INHEALTH CORPORATE

What are the optional benefits?

 

1. Dental Benefits

To avail of this outpatient benefit at the member’s preferred dental clinic (for those who select strict preferred dental facilities) or at any dental clinic (for those who select open-door dental facilities) under the Filipino Doctors Preventive Healthcare Management, Inc., 100% participation of all qualified enrollees (by category, i.e., Officer / Supervisory / Rank & File, with or without their dependents) is required.

 

• Any number of consultations on dental problems including but not limited to lesions, wounds, burns, and gum problems (during clinic hours and by appointment)

• Annual Oral Prophylaxis (mild to moderate cases)

• Unlimited simple tooth extractions, except surgery for impaction or extraction of impacted tooth or complicated extractions involving the use of other dental instruments aside from pliers and/or the re-administration of anaesthesia

• Unlimited temporary fillings

• Unlimited re-cementation of fixed bridges, jacket crowns, inlays and onlays (limited to 4 abutments)

• Dental education and counseling during consultations

• Simple adjustments of denture clasps

• Two (2) surfaces of amalgam fillings

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2. For “open-door” dental plan, add:

• Any number of consultations/dental examinations including treatment of lesions, wounds, burns, gum and other dental problems except diagnostics, prescribed medicines, surgeries and “root canal” procedures

• No limit as to the number of abutments covered (on item 5 above)

• Orthodontic consultations

• Aesthetic dental consultations

• Emergency desensitization of hypersensitive teeth

• Option to choose between two (2) surfaces of amalgam fillings or one (1) surface of “light cure” filling

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3. Life (Group Term) Insurance With Insular Life

This is applicable only to Employee-Principal members.

 

• Minimum of P 10,000 in coverage

• Maximum of P 50,000 in coverage
   

(To avail of this benefit, 100% participation of qualified employee-principals is required. Coverages over the above limits will need special approval. )

 

In accordance with Insular Life Group Term Policy No. G-014175 dated 15 January 1999 and all of its succeeding endorsements, any individual with adverse medical findings shall automatically be covered for one-half (1/2) of coverage of a standard risk for deaths due to natural causes and one hundred percent (100%) of coverage for deaths due to accident.

 

Maternity Benefit

(All regular female employees must enroll but in no case less than 25)

 

• Pre-natal and Post-natal diagnostic procedures at Insular Health Care Clinic or accredited/preferred hospitals.

• Hospital care during pregnancy and delivery. Limits will depend on the needs of the corporate client.

• Ordinary nursing care for newborn baby while mother is confined or for three days, whichever comes earlier.
   

Maternity Benefits shall be available only after the enrollee (principal or dependent member) has been continuously covered under the “Agreement” for a period of 280 days from date of initial enrollment except that in the event of pre-termination of pregnancy within the said period of 280 days, maternity benefit shall be available provided such pregnancy commences after the coverage of the enrollee becomes effective.

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What are examples of Latest Modalities of Treatment?

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The limits of the following procedures shall apply inclusive of professional fees and related incidental expenses:
 

Procedures covered up to MBL or up to certain limits:

1. Laparoscopic Cholecystectomy (LapChole), Adrenalectomy, Hernioplasty / Herniorrhaphy / Herniotomy, Oophorectomy / Oophorectocystectomy are covered up to MBL. All other laparoscopic procedures (except LapChole) for therapeutic purposes are covered up to Php 20,000 per year. All laparoscopic procedures for diagnostic purposes are covered up to Maximum Benefit Limit (MBL).
 

2. Cryosurgery
 

3. Hysteroscopic Myomectomy
 

4. Hysteroscopic D&C and Polypectomy
 

5. Gamma Knife
 

6. Arthroscopic Surgery
 

7. Magnetic Resonance Imaging (MRI) / Magnetic Resonance Angiogram (MRA) / Computerized Tomography (CT Scan)
 

8. Functional Endoscopic Sinus Surgery (FESS)
 

9. Nuclear medicine procedures

• Thyroid Scan

• Thallium Scintigraphy / Thallium Stress Test

• Sestamibi Stress Test / Hexamibi

• Radioactive Isotope Scan

• HIDA Scan

• Radionuclide Renography

• Body Metastatic Survey

• Bone Scan / Imaging / Densitometry

• Dacryoscintigraphy

• Gastric Scintigraphy

• Glomerular Filtration Rate

• Liver or Spleen Imaging

• [Tetro Rest and Stress

• Thyroid Imaging / Scintigraphy

• Other nuclear medicine procedures are covered up to Php 5,000 per session.
   

