MEMORANDUM OF AGREEMENT
 
 
MEDICARD PHILIPPINES, INC., a corporation duly organized and existing under Philippine laws, with office address at the 9th Floor, Sagittarius Building, H.V. dela Costa Street, Salcedo Village, Makati Metro Manila, hereinafter referred to as MEDIcard, hereby issues to the MEMBER named herein this MEDICard MEMORANDUM OF AGREEMENT (MMA) by virtue of the MEMBER’s application into the MEDICard Health Care Program and accepted by MEDICard Health Care Program and accepted by MEDICard under the terms and conditions stipulated herein.

This MEMORANDUM OF AGREEMENT (MMA) contains the terms, conditions and requirements of membership agreed upon and stipulated between MEDICard and the MEMBER. The terms and conditions on the following pages are part of this MEMORANDUM OF AGREEMENT.


General Provisions


ARTICLE I. DEFINITION OF TERMS
SEC. 1.1 MEMBER – An enrollee who has complied with all the requirements of membership under the MEDICARD HMO program and is hereby entitled to its medical benefits. Unless otherwise specified, all members are entitled to all benefits. Unless otherwise specified, all members are entitled to all benefits. Types of members are defined under Article VII.
SEC. 1.2 MEDICAL BENEFITS – The medical, surgical and dental services available as out-patient or in-patient benefits at no cost to MEMBERS, whenever the need for them arises, and when rendered by and in MEDICARD accredited doctors, hospitals, and clinics.
SEC. 1.3 MEDICARD HEAD OFFICE – Means the principal place of business of MEDICard located at the 9th Floor, Sagittarius Building, H. V. dela Costa Street, Salcedo Village, Makati City, Metro Manila.
SEC. 1.4 MEDICAL SERVICE UNITS/TEAMS – A group of MEDICard physicians and other allied health professionals, who will carry out the delivery of MEDICARD medical and hospital services to MEDICARD MEMBERS.
SEC. 1.5 PRIMARY PHYSICIAN/ACCREDITED PHYSICIAN/COORDINATOR – The office-in-charge physician who acts as the family physician of the MEMBERS in their MEDICARD accredited hospital. He directs the MEMBERS’ medical care, examinees, treats and/or refers members to specialists, orders x-ray and other laboratory tests, prescribes medicines and arranges hospitalization, if needed.
SEC. 1.6 MEDICARD ACCREDITED HOSPITAL/CLINICS – Hospital accredited by MEDICARD, where the designated physician assigns MEDICARD members for hospitalization.
SEC. 1.7 MEDICARD IDENTIFICATION CARD – Issued to the MEMBERS for their identification. It contains the member’s name and signature; account number and effectivity date; validating signature; date of birth; type and room rate. The Identification Cards merely provide Information about the MEMBER and do not constitute this Agreement and neither do they guarantee the delivery of the benefits herein contained.
SEC. 1.8 IN-PATIENT – A person who has been admitted to a hospital as a registered bed patient and is receiving services under the direction of MEDICARD physician.
SEC. 1.9 OUT-PATIENT – A person receiving medical services under the direction of a MEDICARD physician, but not as an in-patient.
SEC. 1.10 MEMBERSHIP FEES – Means the amount paid initially upon enrollment and/or due to be paid upon the due dates as specified in the Schedule of the Information attached herewith, required to continued membership in the MEDICard Health Care Program, payable on an annual basis for the duration of this MMA.
SEC. 1.11 PRE-EXISTING CONDITIONS – Any illness, injury or any adverse medical condition shall be considered pre-existing if during the entire period prior and within the first twelve months from the effectivity date of this Agreement:
  1. Any professional advise or consultation and/or treatment was made given as a result of such illness, injury or adverse medical condition; or
  2. The MEMBER was aware or should reasonably have been aware of the signs or symptoms of such illness, injury or adverse medical; or
  3. The pathogenesis or onset of such illness, injury or adverse medical condition has been started during the contestability period for the membership in this Corporate Health Program as determined by MEDICard’s Medical Director or accredited physicians.
  4. 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:
    1. Any dreaded diseases as defined in this Agreement except letters K and I.
    2. Hypertension
    3. Goiter (Hypo/Hyperthyroidism)
    4. Cataract/glaucoma
    5. ENT conditions requiring surgery
    6. Bronchial Asthma
    7. Tuberculosis
    8. Chronic Cholecystitis/choleiithiasis (gall bladder stones)
    9. Acquired Hernias
    10. Prostate disorders
    11. Hemorrhoids and Anal Fistulae
    12. Benign Tumors
    13. Uterine Myoma, ovarian cyst, Endometriosis
    14. Buergher’s Disease
    15. Varicose Veins
    16. Arthritis
    17. Migraine headache
    18. Gastritis/Duodenal or Gastric Ulcer
  5. All “pre-existing conditions” shall be deemed covered by MEDICar benefits only after the lapse of one (1) year of continous membership of the MEMBER concerned, and provided that the applicable benefits shall not exceed the maximum amount of P5,000.00 per “pre-existing condition/disease” per year of membership.
  6. It is understood that the foregoing benefits shall likewise be applicable to “dreaded diseases” as defined under Article IX of this Agreement.
SEC. 1.12 CONVALESCENT CARE OR REHABILITATION CARE: The restoration of a person’s ability to function as normally as possible after a disabling illness or injury.
SEC. 1.13 CUSTODIAL OR MAINTENANCE CARE: Care furnished primarily to provide room and board (which may or may not include nursing care, training in personal hygiene and other forms of self-care and/or supervisory care by a physician); or care furnished to a person who is mentally and physically disabled, and;
  1. Who is not under specific medical, surgical or psychiatric treatment so as to reduce the disability to such extent necessary as to enable them to live outside an institution providing such care; or
  2. when, despite such treatment, there is no reasonable likehood that the disability will be reduced.
SEC. 1.14 DOMICILIARY CARE - Care provided because care in the patient’s home is not available or unsuitable.
SEC. 1.15 COMPLEX DIAGNOSTIC EXAMINATIONS- procedures, which may or may not be invasive in nature involving use of nuclear/radio nuclide scans, digital imaging, fiber optic/video endoscopy, markers/dyes and specific modalities listed in ArticleVIII, Section 8.04, subsection (a).

