Fee corresponding to the effective date of the upgraded plan. In case of downgrade, <HMO> shall refund the excess Membership Fee corresponding to the effective date of the downgraded plan. There shall be no refund of excess Membership Fee if the member has availed any benefits pursuant to this Agreement.

4. INVALIDATION OF MEMBERSHIP. Failure to disclose any Material Information about a Member, including but not limited to gender, date of birth, hierarchy, dependent's relationship or medical information, whether intentional or unintentional, shall automatically invalidate the coverage of the member effective from the date of coverage.

XI. GENERAL PROVISIONS

1. ENTIRE AGREEMENT. This Agreement, Conforme Letter, the application form, the master list of enrolment, rider clauses or warranties and/or any stipulation or endorsement attached or posted to this Agreement or application form, shall constitute the entire contract between <HMO>, and Client. All statements and information contained in the Member's Application Form shall be deemed representations and warranties made by the Member himself for purposes of applying the provisions of this Agreement. The Conforme Letter, Renewal Letter or any other agreement between the Parties shall constitute as execution of this Agreement by the Parties. This Agreement supersedes all prior undertakings, arrangements, representations, agreements, whether verbal or written between the Parties.

Any change to this Agreement must be approved by an authorized officer of <HMO> and such approval must be endorsed or attached to this Agreement. Unless applied for by the Client/Member, no such alteration or endorsement shall affect any Agreement issued prior to the alteration or Endorsement without the written consent of the Client/Member.

The written consent shall be taken as his agreement to the contents of such alteration or Endorsement. HCaDIS

2. AREAS WITHOUT AFFILIATED HOSPITALS. In areas without Affiliated Hospitals, <HMO> will reimburse the following:

a. 100% on room and board charges according to the Member's Room and Board Accommodation.

b. 100% on other hospital bills according to the Member's Room entitlement.

c. Professional Fees based on <HMO> rates for an Affiliated Physician rendering the service in an Affiliated Hospital according to the PF of the Member's Room entitlement.

3. DOWNGRADING OF ROOM ACCOMMODATION. Availment of a room accommodation lower than the Member's Room and Board Accommodation can be done at the option of the Member but there shall be no refund or offsetting for the cost difference in room accommodation and other related medical benefits.

4. ROOM UPGRADING AND INCREMENTAL RATE DIFFERENCES. If a Member is confined in a hospital room of higher category than his Room and Board Accommodation within the <HMO> network for whatever reasons except during Emergency Care referred to under Benefit provisions, incremental rate difference and excess charges due to voluntary or involuntary room upgrading shall be charged to the Member, in accordance with the following:

a. For covered hospital charges or ancillaries, the Member shall pay the amount equivalent to XXX percent (X%) of such charges.

b. For Professional Fees, the Member shall pay the difference between the allowable Professional Fees (PF) of the occupied or upgraded room and allowable PF of member's room entitlement based on <HMO>'s Schedule of Fees.

c. For Room and Board charges, the Member shall pay the difference between the actual rate of the room occupied and the allowable room rate.

d. PhilHealth portion for which the Member is eligible shall be applied to or deducted from allowable charges.

5. EXCESS CHARGE. Any availment that is not covered but is advanced by <HMO> shall be charged to the Member and the Member shall be liable to pay such advances. These shall include but not limited to the following:

a. Benefit availment of lapsed or cancelled Members even if approved by <HMO>.

b. Hospital bills and professional fees that are in excess of <HMO> rates.

c. Amount in excess of the MBL and other inner limitations.

d. Availment that is not intended to be covered by <HMO>, such as exclusions, fraudulent availments, uncoverable items, telephone calls, additional beds, etc.

6. NON-TRANSFERABILITY. All benefits in this Agreement are not transferable or assignable. Client may not assign any of its rights or delegate any of its obligations under this Agreement without the prior written consent of <HMO>. <HMO> may assign any of its rights or delegate any of its obligations upon written notice to Client. Any purported assignment or delegation in violation of this Agreement is null and void. aCIHcD

7. AUTHORITY TO EXAMINE MEDICAL RECORDS. Client hereby represents and warrants that, at the time of the effectivity of this Agreement and effectivity of coverage of each Member and his dependents, it has obtained from the Member and his dependents the required consents authorizing <HMO> and any of its authorized representatives to: (a) obtain, examine and process the Member's personal information, including the medical records of their hospitalization, consultation, treatment or any other medical advice in connection with the benefit/claim availed under this Agreement; and (b) disclose such information to Client and its representatives.

