Professional Documents
Culture Documents
Rev.0
16 June 2013
Page 1 of 2
OUT-PATIENT SERVICES
Referral to specialists Cataract Extraction (excluding lens), including phacoemulsification, is
Regular consultations & treatment (except prescribed medicines) covered up to the dreaded disease limit per member per year subject
Treatment of minor injuries and surgery not requiring confinement to the pre-existing conditions coverage*
X-ray and laboratory examinations Laser Treatment of Glaucoma and retinal detachment (excluding lens)
Eye, Ear, Nose & Throat treatment is covered up to P 20,000.00 per member per year subject to the pre-
Physical and Speech Therapy is covered up to ten (10) sessions existing conditions coverage*
Cauterization of Warts including facial warts up to P1,000.00 First Dose of anti-tetanus is covered up to P1,000.00
Tuberculin Test (except screening) is covered up to P800.00 Consultations for Chronic Dermatoses
Consultations for Scabies is covered at MediCard clnics only
The member can go directly to the primary physician of any accredited hospital or at the Head Office clinic for out-patient consultations. The primary physician will
request for laboratory or diagnostic examinations or refer the member to a specialist. The member may avail of services from any accredited hospital of his choice.
* Inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure
DREADED DISEASES
Dreaded diseases are potentially or actually life threatening conditions or illnesses which may require prolonged or repeated hospitalization or intensive care
management. MediCard shall pay for hospitalization services up to the maximum limit subject to the pre-existing conditions coverage.
The following are considered dreaded disease:
a. Cerebrovascular Accident (stroke) h. Diabetes Mellitus and its complications
b. Central nervous system lesions i. Malignancies and Blood Dyscrasias (Cancer, Leukemia, Idiopathic
(Poliomyelitis/Meningitis/Encephalitis/Neurosurgical conditions) Thrombocytopenic Purpura)
c. Cardiovascular Disease(Coronary/Valvular/Hypertensive Heart j. Injuries from accidents or assaults, frustrated homicide or frustrated
Disease/Cardiomyopathy) murder
d. Chronic Obstructive Pulmonary Disease (Chronic Bronchitis/Emphysema), k. Complications of an apparent ordinary illness including MODS and SIRS
Restrictive lung disease Liver Parenchymal Disease [Cirrhosis, Hepatitis (e.g. sepsis due to pneumonia, typhoid ileitis, cerebral malaria, etc.)
(except type A), New growth] l. Single or multiple organ dysfunction and failure (MODS and MOF)
e. Chronic Kidney/Urological disease (Urolithiasis, Obstructive Uropathies, m. Conditions that may require dialysis
etc.) n. Chronic pain syndrome (greater than six weeks)
f. Chronic Gastrointestinal Tract Disease requiring bowel resection and/or o. Any illness other than the above which would require Intensive Care Unit
anastomosis confinement
g. Collagen diseases (Rheumatoid Arthritis, Systemic Lupus Erythematosus) p. Et cetera
PRE-EXISTING CONDITIONS
1. Any illness, injury or any adverse medical condition shall be considered pre-existing if during the entire period prior and within the first twelve (12) months from
the effectivity date of this Agreement:
a. Any professional advice or consultation and/or treatment was made given as a result of such illness, injury or adverse medical condition; or
b. The MEMBER was aware or should reasonably have been aware of the signs or symptoms of such illness, injury or adverse medical condition; or
c. The pathogenesis or onset of such illness, injury or adverse medical condition has been started during the contestability period for membership in this
Corporate Health Program as determined by MediCard 's Medical Director or accredited physicians.
2. Without necessarily limiting the following enumeration, the following are automatically considered as pre-existing conditions if consultation or treatment is
sought within the first twelve (12) months of coverage:
a. Dreaded Diseases listed above except for letters k & l j. Prostate disorders
b. Hypertension k. Hemorrhoids and Anal Fistulae
c. Goiter (Hypo/Hyperthyroidism) l. Benign Tumors
d. Cataracts/Glaucoma m. Uterine Myoma, Ovarian cysts, Endometriosis
e. ENT conditions requiring surgery n. Buergher's Disease
f. Bronchial Asthma/Allergy/Urticaria o. Varicose Veins
g. Tuberculosis p. Arthritis
h. Chronic Cholecystitis/Cholelithiasis (gall bladder stones) q. Migraine headache
i. Acquired Hernias r. Gastritis/duodenal or gastric ulcers
NOTE: All limits mentioned in this proposal are subject to the Pre-Existing Condition limit, if applicable, based on the given diagnosis
MEMBERSHIP ELIGIBILITY
PRINCIPAL
Salaried personnel at least 18 years old up to age 60 and employed by a COMPANY on a permanent basis.
DEPENDENTS
For Married Employees
The legal spouse at least 18 years old up to age 60
Legitimate and/or legally adopted children 30 days up to 21 years of age and living under the same roof as the principal member
For Single Employees
Parents up to age 60, unemployed and dependent upon the principal member
Brothers and sisters 30 days up to 21 years of age who are not gainfully employed and are living under the same roof as the principal member
For Single Parent Employees
Legitimate and/or legally adopted children 30 days up to 21 years of age and living under the same roof as the principal member (Please provide Birth Certificate)
Enrollees age 41 and above are required to undergo a medical evaluation at MediCard Stand-alone clinics with a minimal fee of P 450.00 per head.
The choice of enrolling dependents must follow a hierarchy. This means that the spouse first must be enrolled followed by the eldest child, second child and so on for
married personnel. For single personnel, the parents must be enrolled first followed by eldest brother/sister and so on.
At least 75% of the total number of principal members shall enroll all their immediate dependents to be able to avail of dependent’s coverage. If the above condition is
not met, dependents would be subject to a separate program and/or premium rate as may be determined from their exact demographics.
PHILHEALTH
It is hereby declared and agreed that hospitalization benefits due under the PHILHEALTH program are assigned to and integrated with the MediCard program such that
any of the MediCard benefits due under this Agreement shall be net of the member’s PHILHEALTH benefits. Computation of dreaded disease limit is net of Phil health
but the Company will give an authorization to MediCard to verify Phil health benefits.
OTHERS
1. An Emergency Assistance Response Service (E. A. R. S.) that operates on a 24-hour/day 365-day/year basis to respond your inquiries. Just dial: Trunk line: 884-
9999; 841-8080 Toll free Nos: 1-800-1888-9001
2. Direct access to a network of 650 accredited hospitals/clinics with 14,000 doctors/specialists nationwide plus fifteen (15) satellite medical clinics, one (1) mall-
based clinic and a Head Office Clinic.