ARTICLE II. THE CONTRACT
SEC. 2.1 The application, any medical certifications and/or documents and any written statements, representations, information or evidences furnished by the MEMBER upon the request of MEDICard, and this MMA constitute the entire contract between the parties.
SEC. 2.2 The MMA maybe amended by written agreement between MEDCard and the MEMBER.
SEC. 2.3 Only the President or other duly authorized officer of MEDICard has authority on behalf of MEDICard to change, modify or waive any provision of this MMA, and then only in writing. MEDICard will not be bound by any promise or representation heretofore or hereafter made by or to any agent person other than specified above.
SEC. 2.4 Any act maybe considered as a partial waiver on the part of MEDICard of any term, condition or requirement under this MMA shall not amount to constitute a waiver by MEDICard of the other provisions, terms conditions and requirements of this MMA.

ARTICLE III. NOTIFICATION OF MATERIAL CHANGE
SEC. 3.1 The MEMBER shall be obliged to promptly notify MEDICard in good faith and in writing of a change on his place of residence, occupation, and other material changes in the information he has furnished as required by MEDICard. All notice sent by MEDICard to the MEMBER to his address of records wit MEDICard shall be considered as validly sent in regardless of the actual address or whereabouts of the MEMBER.

ARTICLE IV. MEMBERSHIP DUES AND CHARGES
SEC. 4.1 All membership dues and charges as stated in the Schedule if Information of this MMA shall be considered due without notice to the MEMBER on the part of the MEDICard.

