FAMILY & INDIVIDUAL PROGRAM

Open Access to Accredited Hospitals Nationwide

Under this plan, a member may use any Insular Health Care accredited hospital nationwide including Asian Hospital & Medical Center, Cardinal Santos Medical Center, Makati Medical Center, St. Luke’s Medical Center (Q.C.), The Medical City,  except St. Luke's Global & Healthway Clinic)

Plan features:

  1. For primary care (non-emergency cases), entry point to all accredited hospitals SHOULD BE THE COORDINATOR’S OFFICE. During off-clinic hours, and only for genuine emergency cases (as defined in the Agreement), a member may go to the Emergency Room for treatment.
  2. Makati Medical Center (MMC) users will first have to pass through the Insular Health Care Clinic (at the Insular Health Care Building in Makati City) and avail of its services. When the member requires services that are only available in MMC will he be referred to the hospital. During genuine emergencies (as defined in the Agreement), a member may use any hospital nearest him. If a member uses an accredited hospital, we afford him full coverage according to his benefits classification. If a member uses a non-accredited hospital, reimbursement of expenses will be governed by the Emergency Benefits provision of the agreement.

  3. Some accredited Metro Manila and provincial hospitals no longer have semi-private rooms or no longer admit HMO patients to semi-private rooms. For members who select the semi-private room accommodation plan and/or use hospitals without semi-private rooms for in-patient benefits, please be advised that these hospitals will automatically admit the member to the next higher room accommodation on a step-ladder basis. For genuine emergency cases (as defined in the Agreement), Insular Health Care takes care of the difference in upgraded costs for the first 24 hours. After the first 24 hours, the member pays for the difference in upgraded costs prior to his discharge from the hospital. For elective cases, the member pays for the difference in upgraded costs from day one of his confinement prior to his discharge from the hospital. Please see provision “b” under Room and Board of In-Patient Benefits.

OUT-PATIENT BENEFITS
ANNUAL PHYSICAL EXAMINATION (To be availed at the Insular Health Care Clinic in Makati City or at designated facilities upon full payment of membership fees for the current contract year)

 

1.     Taking of Medical history

2.     Chest x-ray

3.     Physical examinations

4.     Laboratory examinations

          Complete Blood Count

          Stool Examination

          Urinalysis

5.     Electrocardiogram for members 35 years of age and above

6.     Pap smear for female members 35 years of age and above

PREVENTIVE HEALTH CARE (To be availed at the Insular Health Care Clinic, Accredited or Preferred Hospital)

1.     Immunization (does not include cost of vaccine and determination of susceptibility, except first dose of active/passive anti-tetanus vaccine).

2.     Consultation and advice on diet, exercise and other healthful habits

3.     Periodic monitoring and management of health problems

4.     Family planning counselling (except for infertility)

5.     Health education and wellness program

6.     Medical information dissemination through clinics, newsletters, seminars, etc.

OUT-PATIENT SERVICES (To be availed at the Insular Health Care Clinic, Accredited or Preferred Hospital)

1.     Consultation, including specialist’s evaluation

2.     First-aid treatment of injury or illness

3.     Laboratory examinations and all other diagnostic procedures prescribed by the Insular Health Care Physician, subject to program provisions