It is hereby agreed that it is the sole responsibility of Client to obtain from the Members the consent herein specified and that <HMO> shall have all the right to rely on the representation by Client that this consent shall have been duly and timely obtained. Client shall hold <HMO> free and harmless from and against any and all suits or claims, actions, or proceedings, damages, costs and expenses, including attorney's fees, which may be filed, charged or adjudged against <HMO> or any of its directors, stockholders, officers, employees, agents, or representatives in connection with or arising from the use by <HMO> of the Member's and/or their dependents' medical records and other personal information pursuant to this Agreement and disclosure of such information to Client and its representatives pursuant to <HMO>'s reliance on Client's representation and warranty that <HMO> has the authority to examine, use or disclose, as the case may be, said medical records or personal information.

8. CONFIDENTIALITY. Client, including its employees, agents or representatives, shall not use or reproduce, directly or indirectly any Confidential Information for the benefit of any person, or disclose to anyone such Confidential Information without the written authorization of <HMO>, whether during or after the term of this Agreement, for as long as such information retains the characteristics of Confidential Information.

"Confidential Information" means any data or information, that is proprietary to <HMO> and not generally known to the public, whether in tangible or intangible form, whenever and however disclosed, including, without limitation, (i) personal information, treatments or operations undergone by its Members, (ii) trade secrets, confidential or secret formulae, special medical equipment and procedures, (iii) medical utilization reports, directly or indirectly useful in any aspect of the business of <HMO>, (iv) any vendor names, Member and supplier lists, (v) marketing strategies, plans, financial information, or projections, operations, sales estimates, business plans and performance results relating to the past, present or future business activities of <HMO>, (vi) all intellectual or other proprietary information or material of <HMO>; (vii) all forms of Confidential Information including, but not limited to, loose notes, diaries, memoranda, drawings, photographs, electronic storage and computer print outs; (viii) any other information that should reasonably be recognized as confidential information of <HMO>. All information which Client acquires or becomes acquainted with during the period of this Agreement, whether developed by <HMO> or by others, which Client has a reasonable basis to believe to be Confidential Information, or which is treated, designated and/or identified by <HMO> as being Confidential Information, shall be presumed to be Confidential Information. Confidential Information need not be novel, unique, patentable, copyrightable or constitute a trade secret in order to be designated Confidential Information. AHCETa

9. FUTURE TAXES, LEVIES AND GOVERNMENT IMPOSITION. If during the effectivity of this Agreement, the fees and benefits are made subject to new taxes, levies or fees, or such law, regulation or its equivalent resulted to changes in the formula or manner of computing taxes thereby resulting in additional obligations on the part of <HMO>, any additional amount due shall automatically be charged to the Client/Member in addition to the fees stated therein. Future taxes, levies or fees referred herein are only those that affect the quoting of Membership Fees (Ex. 12% VAT), other future taxes, levies or government impositions that do not affect the quoting of Membership fees are therefore excluded.

10. GOVERNING LAW. This Agreement shall be governed by and construed in accordance with the laws of the Republic of the Philippines.

11. ARBITRATION. Any difference arising between the Client or any Member and <HMO> shall be referred to an arbitrator to be appointed by the parties to the dispute. If the parties are unable to agree on a single arbitrator, two (2) arbitrators shall be appointed (one by each party). In the event of further disagreement, the arbitrators shall select an umpire. If the difference between the parties requires medical knowledge (including any question regarding the appropriate maximum indemnity for any medical service or an operation not listed in the schedule of surgical fees) the arbitrators at the discretion of <HMO>, may be a registered medical practitioners and the umpire in such an instance, shall be a consultant Specialist, Surgeon, or Physician. Determination of an award shall be a Condition Precedent to Any Liability or right of action against <HMO>.

12. AUTHORIZED SIGNATORY. The Parties hereby represent that their respective representatives been duly authorized by the Board of Directors to sign, execute and deliver this Agreement.

13. SEPARABILITY. If any term or provision of this Agreement is declared invalid, illegal or unenforceable under Philippine laws, such invalidity, illegality or unenforceability shall not affect or render unenforceable any other term or provision of this Agreement.