ARTICLE V. MATERIAL MISREPRESENTATION OR NON-DISCLOSURE
SEC. 5.1 Failure to disclose or misrepresentation of any material information by the MEMBER or any applicant for membership under this Agreement, whether intentional or not, shall entitle MEDICard to terminate this Agreement, and/or terminate the membership of the member concerned, respectively, at the option of MEDICard, effective immediately upon receipt of the MEMBER of a notice of termination for this case. Information is deemed material if:
  1. it is among those required to be answered or supplied in the corporate and/or individual application and/or medical examination forms of MEDICard at the time of application;
  2. it would have revealed the existence of a pre-existing condition under Article I, Section 1.11 of a “dreaded disease” as defined under Article IX;
  3. it would be determinative of an “exclusion” defined under Article XV; or
  4. it would have resulted in the disapproval of the application of the MEMBER and/or the member for membership, or the assessment of a higher membership fee for the benefit/s applied for with MEDICard in accordance with the prevailing practice of MEDICard at the time the mispresentationor non-disclosure was discovered.
SEC. 5.2 Upon the termination of such cause, the MEMBER and/or the member, as the case may be, shall forfeit the refund of any corporate and/or individual membership fees which may already have been paid to MEDICard, as well as any and all benefits which may be, under this Agreement before the termination.

ARTICLE VI. CONTRACT PERIOD AND MEMBERSHIP RENEWAL
SEC. 6.1 This MMA shall be effective as of the date effectively specified in the Schedule of Information Attached herewith (1) upon payment of the membership fees required and (2) approval by MEDICard of the application for membership.
SEC. 6.2 This MMA between MEDICard and the MEMBER shall be effective for only one (1) year counted from the date of effectivity as specified in the Schedule of Information hereof unless otherwise renewed or amended in accordance herewith.
SEC. 6.3 This MMA maybe renewed upon the MEMBER’s application for renewal filed before the date of expiration of the subsisting MMA and upon payment of all fees that maybe required by MEDICard based on the current rates.
SEC. 6.4 In the event this MMA lapses due to failure of the MEMBER to pay the membership fee upon the expiration of the 15-day grace period provided in Section 16.1 hereof, the MEMBER may still be reinstated as a member upon approval by MEDICard of his application for reinstatement and payment of the then current Membership Reinstatement Fee, provided, however, the application for reinstatement is filed within fifteen (15) days from the expiration of the aforementioned grace period.
SEC. 6.5 In all other cases, the MEMBER would have to re-apply for membership in the same manner as new applicants.
SEC. 6.6 It is expressly agreed that all re-applications for membership in accordance with this MMA shall be subject to re-evaluation and approval by MEDICard.

ARTICLE VII. MEMBERSHIP ELIGIBILITY
SEC. 7.1 Principal Member:
Any person at least 18 years old and up to 60 years old.
SEC. 7.2 Qualified Dependent Member:
  1. For Married Principal Members
    • The legal spouse up to 60 years old
    • Legitimate and/or legally adopted children 90 days and up to 21 years of age who are not gainfully employed and living under the same roof as the principal member.
  2. For Single Principal Members
    • Parents up to age 60, unemployed and dependent on the principal member.
    • Brothers and sisters 90 days old and up to age 21 who are not gainfully employed and are living under the same roof as the principal member.
SEC. 7.3 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 principal member. For single, the parents must be enrolled first followed by the eldest brother/sister and so on.
SEC. 7.4 Deadline for enrollment of dependents:
  1. For dependents who meet the eligibility requirements within the agreement period -30 days form the date dependent become eligible for membership. (copy of birth certificate or marriage contract must be submitted)
  2. Any additional dependents other than the above can be enrolled upon the renewal of agreement.
  3. After the lapse of the period specified above, MEDICard will no longer receive, evaluate and accept any designation or application to be a qualified dependent from any PRINCIPAL MEMBER.
SEC. 7.5 Underwriting cut-off dates in assigning effectivity date:

Date of Receipt of Application/Endorsement Effectivity Date
11th to 25th of the month 1st of the following month
26th to 10th of the month 16th of the same month
SEC. 7.6 New enrollees who are approaching age of ineligibility must be enrolled at least six (6) months counting from the date of effectivity up to the date that the enrollees become ineligible for them to be accepted as members. All pre-existing condition/ dreaded disease limits will be computed on a prorated basis (i.e. If age of eligibility is up to 60 years old, only who are 60 years and 6 months old and younger will be accepted for membership).
SEC. 7.7 Renewing members who will become age eligible within the next renewal agreement year will be allowed to renew regardless of the remaining months that the member will remain eligible. However, pre-existing conditions/dreaded disease limits will be computed on a prorated basis (i.e. If age of eligibility is up to 60 years old . a renewing member who is 60 years and 9 months old will still be renewed but pre-existing condition/ dreaded disease limits will be computed based on the following formula:

