ICare Insular Life Health Care hmo philippines health care provider

INDIVIDUAL & FAMILY PLAN
(Effective 1-1-2009) (to form part of the application)
Open Access to Accredited Hospital System
Under this Plan, a member may use any I-Care accredited Hospital nationwide.

PLAN FEATURES:

Out/In-patient Services

For primary care (non-emergency), 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.

Makati Medical Center (MMC) users will have to pass through the I-Care Clinic (at the I-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.

Some accredited Metro Manila and provincial hospitals no longer have semi-private rooms or no longer admit HMO patients to semi-private rooms (e.g. Makati Medical Center, The Medical City, UST Hospital, Chong Hua Hospital, Mary Chiles General Hospital, and Dr. Jesus Delgado Memorial Hospital). For members who select the semi-private room accommodation plan and/or uses 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), I-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 provisions "b" under Room and Board of In-Patient benefits.

OUT-PATIENT BENEFITS
ANNUAL PHYSICAL EXAMINATION (To be availed at the I-Care Clinic in Makati City or at designated facilities)

Taking of medical history

Physical examination

Chest X-ray

Laboratory medical examination
* Complete Blood Count
* Stool Examination
* Urinalysis

Electrocardiogram for members 35 years of age and above

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

PREVENTIVE HEALTH CARE (to be availed at the I-Care Clinic, Accredited or Preferred Hospital)

Immunization (does not include cost of vaccine and determination of susceptibility)
Consultation and advice on diet, exercise and other healthful habits
Periodic monitoring and management of health problems
Family planning counseling
Health education and wellness program
Medical information dissemination through clinics, newsletters, seminars, etc.

OUT-PATIENT SERVICES

Consultation, including specialist's evaluation
First-aid treatment of injury or illness
Laboratory examination and all other diagnostic procedures prescribed by the I-Care Physician
Minor surgery not requiring confinement
Eye, ear, nose and throat care

IN-PATIENT BENEFITS

Room and Board

a. In case hospitalization arises either through the advise of the I-Care Medical Coordinator or by way of an "emergency" situation, I-Care shall secure the room chosen by its member using a "step-ladder" system (lowest to highest).
b. For genuine emergency cases (as defined in the agreement) in the event that the room accommodation pre-selected by the member under his I-Care package is nor readily available, the member shall be 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 I-Care with absolutely no obligation on the part of the member. After the first twenty-four (24) hours and there is still 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 rate as well as difference in ancillary expenses between the higher room category and the original room category.
c. Room amenities vary according to actual hospital set-up.'
Services of physicians and surgeons, including surgery
General nursing services
Use of operating room
Use of recovery room
Anesthesia and its administration
Drugs and medication for use in the hospital
Oxygen and its administration
Dressing plaster and cast
Transfusion of blood and other blood elements
Chemotheraphy/radiotheraphy (including out-patient)
ICU confinement (maximum of 14 days but not to exceed benefit limit)
Dialysis (maximum of 10 treatment but not to exceed benefit limit) inclusive of out-patient dialysis
Physical therapy (maximum of 7 sessions but not to exceed maximum benefit limit, inclusive of out-patient physical therapy)
Services and supplies related to the medical management of the patient
Other hospital charges deemed necessary by the I-Care accredited Physician in the treatment of the patient subject to program provisions
Ambulance services (hospital to hospital transfers, limited to P 2,500 per conduction), if requested by an I-Care physician.

EMERGENCY BENEFITS
No charge emergency care services administered in any I-Care accredited hospital/clinic.
1. In case of emergency treatment/confinement in a non-accredited clinic/hospital, I-Care shall reimburse up to 80% of the usual and customary fees which the I-Care preferred clinic/hospital would charge for such treatment/confinement in accordance with the Benefits Classification of the member; or P10,000.00 for clinic/hospital charges and P5,000.00 for professional fees (or a total of P15,000.00), whichever is less, provided that the illness or condition is covered under the contract and provided further that the member follows the Benefit Availment Procedures of the Company.

MAXIMUM BENEFIT LIMIT (MBL)
Limits of the program will depend on the member's room accommodation:
Suite P150,000.00
Private P120,000.00
Semi-private P100,000.00

PHILHEALTH/EMPLOYEES COMPENSATION COMMISSION
Our program is NOT integrated with benefits under Philhealth and/or ECC benefits. If the member is entitled to such benefits, he/she should file for reimbursement directly with Philhealth or ECC

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 I-Care physician.