14. NOTICES. All notices, demands and other communications required or permitted hereunder shall be made in writing and sent to Client or its authorized representative at the address indicated in the Conforme Letter.

15. RIGHT OF SUBROGATION. The coverage under this Agreement is extended to cover injuries of the Member caused by third party(ies) whether liability is determinable or not as in cases of vehicular accidents and other similar instances or related incidents including but not limited to all the claims, losses, damages which may be recovered by the Member or which may have been paid to or due him as a result of the Illness or Disability which have been paid by <HMO> pursuant to the Terms and Conditions of the Agreement and that the Member will subrogate his rights of recovery from any other party to the extent of the value of the services so rendered to <HMO> and will undertake to assist <HMO> in the successful recovery of the losses. cHaCAS

16. CIVIL CODE ARTICLE 1250 WAIVER. The provisions of Article 1250 of the Civil Code of the Republic of the Philippines (Republic Act No. 386) which reads, "In case an extraordinary inflation or deflation of the currency stipulated should supervene, the value of the currency at the time of establishment of the obligation shall be the basis of payment," shall not apply in determining the extent of liability under the provisions of this Agreement.

17. IMPORTANT NOTICE. The Insurance Commission, with offices in Manila, Cebu and Davao, is the government officer in charge of the enforcement of all laws related to Health Maintenance Organization (HMO), and has supervision over HMOs. It is ready at all times to assist the general public in matters pertaining to HMO. For any inquiries or complaints, please contact the Public Assistance and Mediation Division (PAMD) of the Insurance Commission at 1071 United Nations Avenue, Manila with telephone numbers +632-5238461 to 70 and email address [email protected]. The official website of the Insurance Commission is www.insurance.gov.ph.

Schedule A — Benefit Coverage

I. In-Patient Care Benefits

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Room and Board Accommodation	Subject to the Member's Room and Board limit
2	Use of operating room, Intensive Care Unit (ICU), isolation room (if prescribed by Attending Affiliated Physician) and recovery room.	Subject to Maximum Benefit Limit (MBL)/Annual Benefit Limit (ABL)
3	Professional fees in accordance with HMO schedule of rates per physician/specialist.	Subject to MBL/ABL
	a. Attending Physicians
	b. Surgeons
	c. Anesthesiologists
	d. Cardio-pulmonary clearances before surgery and cardiac monitoring during surgery except CP clearances for all elective surgical cases including OB and Gynecology.
4	Standard Nursing Services	Subject to MBL/ABL
5	Medicines for in-patient use	Subject to MBL/ABL
6	Blood products transfusions and intravenous fluids, including blood screening and cross matching if the member patient is the recipient, but excluding expenses for donor screening services	Subject to MBL/ABL
7	X-Ray, laboratory examinations, routine, diagnostic and therapeutic procedures incidental to confinement	Subject to MBL/ABL
8	Dressings, conventional casts (plaster of Paris) and sutures	Subject to MBL/ABL
9	Anesthesia and its administration	Subject to MBL/ABL
10	Oxygen and its administration	Subject to MBL/ABL
11	Standard Admission kit	Subject to MBL/ABL
12	All other items directly related in the medical management of the patient, as deemed medically necessary by the Attending Affiliated Physician	Subject to MBL/ABL

 

II. Emergency Care Benefits ScHADI

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	In Affiliated Hospitals
	a. Physician's services	Affiliated Physician — Non-Affiliated Physician —
	b. Emergency Room Fees	Subject to MBL/ABL
	c. Medicines used for immediate relief during treatment	Subject to MBL/ABL
	d. Oxygen, Intravenous fluids and blood products	Subject to MBL/ABL
	e. Dressings, conventional casts (plaster of Paris) and sutures	Subject to MBL/ABL
	f. X-Rays, laboratory and diagnostic examinations, and other medical services related to the emergency treatment of the patient	Subject to MBL/ABL
2	In Non-Affiliated Hospitals	Reimbursable up to x% of hospital bills & professional fees based on rates incurred during the first 24 hours of treatment up to XX/availment/member/year
3	Outside the Philippines	Reimbursable up to 100% of actual cost subject to the inner limits and MBL/ABL
4	Areas without Affiliated Hospital	a. 100% on room and board charges according to the Member's Room and Board accommodation. b. 100% on other hospital bills. c. Professional fees based on rates for an Affiliated Physician rendering the service in an Affiliated Hospital.
5	Ambulance Land Transfer (Affiliated-Hospital/Clinic to Affiliated Hospital/Clinic)	Up to MBL/ABL
6	Ambulance Land Transfer (Non-Affiliated Hospital/Clinic to Affiliated Hospital/Clinic)	Reimbursable up to Pxx per ambulance conduction

Note: The ambulance service provided herein shall be available regardless of the location within the Philippines.