4.     Minor surgery not requiring confinement

5.     Eye, Ear, Nose, and Throat care

 IN-PATIENT BENEFITS

  1. Room and Board
    In case hospitalization arises either through the advise of the Insular Health Care Medical Coordinator  or by way of an “emergency” situation, Insular Health Care, shall secure the room chosen by its member using a “step-ladder” system (lowest to highest)
    For genuine emergency cases (as defined in the Agreement) in the event that the room accommodation pre-selected by the member under his Insular Health Care package is not readily available, the member shall automatically be upgraded to the next higher room classification for the first TWENTY FOUR (24) HOURS and the ancillary price difference shall be borne by Insular Health Care with absolutely no obligation on the part of the member. After the first 24 hours and there still is no room available under the member’s original room classification, in the succeeding days of his confinement, the member shall pay for the difference in room rates, doctor’s professional fees and other ancillary expenses between the higher room category and the original room category
    Room amenities vary according to actual hospital set-up.
  2. Services of all accredited specialists
  3. General nursing services
  4. Use of operating room
  5. Use of recovery room
  6. Anaesthesia and its administration
  7. Drugs and medications for use in the hospital
  8. Oxygen and its administration
  9. Dressing, plaster cast
  10. Transfusion of blood and other blood elements, except donor screening
  11. Chemotherapy/radio therapy (including out-patient)
  12. ICU confinement (maximum of 14 days, but not to exceed Maximum Benefit Limit of the program)
  13. Dialysis (maximum of 10 treatments, inclusive of out-patient dialysis, but not to exceed Maximum Benefit Limit of the program)
  14. Physical therapy (maximum of 7 sessions inclusive of out-patient physical therapy, but not to exceed the Maximum Benefit Limit of the program)
  15. Speech Therapy (maximum of 7 sessions, inclusive of out-patient speech therapy, but not to exceed the Maximum Benefit Limit of the program)
  16. Services and supplies related to the medical management of the patient
  17. Other hospital charges deemed necessary by the Insular Health Care accredited Physician in the treatment of the patient subject to program provisions
  18.  Ambulance services (hospital to hospital transfers, limited to P 2,500 per conduction), if requested by an Insular Health Care physician.

EMERGENCY BENEFITS

1.     No charge emergency care services administered in any Insular Health Care accredited hospital/clinic for genuine emergency cases as defined in the Agreement.

2.     In case of emergency treatment/confinement in a non-accredited hospital/clinic, or in a medical facility outside the Philippines, Insular Health Care shall reimburse up to 80% of the usual and customary fees which the Insular Health Care preferred clinic/hospital would charge for such treatment/confinement in accordance with the Benefits Classification of the member; or P10,000 for clinic/hospital charges and P 5,000 for professional fees (or a total of P15,000), whichever is less, provided that the illness or condition is covered under the Agreement; and provided further that the member follows the Benefit  Availment  Procedures of Insular Health Care.

MAXIMUM BENEFIT LIMIT (MBL)

The Maximum Benefit Limit per person per illness or injury per year will depend on the member’s Room Accommodation:
Suite - P 150,000
Private – P 120,000
Semi-Private – P 100,000
Ward – P75,000.00

 PHILHEALTH PROVISION

Our program is not integrated with benefits under the PhilHealth. If the Member is entitled to the benefits under PhilHealth, and he/she applies for such benefits prior to hospital discharge, the proceeds for such benefits shall be reimbursed by Insular Health Care to the Member for a minimal processing fee of P 100.00. PhilHealth benefits may not be used to cover excess charges or services not entitled to health care benefits under the Plan.

 ADDITIONAL BENEFITS

 PRESCRIPTION MEDICINE BENEFIT

Up to P 1,000 worth of prescription medicine for immediate relief and/or treatment of illness provided the illness or condition is covered under the Agreement, and medication is prescribed by an Insular Health Care Physician.

 LIFE (GROUP TERM) INSURANCE with INSULAR LIFE

In accordance with Insular Life Group Term Policy No. G - 014175 dated 15 January 1999 and all of its succeeding endorsements, each individual shall be insured in accordance with the following Benefit Schedule:

Room Accommodation Standard Risk
Suite P 50,000
Private 25,000
Semi-Private 15,000

Sub-standard Risk
Suite    P 25,000
Private P12,500
Semi-Private P 7,500

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. However, the insurance of a child below five (5) years old will be subject to “Child’s Lien”, as follows:

 Age of Child at the Time of Death Amount Payable

3 months to less than 1 year One-tenth of the amount of insurance
1 year to less than 2 years One-fifth of the amount of insurance
2 years to less than 3 years Two-fifths of the amount of insurance
3 years to less than 4 years Three-fifths of the amount of insurance
4 years to less than 5 years Four-fifths of the amount of insurance
5 years and above The full amount of insurance

DENTAL BENEFITS (OPTIONAL)