(Total months that member remains eligible/12) x PEC/DD limit = Pro-rated Limit
SEC. 7.8 In relation to his dependents, the MEMBER shall be known as the PRINCIPAL and he shall be deemed to have undertaken to comply with all the requirements and obligations of individual regular membership under this MMA on behalf of said dependent/s, particularly the payment of all the required fees, dues and charges.

ARTICLE VIII. MEMBERSHIP BENEFITS AND PRIVILEGES
SEC. 8.1 PREVENTIVE HEALTH CARE SERVICES
  1. The following no-charge Preventive Health Care Services will be provided to members at MEDICard Head Office Clinic or at nay designated MEDICARD Medical Service Units:
    • Annual Physical Examination (APE) to include:
      Complete Blood Count, Urinalysis (urine examination), Fecalysis (stool examination), Chest X-ray, Electrocardiogram (for adults age 40 and above, or if indicated), Pap Smear (for women age 40 and above, or if indicated)
    • Management of Health
    • Routine Immunization (except cost of vaccines)
    • Counselling on health habits, diets and Family Planning
    • Record Keeping of Medical History
SEC. 8.2 OUT-PATIENT SERVICES
  1. The following Out-Patient Services will be provided to members in any MEDICARD accredited hospital:
    • Referral to specialist
    • Regular Consultations and treatments (except prescribed medicines)
    • Eye, Ear, Nose and Throat treatment
    • X-ray and laboratory examinations prescribed by MEDICARD physician.
  2. The member can go directly to the primary physician of any accredited hospital or at the Head Office clinic for out-patient consultation during regular clinic hours. 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.
SEC. 8.3 DENTAL CARE SERVICES
  1. Members may avail of the following dental care services from any of the accredited dental clinics:
    • Once a year oral prophylaxis (after having paid the annual premium)
    • Consultations and oral examinations
    • Simple tooth extractions, except surgery for impacted tooth
    • Temporary fillings
    • Gum treatment and adjustment of dentures
    • Recementation of loose jackets, crowns in-lays and on-lays
    • Treatment of mouth lesions, wounds & burns.
SEC. 8.4 HOSPITALIZATION CONFINEMENT BENEFIT
  1. The following no charge hospitalization (In-Patient) services will apply when MEDICARD physicians prescribe the hospitalization of members in any MEDICARD Hospitals or MEDICARD centers:
    • No deposit upon admission
    • Room & Board according to type of enrollment
    • Use of operating theater and Recovery Room
    • Services of MEDICard specialist like anaesthesiologists, internists, surgeons, etc.
    • Services and medications for general/spinal anaesthesia or other forms of anaesthesia deemed necessary for a surgical procedure.
    • Fresh whole blood transfusions and intravenous fluids
    • X-ray and Laboratory examinations
    • Administered medicines
    • Dressings, plaster casts, sutures and other items directly related to the medical management of the patient
    • ICU confinements, Chemotherapy, Radiotherapy, and Dialysis are covered subject to maximum limits and pre-existing conditions coverage
    • Modern therapeutic modalities and interventional surgical procedures such as, but not limited to laparoscopic surgery and lithotripsy, are covered up to P20,000 each per years subject to the pre-existing conditions coverage
    • CT Scan, MRI and ultrasound are covered up to P50,000 each per member per year subject to the pre-existing conditions coverage (inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure):
    • The following complex diagnostic examinations and the therapeutic procedures shall be covered up to P5,000.00 each per member per year subject to the pre-existing conditions coverage (inclusive of room and board, operating room charges , professional fees and other incidental expenses relative to the procedure):
      1. Angiography (e.g. coronary, cerebral, retinal, pulmonary, GI, etc.)
      2. Pulmonary perfusion scan
      3. Tests involving use of Nuclear Technologies (e.g. Radionuclide Ventriculography/ Thalium stress testing/ Radionucide/ Thyroid scan, etc). nuclear technologies such as Pyrosphosphate Scintioraphy, Positron Emission Tomography, Radio Isotope Scanning, etc.)
      4. Electromyogrphy. Nerve Conduction Velocity Studies
      5. 24-Hour Holter Monitoring, 2-D Echo and Doppler
      6. Treadmill Stress Test
      7. Myelogram
      8. Endoscopy uncluding one of video
      9. Orthopedic Arthroscopy
      10. Adrecortical Function (e.g. Primary Aldosterinism, Cushing Disease)