7

Initial treatment of Animal bites except cost of vaccines

Covered for the first 24 hrs. from the time of bite subject to MBL

 

III. Out-Patient Care Benefits DACcIH

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Consultations and treatment prescribed by an affiliated physician or specialist.	Subject to Maximum Benefit Limit (MBL)/Annual Benefit Limit (ABL)
2	Pre and Post Natal consultations.	Subject to MBL/ABL
3	Treatment for minor injuries and minor surgery except out-patient medicines.	Subject to MBL/ABL
4	Dressings, conventional casts (plaster of Paris) and sutures.	Subject to MBL/ABL
5	Routine diagnostic examinations and therapeutic procedures prescribed by an Affiliated Physician/Specialist provided however that the cost of diagnostic and therapeutic procedures covered shall be limited to a specific amount.	Subject to MBL/ABL
6	Laser Eye therapy only for retinal tear, retinal hole, retinal detachment and glaucoma prescribed by an Affiliated Physician/Specialist.	Up to xx/eye/member/year
7	Electrocauterization of skin lesions such as plantar warts, flat warts, periungual warts, filiform warts and molluscum contagiosum, in any part of the body prescribed by an Affiliated Physician/Specialist.	Up to xx/member/year
8	Sclerotherapy for varicose veins (except medicines and for cosmetic purposes) as prescribed by an Affiliated Physician, to be availed through affiliated vascular surgeons.	Up to xx/leg/member/year
9	Allergy Testing/allergy screening and other related examinations prescribed by an Affiliated Physician.	Up to xx/member/year
10	Speech therapy for stroke patients only. Note: Consultations shall be part of the limit and treated as sessions.	Actual charge up to xx/member/year
11	Tuberculin test	Up to xx/member/year

 

IV. Preventive Care Benefits

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Passive and active vaccines including anti-venom for tetanus, animal bites as well as snake bites; and its administration	Up to xxx/member/year
2	Health-education and counseling on diets or exercise	Covered
3	Health habits and Family Planning counseling	Covered

 

V. Benefits Covered Whether Out-Patient or In-Patient aICcHA

1. ROUTINE PROCEDURES (whether OP or IP)

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Blood Chemistries	Actual Cost subject to MBL/ABL
2	Chest X-Ray	Actual Cost subject to MBL/ABL
3	Complete Blood Count (CBC)	Actual Cost subject to MBL/ABL
4	Fecalysis	Actual Cost subject to MBL/ABL
5	Urinalysis	Actual Cost subject to MBL/ABL

 