1.     Any number of consultations on dental problems including but not limited to lesions, wounds, burns, and gum problems
2.     Annual Oral Prophylaxis (mild to moderate cases)
3.    
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
4.    
Unlimited temporary fillings
5.    
Unlimited re-cementation of fixed bridges, jacket crowns, inlays and on lays (limited to 4 abutments)
6.    
Dental education and counseling during consultations
7.    
Simple adjustment of denture clasps
8.    
Two (2) surfaces of amalgam fillings
9.    
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
10.  
No limit as to the number of abutments covered (on item 5 above)
11.  
Orthodontic consultations.
12.  
Aesthetic dental consultations.
13.  
Emergency desensitization of hypersensitive teeth.
14.  
Instead of Item 8 above*, option to choose between three (3) surfaces of amalgam fillings or two (2) surfaces of “ light cure” filling

LATEST MODALITIES OF TREATMENT (examples of; The limits of the following procedures shall apply inclusive of professional fees and related incidental expenses)

 1.     Laparoscopic Cholecystectomy (LapChole) is covered up to MBL. All other laparoscopic procedures for therapeutic purposes are covered up to P 20,000 per session.

2.     Hysteroscopic Myomectomy is covered up to MBL. All other hysteroscopic procedures are covered up to P 5,000 per session.

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

4.     Functional Endoscopic Sinus Surgery (FESS) is covered up to MBL.

5.     Lithotripsy (limited to one session per year) is covered up to P 30,000.

6.     Magnetic Resonance Imaging (MRI) / Magnetic Resonance Angiogram (MRA) / Computerized Tomography (CT Scan) are covered up to P 5,000 per session.

7.     All nuclear medicine procedures (e.g., Thallium Scintigraphy, Radioactive Isotope Scan, Hexamibi, etc.) are covered up to P 5,000 per session.

8.     Cryosurgery is covered up to MBL.

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

10.   Gamma Knife is covered up to MBL.

11.   Percutaneous Ultrasonic Nephrolithotomy (PUN) with Electro Shock Wave Lithotripsy is covered up to P 30,000 (one session per year).

12.   Stereotactic Brain Biopsy is covered up to P 20,000 per session.

13.   Transurethral Microwave Therapy of Prostate is covered up to P 30,000 per session.

14.   Laser eye procedures (one session per eye per year) and all other laser procedures (per year) are covered up to P 5,000 except Photorefractive Keratectomy.

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

16.   Sleep Studies is covered up to P 5,000 per year.

17.   Pain Management is covered up to P 3,000 per year.

18.   Arthroscopic surgery is covered up to P 30,000 per year.

 

DREADED DISEASES (examples of)
Coverage is subject to the Maximum Benefit Limit per person per illness or injury per year:

1.     Neurological Disorder

2.     Blood dyscrasia

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

9.     Intensive Care Unit

10.   Accidental injuries

11.   Other conditions causing partial or total

12.   organ damage or failure

 PRE-EXISTING CONDITIONS (PECs)

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

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

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

             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

    such PECs were declared by the member in the original/renewal application;

    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. 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.   Liver Cirrhosis

   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 and all services 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 P 10,000.
       
4.     Chronic glomerulonephritis, gullain-barre syndrome
       
5.     Physical deformities (e.g., scoliosis, spinal stenosis, etc.); vitiligo & psoriasis; (Onlyconsultations are covered)

 PERMANENT EXCLUSIONS (examples)

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.     All dental related services not expressly stipulated in the dental rider

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

5.     Rest cures, custodial, domiciliary or convalescent care

6.     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

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

8.     Sexually transmitted diseases

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

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

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

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

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

14.   Reimbursement of procedures obtained through government programs

15.   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

16.   Out-patient/take-home medicines

17.   Valvular Heart Disease and Rheumatic Heart Disease

18.   Medico-legal consultations

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

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

21.   All hospital charges and professional fees after the day and time the hospital discharge had been duly authorized

22.   Professional fees of Assistant Surgeons

23.   All confirmatory tests used to document health conditions not covered under the plan

24.   Conditions excluded by medical underwriting

25.   Concealment cases

26.   Hypersensitivity/Allergy tests

27.   Hospital Admission Kits

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

29.   Use of Emergency room Facilities on non-emergency cases or by reason of conditions/injuries not falling under the term “Emergency”. Emergency shall mean the sudden, unexpected onset of illness or injury having the potential of causing immediate disability or death, or requiring the immediate alleviation of severe pain & 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.