      11. Plasma/Urinary Cortisol, Plasma Aldosterone, etc.
      12. Mammography (breast cancer) and Sonomammogram
      13. Bone densitometry scan (Dexascan)
      14. Anti-nuclear antibody (ANA), C-Reactive protein (Rheumatic and its complications), Lupus cell exam
      15. Laboratory/ancillary services for conditions whose pathogenesis or subsequent clinical improvement is not yet fully established in Medical Science.
      16. Mew modalities and/or diagnostic treatment procedures for conditions with established etiologies and its use is only as alternative to the conventional methods.
      17. Genetic/Immunologic studies
      18. Radioactive Iodine Therapy
    • Assistance in administrative requirements through the liaisons officers
    • All other items related to the management of the case
    Note: Above limits are inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure.
  2. Non-emergency confinement or surgery (elective cases) shall be subject to prior review and approval by the MEDICard review board. MEDICard reserves the right to direct the members to other physicians or specialist for further opinions as needed so as to protect the interest of both the member and MEDICard.
  3. In case a member is simultaneously covered under more than one corporate or group health maintenance agreements with MEDICard, the premiums for which are paid by the member’s employer and/or principal, the member, on a per confinement basis, shall only avail of the benefits accruing from one agreement. The member must choose which agreement will apply and his confinement will be governed by the terms and conditions and the limits of the agreement of his choice. The provision is without prejudice to the member’s availment of the benefits under another agreement which may apply for other confinements.
  4. The maximum benefit limit shall be inclusive of consultations, diagnostic procedures, and hospitalization.
  5. Hospitalization or in-patient coverage of a member will depend on his/her final diagnosis. All diagnostic procedures will depend on his/her final diagnosis. All diagnostic procedures will only be covered if results are within inclusions of this Agreement.
  6. For confinements and availments in Makati Medical Center which has a blanket authority policy, all disapproved charges and excess in limits shall be settled directly with the hospital upon exhaustion of limit. Failure of patient to settle the excess bills shall necessitate MEDICard to bill the MEMBER with corresponding 20% service fee and payable within ten (10) working days from receipt of billing.
  7. Effective Feb. 6, 2001 Makati Medical Center (MMC) will only accommodate HMO patients enrolled under Plan 1100 or Small Private and up. Plans below 1100 or Ward and Semi-Private will no longer be applicable to the said hospital.
SEC. 8.5 EMERGENCY CARE BENEFITS
  1. When the member is under Emergency Case and ends up at the emergency room of MEDICARD Accredited Hospitals or MEDICARD centers, the following are provided free of charge:
    • Doctor’s services
    • Medicines used during treatment or for immediate relief
    • Oxygen and intravenous fluids
    • Dressings, casts, and sutures
    • Laboratory, X-ray and other diagnostic examinations directly related to the emergency management of the patient.
  2. EMERGENCY CARE IN NON-MEDICARD Accredited Hospitals
    1. When a member is in immediate danger of losing a limb, eye or other parts of the body or is in severe pain that requires immediate relief and enters a non-MEIDCARD accredited hospital for treatment, MEDICARD agrees to reimburse only (80%) of the total hospital bills inclusive of professional fees and base on relative values for MEDICARD accredited hospitals, but not to exceed the amount of P5, 000.00.
    2. MEDICARD shall pay the said amount when it is verified that MEDICARD facilities were not used because to have done so would entail a delay resulting in death, serious disability or significant jeopardy to the member’s condition or the choice of hospital was beyond the control of the member or the member’s family. Other expenses not covered in using non-MEDICARD Accredited Hospitals for emergency care are:
      1. Follow-up care
      2. Transportation to MEDICARD facility
SEC. 8.6 MEDICard RULES AND REGULATIONS
  1. (a) It is expressly agreed that the MEMBER shall abide by such reasonable rules and regulations concerning the Health Care Program that maybe issued by MEDICard in the interest of improving the over-all efficiency and effectiveness of the delivery of all the medical benefits under this MMA to all MEDICard MEMBERS.