10. Laser eye procedures (one session per eye per year): Laser lridotomy / Iridectomy, Yag Laser, and Argon Laser are covered up to MBL. All other Laser Procedures (one session per year) are covered up to Php 5,000 except Photorefractive Keratectomy
 

11. Electro Shock Wave Lithotripsy (ESWL) (limited to one session per year)
 

12. Electrocautery (ECT), paring and curettage, and other related procedures in the treatment of warts, molluscum contagiosum, and milia shall be covered up to Php 1,000 per year.
 

13. Endoscopic Procedures is covered up to MBL for diagnostic purposes; and Php 5,000 per session for therapeutic purposes.
 

14. Percutaneous Ultrasonic Nephrolithotomy (PUN) is covered up to Php 40,000 (one session per year).
 

15. Stereotactic Brain Biopsy is covered up to Php 20,000 per session.
 

16. Transurethral Microwave Therapy of Prostate is covered up to Php 30,000 per session.
 

17. Speech Therapy (inclusive of out-patient speech therapy)
 

18. Positron Emission Tomography Scan (PET Scan) is covered up to Php 5,000 per session.
 

19. Sleep Studies is covered up to Php 5,000 per year.
 

20. Pain Management is covered up to Php 3,000 per year.
 

21. Post-operative Analgesia is covered up to Php 3,000 per operation.

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What are examples of Dreaded Diseases?

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Coverage is subject to the Maximum Benefit Limit per person per illness or injury per year.

 

1. Neurological disorder

2. Blood dyscracia

3. Collagen/Immunological disorder

4. Liver Cirrhosis

5. Chronic Pulmonary/Renal disorder

6. Cardiovascular disorder

7. Cancer

8. Any condition which necessitates the use of Intensive Care

9. Unit subject to other limitations

10. Accidental injuries

11. Other conditions causing partial or total organ damage or failure

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What are Pre-Existing Conditions (PECs)?

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A. An illness or condition shall be considered pre-existing if before the Effective Date of the Agreement:

1. Any professional advice or treatment was given for such illness or condition

2. Such illness or condition was in any way evident to the member

3. The pathogenesis of such illness or condition has already started (which the member may not be aware of).

 

B. PECs are not covered in the first year of coverage.
 

C. After the member has been continuously covered with Insular Health Care for 12 months and the agreement is renewed, the following provisions on PECs shall apply:
 

1. PECs are covered provided that the PECs are not considered part of the “Permanent Exclusions to Health Care Coverage”, and that

1. such PECs were declared by the member in the original application;

2. such PECs are unknown to the member (without established medical history);
    

2. Undeclared PECs with established medical history are excluded from coverage. However, said PECs may be evaluated for possible future consideration.
 

3. In case an application is disapproved due to an adverse medical condition, an applicant may still avail of the Insular Health Care program by executing a “waiver” relinquishing or limiting coverage for the particular adverse condition/s (as stated in the provision on Enrollment / Approval of Application).
 

D. Examples of PECs: (inclusive of complications)

1. Hernias

2. All tumors and malignancies involving any body organ or system

3. Endometriosis, Dysfunctional Uterine Bleeding

4. Hemorrhoids

5. Diseased tonsils requiring surgery

6. Pathological abnormalities of the nasal septum and turbinates

7. Thyroid Dysfunction/Goiter

8. Cataract

9. Sinus condition requiring surgery

10. Asthma / Chronic Obstructive Pulmonary Disease

11. Cirrhosis of the liver

12. Tuberculosis

13. Anal Fistula

14. Cholelithiasis / Cholecystitis

15. Calculi of the urinary system

16. Gastric or Duodenal Ulcer

17. Hallux Valgus

18. Diabetes Mellitus

19. Hypertension

20. Collagen Disease / Auto Immune Disease

21. Cardiovascular Disease

22. Hormonal Dysfunction

23. Seizure Disorder / Cerebral Insufficiency / Stroke
     

E. The following health conditions may be covered (either fully or up to certain amounts) provided pre-existing conditions of an account are likewise covered:

