Insular Life Health Care Icare hmo philippines health care provider, group hospitalization insurance Pre-existing condition

Insular Life Health Care Inc.
A Subsidiary of the Insular Life Assurance Co. Ltd.

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PRE-EXISTING CONDITION EXPLAINED

Pre-existing condition (PEC) - 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 prior to effective date of coverage.
Such illness or condition was in any way evident to the member prior to effective date of coverage.
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.

Explanation:
Any illness, disease, or adverse health condition which a member has upon enrollment, whether he is aware of it or not, is not covered during the first year of membership. Upon renewal with I-Care the same may be covered subject to evaluation.

Examples of PECs are, but not limited to:

Hernias

All tumors involving any body organ or system

Endometriosis

Hemorrhoids

Diseased tonsils requiring surgery

Pathological abnormalities of the nasal septum and turbinates

Hyperthyroidism/goiter

Cataract

Sinus condition requiring surgery

Asthma

Cirrhosis of the liver

Tuberculosis

Anal fistulae

Cholethiasis/Cholecystitis

Calculi of the urinary system

Gastric or duodenal ulcer

Hallux valgus

All tumors of the skin, muscular tissue, breastbone or malignancies of the blood

Diabetes mellitus

Hypertension

Collagen disease

Cardio-vascular disease

Hormonal dysfunction

QUESTION: Pa'no yan, hindi ko naman alam na may sakit ako, ngayon ko lang nalaman?
ANSWER : As defined, the pathogenesis of such illness may have started prior or before enrollment, kaya maaring hindi mo lang alam, na may sakit ka na. Example: Ulcer doesn't take one week to develop, it take years, kaya kung nag-enroll ka ngayon and it was found out that you have ulcer, it will not covered during the first year, but upon renewal, it can be covered.

QUESTION: Kaya nga ako nag-enroll, eh alam kong may sakit ako, para maka-tipid ako sa hospital bills.
ANSWER: You must understand that HMO is a risk-taking business. If HMOs will give immediate coverage to Pre-exisiting conditions, wala nang HMO ngayon, because yung may mga sakit lang ang mag-e-enroll and no HMO will take immediate risks upon payment of premium. Kaya may one year holding period because HMOs like I-Care, will have at least one year to invest your premium, and on the second year would have earned enough to take the risk and give you benefits for that illness/disease.

QUESTION : So bale-wala, kung hindi rin ma-co-cover yung Pre-existing condition ko?
'Yung ibang sakit na hindi pre-existing ay covered. Eh pa'no yan kung bigla kang ma-dengue. 'Tsaka kung ang premium mo ay P15,000.00 at may sakit ka and kailangan mo operation next year gagastos ka ng P100,000.00, yan bang P15,000.00 mo kung itatago mo lang sa bangko ay magiging ng P100,000.00? Samantalang kung ibayad mo sa I-Care and mag-renew ka, wala ka nang problema sa operation mo next year and na-enjoy mo pa yung ibang benefits, like dental OPD consultations, prescription medicine, etc.

QUESTION : What if, kung talagang within the first year of membership na-acquire yung any of the pre-exisitng condition?
Hindi pa rin ma-co-cover, sa first year of membership. For as long as it is in the list of pec and/or the pathogenesis of the condition has already begun, it will not be covered.

QUESTION: Bakit yung kakilala ko nag-tratrabaho sa isang malaking company, first time lang nila mag-HMO but covered ang kanilang PECs?
ANSWER: Nag-tra-tabaho siya sa malaking Kumpanya, kaya chances are they are under Group Plan or corporate Plan. Sa Group Plan ng isang malaking Kumpanya, ang kanilang premium lahat-lahat ay umaabot ng milyun-milyon. For example sa 1,000 employees paying a premium of P6,500.00 per annum that is the equivalent of P6,500,000.00. In that case, HMOs like I-Care have the capability to "spread the risk". Sa ganoong kalaking halaga, ay kaya nang i-cover ng HMO ang PECs.

QUESTION : So pwede naman palang ma-waive yung PECs? Ano-ano naman ang kailangan para ma-waive yun?
ANSWER : Yes, talagang pwedeng ma-waive subject to certain conditions. 1. Kailangan you are under Group Plan with more than 300 employees, or, 2. You are presently enrolled under group plan with other HMOs, and, 3. Sa individual accounts, maybe waived sa second year ng enrollment, subject to evaluation.