ARTICLE IX. DREADED DISEASE
SEC. 9.1 “Dreaded disease” are potentially or actually life conditions threatening conditions. They may also be illnesses that may require unusually or uncustomary prolonged or repeated hospitalizations and may likewise require intensive care management. These are enumerated but not limited to the illnesses/conditions in Section2 of this Article.
SEC. 9.2 The following are considered dreaded disease:
  1. Cerebrovascular Accident (stroke)
  2. Central Nervous System lesions (Poliomyelitis/ Meningitis/ Encephalitis/ neurosurgical conditions)
  3. Cardiovascular Disease (Coronary/ Valvular/ Hypertensive Heart Disease/ Cardiomyopathy)
  4. Chronic Obstructive Pulmonary Disease (Chronic Bronchitis/Emphysema). Restrictive Lund Disease
  5. Liver Parenchymal Disease (Cirrhosis, Hepatitis (except Type A). New Growth)
  6. Chronic Kidney/Urological disease (Urolithiasis, Obstructive uropathies, etc.)
  7. Chronic Gastrointestinal Tract Disease requiring bowel resection and/or anastomosis
  8. Collagen diseases (Rheumatoid Arthritis, Systemic Lupus Erythematosus)
  9. Diabetes Mellitus and its complications
  10. Malignancies and Blood dyscrasias (Cancer, Leukemias, Idiopathic Thrombocytopenic Purpura)
  11. Injuries from accidents or assaults, frustrated homicide or frustrated murder, subject to police report
  12. Complications of an apparent ordinary illness including MODS and SIRS (e.g.sepsis due to pheumonia, typhoid ileitis, Kawasaki disease, cerebral malaria,, etc.)
  13. Single or multiple organ dysfunction and failure (MODS and MOF)
  14. Conditions that may require dialysis
  15. Chronic pain syndrome (greater than six weeks)
  16. Any illeness other than the above which would require Intensive Care Unit confinement
  17. Et cetera
SEC. 9.3 MEDICard shall pay for the hospitalization services, as herein defined, of a member for “dreaded disease’ up to the maximum amount or limit as specified in Annex A per illness per year
SEC. 9.4 “Dreaded diseases” which are pre=existing in accordance with this Agreement are to b e governed by the provision in Article IX.

ARTICLE X. MEMBERS SATISFACTION SERVICE
SEC. 10.1 All question or concerns of Members about the medical services and benefits shall be directed to MEDICARD Head Office and/or the appropriate staff or Administrative Personnel can work with the member to resolve the Member’s concern in timely manner.
SEC. 10.2 An Emergency Assistance Response Service (E.A.R.S) that operates on a 24 hour/day 365 day/year basis to respond to inquiries. Just dial
Tel. Nos.: 840-2020
Toll Free Nos.: 1800-1888-9001; 1800-1800-9002 (Luzon)
1800-1888-9003 (Visayas)
1800-1888-9004 (Mindanao)
Text MEDICard:       0917-7518365
0919-2476240
SEC. 10.3 Open door policy. Direct access to a network of 240 accredited hospitals/ clinics nationwide, four (4) satellite medical clinics and one Head Office Clinic.

ARTICLE XI. PHILHEALTH
SEC. 11.1 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 the net of the member’s PHILHEALTH benefits.