30.   Miscellaneous Fees not related in the diagnosis and treatment of a member’s condition such as, but not limited to, nursing fee, waste/biologic hazard disposal fee, management fee, local taxes, and other analogous fees

 MEMBERSHIP ELIGIBILITY 
A.    
Individual members
              
At least 15 days to less than 60 years old for new members and up to less than 60 years.

B.     Principal members
             
At least 18 years to less than 60 years old (new members)
C.    Dependents of Principal members (Following Hierarchy Guidelines)
         
For single Principal members: 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.
         
For single parent Principal members: Eldest child down to the youngest, 15 days to less than 21 years old, unmarried and not gainfully employed.
         
For married Principal members: 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.

   Parent(s) or spouse 60 years old to less than 65 years old for renewing members only.

 

DEPENDENT/SECONDARY MEMBER’S COVERAGE

Accommodation / Plan of Dependents / Secondary Members should be equal to or lower than the Principal / Primary Member’s accommodation/plan.

ENROLLMENT/APPROVAL OF APPLICATION
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 membership card.Exceptions, if any, will be handled on a case-to-case, non-precedent 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 conditionfor which an underwriting requirement has been prescribed.

MEMBERSHIP FEE / BILLING NOTICE
Membership fee is due and payable on Effective Date of the Agreement. The enrolment  fee of P 165.00 per applicant is a one-time non-refundable fee. Payment should be on or before due dates corresponding to a mode pre-selected by the Member. Non-receipt by the Member of a billing notice does not constitute a valid reason for non-payment of membership fees. 

Membership fees are payable at any Insular Health Care office or through a duly authorized collection agent of Insular Health Care. Non-payment of membership fees for 31 days from the 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/her membership card. Any misuse of the membership card will be for the account of the member.

EXTRAORDINARY INFLATION OR DEFLATION
In case an extraordinary inflation or deflation of the Philippine Peso should supervene during the term of the Agreement, Insular Health Care shall be authorized to adjust the Membership Fees accordingly or shall be released in whole or in part, from performance of its obligation, when such has become so difficult on its part as to be manifestly beyond that contemplated in the Agreement. 

EXTRAORDINARY INCREASE IN HOSPITAL/CLINIC RATES
In case of more than thirty percent (30%) increase in the rates of accredited hospitals/clinics of Insular Health Care during the contract period of the Agreement, Insular Health Care shall be authorized by the Client/Member to either adjust the Membership Fees accordingly or exclude the said hospitals/clinics from the list of accredited hospitals/clinics where a Client/Member may avail its benefits under the Agreement. However, Insular Health Care shall first notify the Client/Member at least fifteen (15) days prior to implementation of the adjustment in Membership Fees or prior exclusion of the concerned hospitals/clinics, whichever is applicable.


NEW TAXES AND GOVERNMENT LAWS
If during the effectivity of the Agreement, the fees and benefits are made subject to new taxes, levies or fees, and such law, regulation or its equivalent result in additional obligations on the part of Insular Health Care, any additional amount due shall be charged to the Client/Member in addition to the Fees stated herein. Future taxes, levies or fees referred herein are only those that affect the computation of Membership Fees, other future taxes, levies or government impositions that do not affect the computation of Membership Fees are excluded.


EFFECTIVITY
The Agreement is deemed to take effect on the effective date shown in the Data Page. This may either be on the 1st, 8th, 16th, or 24th of the month after receipt (and evaluation) of the application; receipt of the initial deposit for membership fees; and/or after underwriting requirements, if any, have been complied with by the applicant and upon delivery of the Agreement during the lifetimeand good health of the member. 12:01 am. standard time at the address of the member shall be deemed to be the effective time with respect to any dates referred to in the Agreement.


SETTLEMENT OF DISPUTES
In case of dispute or disagreement arising out of or related to the Agreement which cannot besettled mutually by Parties through available manner of resolutions (e.g. mediation), the Parties hereby agree that any suit, action or proceeding shall be exclusively filed at and resolved in the proper Courts of Makati City
in accordance with the laws of the Republic of the Philippines.