Implementing Rules and Regulations of the Supreme Court Health and Welfare Plan for the Lower Courts

March 26, 2012

OCA CIRCULAR NO. 22-12

 

For the information of all concerned, the Court en banc, in Its Resolution dated January 31, 2012 in A.M. No. 98-8-01-SC (Re: Supreme Court Health and Welfare Plan [re Implementing Rules and Regulations]), approved the hereunder Implementing Rules and Regulations of the Supreme Court Health and Welfare Plan for the Lower Courts:

Implementing Rules and Regulations of the Supreme Court Health and Welfare Plan for the Lower Courts

I. Overview

The Supreme Court Health and Welfare Plan for the Lower Courts is a medical benefits scheme which aims to provide financial assistance to officials and personnel of the Lower Courts (RTCs, MeTCs, MTCCs, MTCs, MCTCs, Shari'a District Courts, Shari'a Family Courts and Shari'a Circuit Courts). Membership to the Plan shall be voluntary. Benefits assistance is, primarily, by way of reimbursement of hospitalization and other medical expenses.

The groundwork for the implementation of the Supreme Court Health and Welfare Plan (SCHWP) was laid down through En Banc Resolution in A.M. No. 98-8-01 SC (Creation and Operation of the Supreme Court Health and Welfare Plan) dated August 19, 1998.

Policy-making and administrative supervision over SCHWP matters shall be exercised by a Board. ICHcTD

Screening and processing for payment of claims for the SCHWP for the Lower Courts shall be done through a complement of workers, collectively called "Secretariat". Medical Screening Committees evaluate claims prior to approval by the Board. There are three (3) screening committees, Committees "A", "B", and "C", headed by a medical doctor, and composed of 3 other members who are representatives of the Office of the Chief Justice, the Office of the Clerk of Court-En Banc, and the Office of the Court Administrator.

II. Membership/Coverage

1. Membership to the Plan shall be voluntary for all judges, officials and personnel of first and second level courts nationwide, including maintenance staff in the Halls of Justice;

2. Active membership commences once initial monthly dues has been paid.

3. Payment of monthly dues is through salary deduction; the rates shall be uniform.

III. Benefits

1. Hospital Confinement (Medical or Surgical)

• Up to P50,000.00 per member per year, exclusive of PhilHealth benefits;

• Additional P20,000.00, if illness is dreadful (Total: P70,000.00 per member per year);

• Covers all in-patient services which are medically necessary, including room and board, professional fees, use of operating room and recovery room, medicines, blood and blood products, x-ray, and other laboratory procedures.

2. Out-Patient Benefits

• Up to P20,000.00 per member per year deductible from the maximum benefit limit of P50,000.00 per member per year; TcCEDS

• Additional P30,000.00, if illness is dreadful (Total: P50,000.00 per member per year);

• Includes professional fees and charges for consultation, prescribed diagnostic procedures, treatment of minor injuries, emergency care, and prescribed vaccinations and/or medications excluding vitamins and food supplements.

3. Special Out-Patient Procedures

The following special procedures may be reimbursed up to P50,000.00 even as out-patient:

• Cataract extraction including cost of lens and professional fees;

• Extra Corporial shock wave lithotripsy;

• Chemotherapy, radiotherapy, bracchytherapy, and other similar modalities for treatment of a dreadful condition;

• Hemodialysis and/or peritoreal dialysis;

• Coronary angiography, angioplasty and other similar procedure either for diagnostic or therapeutic.

4. Dreadful Illnesses

The following ailments shall be considered as dreadful:

• Cerebrovascular accidents (thombo-embolic or hemorrhagic) with resultant coma or paralysis;

• Central nervous system tumor or infections (e.g., encephalitis, meningitis and the like);

• Complicated cardio-vascular conditions;

• Chronic obstructive pulmonary disease stages III and IV;

• All forms of malignancy (in any stage);

• Chronic kidney failure, stages IV and V; IEaHSD

• Decompensated Liver Cirrhosis;

• Gastro-intestinal tract bleeding and other related conditions requiring exploratory laparotomy/intestinal resection and/or anastomosis;

• Blood dyscrasias, (e.g., Leukemias, lymphoma, idiopathic thrombocytopenic purpura, and the like);

•Major forms of trauma with attendant complications such as paralysis and/or similar conditions.