2. DIAGNOSTIC PROCEDURES (whether out-patient or in-patient)

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	12-Lead Electrocardiogram (ECG)	Actual Cost subject to MBL/ABL
2	24-hour Electroencephalogram (EEG) Monitoring	Actual Cost subject to MBL/ABL
3	24-hour Holter Monitoring	Actual Cost subject to MBL/ABL
4	Adrenocortical Function	Actual Cost subject to MBL/ABL
5	Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam	Actual Cost subject to MBL/ABL
6	Arterial Blood Gas	Actual Cost subject to MBL/ABL
7	Arthroscopic Procedures, Orthopedic Arthroscopy	Actual Cost subject to MBL/ABL
8	Audiograms and Tympanograms	Actual Cost subject to MBL/ABL
9	Bone Densitometry Scan (Dexascan)	Actual Cost subject to MBL/ABL
10	Bone Mineral Density Studies	Actual Cost subject to MBL/ABL
11	Cardiac Stress Tests (Thallium and Dipyridamole Stress Tests)	Actual Cost subject to MBL/ABL
12	Computed Tomography (CT) Scans	Actual Cost subject to MBL/ABL
13	Diagnostic Radiographs:	Actual Cost subject to MBL/ABL
	a. Biliary tract: Cholecystogram and Cholangiogram	Actual Cost subject to MBL/ABL
	b. Chest, ribs, sternum and clavicle	Actual Cost subject to MBL/ABL
	c. Digestive: Plain film of the abdomen, Barium Enema, Upper Gastrointestinal (GI) Series, Lower GI Series, Small Bowel series	Actual Cost subject to MBL/ABL
	d. Face (including sinuses), Head and Neck	Actual Cost subject to MBL/ABL
	e. Urinary: Kidney, Ureter and Bladder (KUB) Pyelograms and Cystograms	Actual Cost subject to MBL/ABL
	f. X-ray of the extremities and pelvis	Actual Cost subject to MBL/ABL
	g. X-ray of the spine (cervical, thoracic, lumbo-sacral)	Actual Cost subject to MBL/ABL
14	Diagnostic Ultrasounds:	Actual Cost subject to MBL/ABL
	a. 2D-Echo with Doppler	Actual Cost subject to MBL/ABL
	b. Abdomen	Actual Cost subject to MBL/ABL
	c. Duplex Scan	Actual Cost subject to MBL/ABL
	d. Digestive and Urinary Systems	Actual Cost subject to MBL/ABL
	e. Ultrasound of the Lungs	Actual Cost subject to MBL/ABL
15	Electroencephalogram (EEG) Monitoring	Actual Cost subject to MBL/ABL
16	Electromyelography and Nerve Conduction Studies	Actual Cost subject to MBL/ABL
17	Endoscopic Procedures	Actual Cost subject to MBL/ABL
18	Fluorescein Angiography	Actual Cost subject to MBL/ABL
19	Impedance Plethysmography	Actual Cost subject to MBL/ABL
20	Magnetic Resonance Angiography (MRA)	Actual Cost subject to MBL/ABL
21	Magnetic Resonance Imaging (MRI)	Actual Cost subject to MBL/ABL
22	Mammogram and Sonomammogram	Actual Cost subject to MBL/ABL
23	Myelogram	Actual Cost subject to MBL/ABL
24	Nuclear Radioactive Isotope Scan	Actual Cost subject to MBL/ABL
25	Pap's Smear	Actual Cost subject to MBL/ABL
26	Perfusion Scan	Actual Cost subject to MBL/ABL
27	Plasma Urinary Cortisol, Plasma Aldosterone	Actual Cost subject to MBL/ABL
28	Polysomnograms (Sleep Recording)	Actual Cost subject to MBL/ABL
29	Pulmonary Function Tests	Actual Cost subject to MBL/ABL
30	Radioisotope Scans and Function Studies:	Actual Cost subject to MBL/ABL
	a. Cardiac	Actual Cost subject to MBL/ABL
	b. Gastrointestinal	Actual Cost subject to MBL/ABL
	c. Liver	Actual Cost subject to MBL/ABL
	d. Parathyroid Bone, Pulmonary (Perfusion/Ventilation Lung Scans)	Actual Cost subject to MBL/ABL
	e. Renal	Actual Cost subject to MBL/ABL
	f. Thyroid Scans	Actual Cost subject to MBL/ABL
	g. Total Body Scans	Actual Cost subject to MBL/ABL
31	Radionuclide Ventriculography	Actual Cost subject to MBL/ABL
32	Surface Electromyography (SEMG)	Actual Cost subject to MBL/ABL
33	Thallium Scintigraphy	Actual Cost subject to MBL/ABL
34	Treadmill Stress Test (TMST)	Actual Cost subject to MBL/ABL

 

3. THERAPEUTIC PROCEDURES

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

1	Anti-neoplastic Chemotherapy	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
2	Arthrocentesis	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
3	Continuous Positive Airway Pressure (CPAP) titration for sleep study	Up to Px shared limit for OP and IP
4	Dialysis	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
5	Oral anti-neoplastic chemotherapy	Up to x shared limit for OP and IP
6	Physical therapy	Shared limit of up to x sessions/member/year subject to MBL/ABL for OP; Up to MBL/ABL for IP *Define session
7	Therapeutic Radiology:
	a. Brachytherapy	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
	b. Cobalt	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
	c. Linear Accelerator Therapy	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
	d. Radioactive Cesium	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
	e. Radioactive Iodine	Up to x sessions subject to MBL/ABL for OP; Up to MBL/ABL for IP
8	Thoracentesis	Up to MBL/ABL shared limit for OP and IP

 

4. ADDITIONAL PROCEDURES AND MODALITIES (shared limit for OP and IP; Professional Fees, Hospital Bills and other incidental expenses relative to the procedure shall form part of the limit).