1. Organ transplants and/or open-heart surgery / angioplasty and all services (e.g., coronary angiogram) related thereto (except organ donor services)

2. AIDS and AIDS-related diseases except when sexually transmitted

3. Congenital abnormalities and conditions are covered up to Php 25,000.

4. Chronic glomerulonephritis, gullain-barre syndrome

5. Scoliosis, Spinal Stenosis and Kyphosis are covered up to Php 25,000. For all other physical deformities, only consultations are covered.

6. For Vitiligo and Psoriasis, only consultations are covered.

7. Confirmatory Tests are covered up to the MBL provided the tests are done for valid diagnoses. Coverage shall be extended only up to the time the condition in question has been ruled in/out. Confirmatory tests are not applicable to health conditions listed under Permanent Exclusions.

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What are examples of Permanent Exclusions?

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1. Care by non-accredited Physician and / or in a non-preferred hospital/clinic except in emergencies wherein the emergency provision of the agreement will apply

2. All pregnancy related conditions requiring medical/surgical care and screen tests related thereto.

3. Sterilization of either sex or reversal of such, artificial insemination, sex transformations or diagnosis and treatment of infertility, and circumcision

4. Rest cures, custodial, domiciliary or convalescent care

5. Cosmetic surgery, dental/oral surgery, and dermatological procedures for the purpose of beautification except reconstructive surgery to treat a dysfunctional defect due to disease or accident

6. Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, adjustment disorders, alcoholism and its complications or conditions related to substance or drug abuse, addiction and intoxication

7. Sexually transmitted diseases

8. Medical and surgical procedures which are not generally accepted as standard treatment by the medical profession

9. Procurement or use of corrective appliances, artificial aids, durable equipment, and orthopedic prosthesis and implants

10. Surcharges resulting from additional personal (luxuries/accommodation) request or service including special nursing services

11. Physical examination required for obtaining employment, medical certification, insurance or a government license

12. Injuries or illnesses due to military, paramilitary, police service, high risk activities, or suffered under conditions of war

13. Reimbursement of procedures obtained through government programs

14. Injuries or illnesses, which are self-inflicted, caused by attempt at suicide or incurred as a result of or while participating in a crime or acts involving the violation of laws or ordinances

15. Out-patient/take-home medicines

16. Valvular Heart Disease and Rheumatic Heart Disease

17. Medico-legal consultations

18. When a member is discharged against medical advice, and all 19. subsequent benefits/services related thereto.

19. Blood / Organ Donor screening / other screening procedures that are purely diagnostic or for screening purposes including among others, Purified Protein Derivative (PPD), and procedures conducted prior to hormonal replacement therapy

20. All hospital charges and professional fees after the day and time hospital discharge has been duly authorized and professional fees of Assistant Surgeons

21. All conditions and complications requiring dental care

22. Hypersensitivity/allergy tests

23. Diseases declared by the Department of Health (DOH) as Epidemic

24. Use of Emergency Room Facilities on non-emergency cases or by reason of condition/injuries not falling under the term “Emergency” as defined in the Agreement (“Emergency” shall mean the sudden, unexpected onset of illnes or injury having the potential of causing immediate disability or death, or requiring the immediate alleviation of severe pain or discomfort.) For the purpose of implementation, the final diagnosis shall be the basis for a member’s eligibility to emergency care benefits under the plan.

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What's the Membership Eligibility?

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1. Membership fees are based on a specific number of principal-enrollees that were culled from the client’s employee census.

2. If membership fee is employer-employee shared or employee-paid, we require at least 75% participation of employee principals.

3. Accommodation / Benefits Plan of Principal Members must follow a uniform category (e.g., officers at Private room, rank-and-file employees at Semi-Private room, etc.) pre-established by the client at the start of the program.