NOTE: Any illness/condition(s) not among those mentioned above shall not be regarded as dreadful, unless medical evaluation shows otherwise.

5. Burial Assistance

• P20,000.00 per member.

IV. Exclusions

Not covered under the benefits are the following:

1. Herbal medicines and medicinal products not licensed by BFAD;

2. Alternative methods of health care which include but not limited to acupuncture, acupressure, chiropractics, nutritional therapy, and other similar methods of treatment are not reimbursable under this plan, unless the method was availed as remedy when conventional methods of cure have proven to be ineffective. To be reimbursable, the availed method should have been prescribed and/or undertaken under supervision by a licensed physician and/or chiropractor;

3. Dental procedures, such as tooth extraction, root canal treatment, oral prophylaxis, gum treatment, prosthesis and the like except surgical removal of impacted tooth when indicated as certified by attending Orthodontist; AcIaST

4. Expenses for optical and hearing aid devices;

5. Pregnancy-related expenses including pre-natal check-ups, normal spontaneous delivery, caesarian section, dilatation and curettage due to spontaneous abortion, and post-delivery care;

Note: In cases when spontaneous delivery is attended by complication such as uncontrolled vaginal bleeding with resultant emergency hysterectomy (removal of the uterus) the expenses incurred for said procedure i.e., hysterectomy, may be reimbursable upon thorough evaluation by the SCHWP Screening Committee.

6. Treatment of any injury attributable to a member's own misconduct, gross or contributory negligence, intemperate use of drug or alcoholic beverages, vicious or immoral acts, direct or indirect participation in the commission of crime, violation of law or ordinances;

7. Treatment of injuries or illness resulting from suicide or self-destruction whether sane or insane;

8. Cosmetics services, plastic and reconstructive surgery, experimental procedure, sex transformation and services related to fertility, infertility, artificial insemination circumcision and organ transplant;

Note: In case of severe trauma wherein restoration of the anatomical function of the affected part is deemed necessary, reconstructive surgery may be considered upon thorough evaluation of the SCHWP committee.

9. Congenital defects;

10. Sexually transmittable diseases, such as, but not limited to the following: Gonorrhea, Urethritis (gonococeal or non-gonococeal), Penile/Vaginal Warts, and the like, except HIV-related diseases, such as AIDS;

11. All other items not directly related to the medical management of the member-employee such as extra bed, extra food, extra television and other amenities. IECAaD

V. Rules on Filing Claims

1. Claims should be filed within the reglementary period as follows:

a. Out-patient Claims

 File within 30 days from date of availment/payment of doctor's fee, purchase of medicines and/or payment of laboratory fees);

b. Hospital Confinement

 File within 60 days from date of discharge;

c. Dreadful diseases

 File within 90 days from date of discharge for hospital confinement claims or date of availment/payment of doctor's fee, purchase of medicines and/or payment of laboratory fees for out-patient claims;

d. Burial

 File within 365 days from date of death.

2. If the claim is directly filed at SCHWP Secretariat, the date of receipt at SCHWP is the date of filing.

3. If a claim is mailed, the date of mailing indicated in the envelope shall be the date of filing.

4. All necessary documentary requirements shall be complied with upon filing. Claims filed with incomplete documentary requirements shall outright be disapproved.

5. If an illness is continuing, medical certification, and/or prescription for said illness should be updated at least every 6 months.