LIFE (GROUP TERM) INSURANCE
In accordance with Insular Life Group Term Policy No. G-01494 dated 01 January 1992 and all its succeeding endorsements, each individual shall be insured in accordance with the following benefit schedule:

Room Accommodation	Standard Risk	Sub-standard Risk
Suite	P50,000	P 25,000
Private	25,000	12,500
Semi-private	15,000	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 accident. However, the insurance of a child below five (5) years old will be subject to "Child's Lien" as follows:

Age of Dependent Child at the time of Death	Amount payable
3 mos. to less than 1 yr	1/10th of the amount of insurance
1 yr to less than 2 yrs	1/5th of the amount of insurance
3 yrs. To less than 4 yrs.	2/5th of the amount of insurance
4 yrs. To less than 5 yrs.	3/5th of the amount of insurance
5 years and above	The full amount of insurance

DENTAL BENEFITS

Any number of consultations during clinic hours
Annual oral prophylaxis (mild to moderate cases)
Unlimited simple tooth extraction (complicated extractions involve use of dental instruments except pliers)
Lesions, wounds, burns and gum or dental problems requiring dental management surgeries.
Unlimited temporary fillings
Unlimited recementation of fixed bridges, jacket crowns, inlays and onlays (limited to 2-4 abutment)
Dental education and counseling during consultations
Unlimited adjustments of dentures (limited to adjustment of clasp)
Two (2) permanent amalgam fillings (surfaces)
Orthodontic & Aesthetic dental consultations
Emergency desentizations of hypersensitive teeth.

LATEST MODALITIES OF TREATMENT(examples of)

Laparoscopic Cholecystectomy (LapChole) is covered up to MBL
All other laparoscopic procedures for therapeutic purposes (except LapChole, Hyteroscopic D&C and Hysteroscopic Myomectomy) are covered up to P20,000 per session.

Lithotripsy (limited to one session per year) up to P 30,000.00.

Magnetic Resonance Imaging / Magnetic Resonance Antiogram (MRA)Computerized Tomography (CT Scan) are covered up to P5,000.00 per session.

All nuclear medicine procedures (e.g. Thallium Scintigraphy, Radioactive Isotopic Scan, etc are covered up to P5,000 per session.

Cryosurgery up to Maximum Benefit Limit.

Electrocautery for warts - P1,000.00 per year.

Endoscopic procedure (except FESS) - Diagnostic - Maximum Benefit Limit. Therapeutic - P5,000.00 per session.

Functional Endoscopic Sinus Surgery -(FESS) is covered up to Maximum Benefit Limit.

Gamma Knife is covered up to MBL.

Percutaneous Ultrasonic Nephrolithotomy (PUN) with electro Shock Wave Lithotripsy is covered up P30,000.00 (one session per year).

Stereotactic Brain Biopsy is P20,000.00 per session.

Transurethal Microwave Theraphy of Prostrate is covered up to P30,000.00 per year.

Laser Eye Procedures (one session per eye per year) is covered up to P5,000.00 except Photorefractive Keratectomy.

Speech theraphy - maximum of seven sessions.

Positron Emission Tomography Scan (PET Scan) up to P5,000 per session.

Sleep Studies up to P5,000 per year.

Pain Management up to P3,000 per year.

DREAD DISEASE (examples of)
Coverage is subject to the Maximum Benefit Limit per person per illness or injury per year.

Neurological Disorder
Blood dyscrasia
Collagen/Immunological disorder
Liver Cirrhosis
Chronic Pulmonary/ Renal disorder
Cardiovascular disorder
Cancer
Any condition which necessitates the use of ICU
Accidental injuries
Other conditions causing partial or total organ failure.