4. A. Principal members: Regular employees at least 18 years old to less than 65 years old.

5. B. Dependents: (Following Hierarchy Guidelines)

6. For single employees: Parent(s) first who is/are less than 65 years old and not gainfully employed; followed by the eldest sibling down to the youngest who is/are 15 days to less than 21 years old, unmarried and not gainfully employed.

7. For single parent employees: Eldest child down to the youngest, 15 days to less than 21 years old, unmarried and not gainfully employed.

8. For married employees: Spouse first who is less than 65 years old; followed by the eldest child down to the youngest, 15 days to less than 21 years old, unmarried and not gainfully employed.

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What's the Dependents Coverage?

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Participation and Enrollment:

• If Dependents’ Coverage is Employer-paid, we require 100% participation of employee-principals enrolling at least two (2) immediate dependents each following our hierarchy guidelines.

• If Dependents’ Coverage is Employer-Employee-shared or Employee-paid, we require at least 75% participation of employee-principals enrolling at least two (2) immediate dependents each following our hierarchy guidelines.

• In both instances above, if the minimum participation requirement is not met (because of employees who may have only one or no eligible dependent/s), we may still offer Dependents’ Coverage. Applications will be individually underwritten subject to acceptance or denial as the case may be. It is understood that a re-quote of dependents’ rates based on the actual number of enrollee-dependents may be done, if necessary.

• Dependents should be enrolled simultaneously with principal members.

• Newly married spouse, newly born child / sibling should be enrolled within 31 days from date of qualification as a dependent.

• Accommodation / Benefits Plan of Dependents must follow a uniform category pre-established by the client at the start of the program; and must be equal to or lower than the Principal’s accommodation /benefits plan.

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How about Philhealth / ECC?

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• Our program is integrated with benefits under Philhealth and/or Employees Compensation Commission (ECC); therefore such Philhealth and / or ECC benefits to which the member is entitled to shall be deducted from the claim cost in the computation of benefits under our program, unless agreed otherwise through a special endorsement in the contract.

• All covered members are assumed to be Social Security System (SSS) members. In case a member and/or any dependent is not an SSS member, he shall be charged the amount equivalent to the Philhealth benefit in case he is hospitalized. Insular Health Care shall pay only all hospital bills in excess of the Philhealth benefits.

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How is the Enrollment / Approval of the Application?

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• An applicant applying for coverage is required to accomplish an enrollment form otherwise there will be no coverage despite having paid a deposit for membership fees.

• Changes in the application may be done prior to the underwriting process or the issuance of the ID card. Exceptions, if any, will be handled on a case-to-case, non-precedent setting basis.

• It is understood that Insular Health Care reserves the absolute right to approve or disapprove any application for membership. In case an application is disapproved due to an adverse medical condition, an applicant may still avail of the Insular Health Care program by executing a “waiver” relinquishing or limiting coverage for the particular adverse condition.

• Non-compliance of underwriting requirements within the prescribed period will mean the exclusion from coverage of the condition for which an underwriting requirement has been prescribed.

• In case of pre-termination of coverage or resignation/deletion of members, the client should return the ID card(s) of its members. Any misuse of the ID card by a member will be for the account of the client and / or the member.

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Can you tell me about the Membership Fee / Billing Statement?

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• Membership fee is due and payable on Effective Date of the Agreement. Payment should be on or before due dates corresponding to a mode pre-selected by the client.

• Non-receipt (by the client) of a billing notice does not constitute a valid reason for non-payment of membership fees.

• Non-payment of Membership Fees for 31 days from due date will automatically void the “Agreement”.

• Benefits under the “Agreement” are allowed only if membership fees have been paid PRIOR to availment of such benefits.

• If for any reason the Insular Health Care membership is pre-terminated, the member must surrender to Insular Health Care his ID card.

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What is the Effective Date of Coverage?

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Effective date of coverage will be any day preferred by the corporate client after receipt (and evaluation) of the Corporate Application; receipt of the initial deposit for membership fees; and / or after underwriting requirements, if any, have been complied with by the corporate client.