6. Claims filed beyond the reglementary periods shall be disapproved.

7. Motion for Reconsideration of denied claims shall be filed within ten (10) working days from receipt of a notice of disapproval. cDCaHA

VI. Documentary Requirements for Processing/Payment of Claims

1. Confinement:

a. Application Form duly accomplished, attested by the Judge/Exec. Judge, or whenever appropriate, the Chief of Office, Administrative Services-Office of the Court Administrator, or the concerned Deputy Court Administrator;

b. Medical Certificate (should indicate date of issuance, name of patient, and diagnosis);

c. Statement of Account (should indicate the MEDICARE/PHILHEALTH deduction);

d. Medical Prescription and Receipts of medicines purchased;

e. Hospital Bill Receipts — original copy (should indicate the MEDICARE/PHILHEALTH deduction); DHESca

Note: Claimants whose hospital bill has been paid by a private HMO shall submit either a certificate of payment issued by the private HMO or a certified true copy of the receipt issued by the hospital to the HMO. Either of the two documents shall be submitted within sixty (60) days from the date of the filing.

f. Professional fee receipts — original copy (should indicate the MEDICARE/PHILHEALTH deduction);

Note: Acknowledgment receipts issued by attending doctors shall not be honored as official receipt.

g. Operative and Anesthesia Records — certified true copy issued by the hospital (if necessary);

h. Histopathology results (if necessary).

Note: Failure to submit above requirements within reglementary period shall be a ground for disapproval.

2. Out-patient:

a. Application Form duly accomplished, attested by the Judge/Exec. Judge, or whenever appropriate, the Chief of Office, Administrative Services-Office of the Court Administrator, or the concerned Deputy Court Administrator;

b. Medical Certificate — original or certified true copy (should indicate date of issuance, name of patient, and diagnosis);

c. Medical Prescription and Receipts of medicines purchased (should indicate clearly the items purchased) (if medicine expenses are to be reimbursed);

d. Professional/consultation fee receipts (if professional/consultation fees are to be reimbursed);

e. Doctor's request/results of laboratory exams including original official receipt (OR) of the examination done (if laboratory fees are to be reimbursed). AHaETS

3. Burial:

a. Application Form duly accomplished, attested by the Judge/Exec. Judge, or whenever appropriate, the Chief of Office, Administrative Services-Office of the Court Administrator, or the concerned Deputy Court Administrator;

b. Death Certificate (certified true copy);

c. Marriage contract (if married at the time of death, optional);

d. If the claimant is other than the indicated beneficiary, proof of funeral expenses (e.g., Original receipts, certification for funeral parlor, etc.) and affidavit of waiver;

e. Affidavit of Guardianship (for dependents of minor age).

VII. Policies in Claim Processing

1. Only out-of-pocket (OOP) payment claims shall be processed.

2. Only original official receipts shall be accepted. VAT-registered cash invoice and sales invoice may be allowed if it indicates the name of pharmacy/drugstore, address, Tax Identification Number, VAT registration number and clearly indicates the item(s) bought; otherwise, it shall not be honored.

3. Drugs/medicines and laboratory procedures/examinations shall be reimbursed if deemed medically necessary and related to the actual diagnosis as per attached medical certificate.

4. Prescription for maintenance medication should be updated every six (6) months. Non-compliance with this requirement shall be a basis for disapproval of claim.

VIII. Policies on Distribution of Benefits and Burial Assistance of Deceased Member

1. The burial assistance and medical reimbursements of the deceased member shall be equally divided among the declared beneficiaries. CSIcHA

2. In the absence of declared beneficiaries, the burial assistance and medical reimbursements of the deceased member shall be distributed in accordance with the applicable provisions on testate or intestate succession. In the absence of any qualified claimant, the claim shall be forfeited by the SCHWP.

3. Those who paid for the funeral expenses can claim the burial assistance but not the medical reimbursements provided that the claimant shall comply with the requirements indicated in VI.3 herein.

IX. Liberal Construction

In exceptional and meritorious cases, the Board may relax the application of the rules for the benefit of the claimant.

X. Effectivity

These guidelines shall take effect upon approval of the Court En Banc for all SCHWP claims with admission/confinement dates filed thereafter.

Previous memoranda and/or board resolutions inconsistent with these guidelines are hereby revoked or repealed.

 

(SGD.) JOSE MIDAS P. MARQUEZCourt Administrator