The following procedures and modalities are subject to the inner limits when specified, otherwise Actual Cost, subject to MBL/ABL. aDSIHc

 

HEALTHCARE BENEFITS

HEALTHCARE BENEFITS

1	Angiography (gastrointestinal, brain, retinal and peripheral vascular)	Actual Cost subject to MBL/ABL
2	Coronary Angiogram and/or Angioplasty/Coronary Artery Bypass Graft
3	Cryosurgery	Actual Cost subject to MBL/ABL
4	Gamma Knife Surgery	Actual Cost subject to MBL/ABL
5	Hysteroscopic Myoma Resection	Actual Cost subject to MBL/ABL
6	Hysteroscopically-guided D&C	Actual Cost subject to MBL/ABL
7	Laparoscopy	Actual Cost subject to MBL/ABL
8	Lithotripsy	Actual Cost subject to MBL/ABL
9	Percutaneous Ultrasonic Nephrolithotomy	Actual Cost subject to MBL/ABL
10	Stereotactic Brain Biopsy	Actual Cost subject to MBL/ABL
11	Conventional Hemorrhoidectomy	Actual Cost subject to MBL/ABL
12	Scalpel Hemorrhoidectomy	Up to Pxxx
13	Stapled Hemorrhoidectomy	Up to x/member/year
14	Mammotome/Vaccum Assisted Breast Biopsy	Up to x/member/year
15	4D Ultrasound except for maternity-related cases	Up to x/member/year
16	Esophageal Manometry	Up to x/member/year
17	Intensified Modulated Radiotherapy	Up to x/member/year
18	Botox which is not cosmetic in nature nor for beautification purpose	Up to x/member/year
19	Positron Emission Tomography (PET) Scan	Up to x/member/year
20	CT Pulmonary Angiography	Up to x/member/year
21	Photodynamic Therapy	Up to x/member/year
22	Other medically necessary modalities not mentioned above and those for which there are no comparable, conventional or traditional counterparts	Up to x/procedure/member/year
23	Transurethral Microwave Therapy of Prostate	Up to x/member/year

 

VI. Additional Benefits EHaASD

The following procedures and modalities are subject to the inner limits when specified, otherwise Actual Cost, subject to MBL/ABL.

 

HEALTHCARE BENEFITS

COVERAGE/LIMIT

2 *	Motor Vehicular Accidents	Subject to MBL/ABL and exclusions and limitations
3	Unprovoked Assault, including domestic violence, whether initiated by the Member or by a known or unknown third party	Up to MBL/ABL
4	Scoliosis including necessary procedures, except physical therapy sessions, whether congenital, pre-existing, developmental or acquired. Note: Physical Therapy sessions shall form part of the Physical therapy/Occupational therapy limits.	Up to xx/member/year (shared limit for OP and IP)
5	Congenital Conditions except physical therapy sessions and developmental disorders. Note: Physical Therapy sessions shall form part of the Physical therapy/Occupational therapy limits.	Up to xx/member/year (shared limit for OP and IP)
5 *	Congenital Hernia	Up to MBL
6	Chronic Dermatoses (Consultations only)	Up to MBL
7	Scabies (consultations and treatments)	Up to MBL
8	Valvular heart disease (congenital and/or acquired) including Cardiomyopathies, Chronic Glomerulonephritis, previous craniotomy sequelae/hearing impairment/Neurologic disease and Spinal Stenosis (if pre-existing)/Poliomyelitis/Slipped disc (if pre-existing) and Guillain-Barre Syndrome, Diabetes and its complications (if pre-existing), Complicated Hypertension (e.g., those with history of stroke, myocardial ischemia or infarction and poor kidney function), and all malignant tumors (if pre-existing)	Up to MBL (if acquired) and subject to Pre-existing provision (if Pre-existing)
9	Hepatitis B except vaccines and screening	Up to MBL/ABL (if acquired)

 

VII. Optional Benefits

1. ANNUAL CHECK-UP (ACU)

 

1	Physical Examination	Covered
2	Complete Blood Count	Covered
3	Urinalysis	Covered
4	Fecalysis	Covered
5	Chest X-Ray	Covered
6	Electrocardiogram (ECG)	(Optional) For members 35 years old and above
7	Pap's Smear	(Optional) For female members 35 years old and above

 

2. EXECUTIVE CHECK-UP (ECU) ATICcS

 

1	Executive Check-up (IP)	Covered
2	Executive Check-up (OP)	Covered
3	Semi-Executive Check-up (OP)	Covered

 

3. DENTAL BENEFIT

The following procedures and modalities are subject to the inner limits when specified, otherwise Actual Cost, subject to MBL/ABL.