PRE-EXISTING CONDITIONS (PEC)

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 prior to effective date of coverage.
2. Such illness or condition was in any way evident to the member prior to effective date of coverage.
3. The pathogenesis of such illness or condition has already started prior to effective date of coverage.
After the member has been continuously covered for 12 months and the agreement is renewed, the provision on PEC excluded from I-Care coverage shall be waived, provided that such PEC is not considered part of the "Permanent Exclusions to Health Care Coverage" and that such PEC was disclosed by the member in the original application.
Examples of PECs (inclusive of complications)

Hernias

All tumors involving any body organ or system

Endometriosis, dysfunctional uterine bleeding

Hemorrhoids

Diseased tonsils requiring surgery

Pathological abnormalities of the nasal septum and turbinates

Hyperthyroidism/goiter

Cataract

Sinus condition requiring surgery

Asthma/Chronic Obs Pulmo Disease

Liver Cirrhosis

Tuberculosis

Anal fistulae

Cholethiasis/Cholecystitis

Calculi of the urinary system

Gastric or duodenal ulcer

Hallux valgus

Diabetes mellitus

Hypertension

Collagen disease

Cardio-vascular disease

Hormonal dysfunction

Seizure disorder

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

Organ transplant and/or open heart surgery and all services related thereto (except organ and donor services)

AIDS and AIDS-related diseases

Congenital abnormalities and conditions are covered up to P10,000.00.

Chronic glomerulonephriitis, gullain-barre syndrome

Physical deformities (e.g., scoliosis, spinal stenosis, vitiligo, psoriasis, etc.) Only consultation are covered

PERMANENT EXCLUSION (examples of)

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.
All pregnancy related conditions requiring medical/surgical care.
Sterilization of either sex or reversal of such, artificial insemination, sex transformations or diagnosis and treatment of infertility.
Rest cures, custodial, domiciliary or convalescent care
Cosmetic surgery, dental/oral surgery for the purpose of beautification except reconstructive surgery to treat dysfunctional defect due to disease or accident.
Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, adjustment disorders, alcoholism and itrs complications or conditions related to substance or drug abuse, addiction and intoxication.
Sexually transmitted disease
Medical and surgical procedures which are not generally accepted as standard treatment by the medical profession.
Procurement or use of corrective appliances, artificial aids, durable equipment, and orthopedic prosthesis and implants.
Surcharges resulting from additional personal (luxuries/accommodation) request or service.
Physical examination required for obtaining employment, insurance or a government license, and procedures for purely diagnostic purposes.
Injuries or illness due to military, para-military, police service, high risk activities or suffered under conditions of war
Reimbursement of procedures obtained through government programs.
Injuries or illnesses which are self-inflicted, caused by attempt at suicide or incurred as a result of, or while participating in a crime.
Out-patient/take-home medicines.
Cardio-valvular disease or Rheumatic Heart Disease.
Medico-legal consultations
When a member is discharged against medical advise
Blood donor screening/other screening procedure
All hospital charges and professional fees after the day and time hospital discharge has been duly authorized

MEMBERSHIP ELIGIBILITY

PRINCIPAL
At least 18 years to less than 60 years old
Dependents: (Following hierarchy guidelines)
* For single individual: Parent(s) first who is/are less than 60 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 married individuals: Spouse first who is less than 60 years old; followed by the eldest child down to the youngest, 15 days to less than 21 years old, unmarried and not gainfully employed.

DEPENDENT'S COVERAGE
Accommodation/Plan of Dependents should be equal to or lower than the principal's accommodation

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 ID card. Exceptions if any, will be handled on a case-to-case basis. It is understood that I-Care reserves the absolute right to approve or disapprove any application for membership. In case an application is disapproved due to adverse medical condition, an applicant may still avail of the I-Care program by executing a "waiver" relinquishing or limiting coverage for the particular adverse condition. Non-compliance of underwriting requirements within the prescrived period will mean the exclusion from coverage of the condition for which underwriting requirement has been prescribed. It will likewise mean non-issuance of the member's ID.

MEMBERSHIP FEE/BILLING STATEMENT
Membership fee is due and payable on Effective Date of Agreement. The enrollment fee of P150.00 per appplicant is a one-time fee, non-rfundable if application is declined. Payment should be on or before Due Dates corresponding to a mode pre-selected by the client. Non-rceipt by the client of a billing notice does not constitue 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 I-Care membership is pre-terminated, the member must surrender his ID card.

EFFECTIVITY DATE OF COVERAGE
Effectivity Date of coverage will either be 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 by the applicant.