 

1	Annual Dental examination and consultation	Covered
2	Emergency out-patient dental treatment — to be availed at affiliated dental clinics only	Covered
3	Oral Prophylaxis	Covered*
4	Simple tooth extractions	Covered
5	Restorative and prosthodontic treatment planning	Covered
6	Temporary fillings.	Covered*
7	Desensitization of hypersensitive teeth.	Covered*
8	Simple adjustment and repair of dentures.	Covered
9	Re-cementation of loose crowns, bridges, inlays and onlays.	Covered
10	Dental nutrition and dietary counseling.	Covered
11	Dental health education.	Covered
12	Permanent fillings (not applicable for basic dental package)	Covered*
13	Palliative treatment for simple mouth sores and blisters	Covered
14	Open incision and drainage (intraoral)	Covered
15	Pre-natal check of teeth and gums	Covered
16	Temporo Mandibular Joint Consultation (Initial consult only, referral to specialist not covered)	Covered
17	Gum Treatment for cases like inflammation or bleeding	Covered

 

4. MATERNITY BENEFIT — Optional

 

1

Covered Members

Female Employees (Married or Single/Married only) and Spouse of Male Employees

2	The HMO shall cover the hospital bills and professional fees incurred by covered Member for maternity services/procedures, up to the following limit:

	Normal Delivery	(Specify Limit)
	Caesarian	(Specify Limit)
	Miscarriage and Abortion	(Specify Limit)
	Ectopic Pregnancy	(Specify Limit)
	H.Mole Pregnancy	(Specify Limit)
	Home Delivery	(Specify Limit)
	Other Complications	(Specify Limit)
3	Type of Availment	LOA-facilitated if availed within the network; and shall be on reimbursement basis based on actual amount and subject to above mentioned limits if availed outside the network
4	280 days Waiting Period	Waived/Applicable
5	Laboratory procedures/work-ups (limited to nine (9) procedures only)	Covered/Not Covered

6	For availments in Affiliated Hospitals but with Non-Affiliated Physicians, the HMO shall provide outright coverage for the hospitals bills and the professional fees of Non-Affiliated Physicians shall be on a reimbursement.

 

Schedule B — Membership Fees

ANNEX C

LETTERHEAD

Date _______________

Insurance Commissioner

CERTIFICATION

Sir/Madam:

I, _________________________ (Name of Actuary), do hereby certify that: DaIAcC

1. The actuarial formulations used for ____________________ (Name of Plan) are accurate and in accordance with generally accepted actuarial principles and are in compliance with regulatory requirements.

2. The actuarial assumptions used in the derivation of the Gross Membership Fee, and Reserves (Membership Fee Liability and Claims Liability (IBNR)) are in my opinion, reasonable and appropriate based on company's experience and existing conditions and the company's reasonable expectations of future outcome throughout the duration of the coverage.

3. The provisions of the HMO Agreements and all endorsements have been reviewed and all its benefits have been quantified and considered in the pricing and determination of the Gross Membership Fee and Reserves. SICDAa

4. I have followed the Executive Order 192, s. 2015, pertinent IC circulars, and guidelines and standards of the Actuarial Society of the Philippines (ASP), and I have adhered to generally accepted actuarial principles and practices where no guidelines or standards from the ASP are applicable.

5. I acknowledge my personal liability as a consequence of this Certification, warranting disaccreditation by the Insurance Commission or any other appropriate action that may be taken, before the proper forum.

____________________________________________________

REPUBLIC OF THE PHILIPPINES

Subscribed and sworn to me before this _____ day of _______________, at _______________. Affiant exhibited to me his/her and _________________________ (government issued identification card) issued on _______________ at _______________.

NOTARY PUBLIC

Doc. No. ___________

Page No. ___________

Book No. ___________