ARTICLE XII. MOTOR VEHICLE LIABILITY
SEC. 12.1 MEDICARD medical and hospital services are extended to a member if the member’s bodily injuries and fractures are claimed to have been caused by any act or omission of a third party through a motor vehicle. Provided, however, that the member executes an agreement to subrogate to MEDICARD whatever rights the member may have by reason of such accident or event that gave rise to such claim to the extent of the value of the services so rendered. The agreement to subrogate from is available at MEDICARD Head Office.

ARTICLE XIII. GENERAL PROVISIONS FOR ROOM ACCOMODATION
SEC. 13.1 If a member occupies a room higher than what he is entitled to, he shall share in the medical expenses according to the following formula:
  1. If a member a higher priced room of the same category, the member shall pay the excess on room & board:
  2. If a member a room one category higher than what he is entitled to, the member shall pay for the incremental cost on hospital expenses and professional fees and the excess on room & board.
    • Incremental cost for hospital expenses and professional and board charges) multiplied by 30%
    • Incremental cost for professional fees:
      • Medical case: Actual charges – MEDICard Rate
      • Surgical case: Ward to Private Room: Actual Charges – MEDICard Relative Value
      • Private Room to Suite: Actual Charges – MEDICard Relative Value

ARTICLE XIV. CLAIMS AND REIMBURSEMENTS
SEC. 14.1 REIMBURSEMENT PROCEDURE
  1. All claims for reimbursement must be submitted or forwarded to MEDICard Head Office within thirty (30) calendar days after discharge from the hospital. Failure to do shall invalidate the claim, except if it can be shown in writing that it was not reasonably possible to furnish such documents in availing reimbursement.
  2. Required documents in availing reimbursement:
    1. Emergency confinement in non-accredited hospital attended by a non-accredited doctor.
      • Duly filled-up claim form
      • Clinical Abstract
      • Medical Certificate to include complete final diagnosis
      • Surgical/ Operative report if an operation was done
      • Original Official Receipt paid to hospital and doctor
      • Hospital Statement of account and corresponding charge slips
      • Police report if due to accident or medico-legal case
      • Incident report why member was confined in a non-accredited doctor.
    2. Emergency confinement in an accredited hospital attended by a non-accredited doctor.
      • Duly filled-up claim form
      • Clinical Abstract
      • Medical Certificate to include complete final diagnosis
      • Original Official Receipt paid to the hospital and doctor
      • Hospital Statement of account and corresponding charges slips
      • Police report if due to accident or medico-legal case
      • Incident report or proof that MEDICard accredited doctor is not available during the time of confinement
    3. Out-Patient emergency consultation/treatment by a non-accredited doctor in areas where there are accredited hospitals/ clinics.
      • Medical certificate to include complete final diagnosis
      • Original Official Receipt paid to the doctor
      • Incident report
      • Police report if due to accident or medico-legal case
    4. Out-Patient emergency or non-emergency consultation/ treatment by a non-accredited Hospital/ Clinic.
      • Medical certificate to include complete final diagnosis
      • Original Official Receipt paid to the doctor
      • Incident report
      • Police report if due to accident or medico-legal case
    5. For Member Financial Assistance.
      • MEDICard I.D.
      • Affidavit of next of kin or marriage agreement
      • Death Certificate (certified true copy)
      • Attending Physician’s Statement (duly notarized)
      • Certificate of employment of principal member
      • Police report (in case of accident)
SEC. 14.2 RECONSIDERATION OF DENIED REQUEST FOR PAYMENT
  1. If a request for payment is denied, the Member’s authorized representative may appeal the decision by filling a written request with MEDICARD Head Office within thirty (30) days after receiving a negative decision. The request must set forth why the Member believes that the decision was in error. The member may examine pertinent documents not subject to “privileged communication” or disclosure and may submit additional written statements for consideration of the appeal.
  2. Upon completion of the procedure, the Member will receive a written notice stating the final MEDICARD decision and the reason for such decision.

ARTICLE XV. LIMITATIONS, RESTRICTIONS AND EXCLUSIONS
SEC. 15.1 PRE-EXISTING CONDITIONS
  1. All pre-existing illnesses or diseases as defined under Section 1.12 hereof are not covered and MEDICard will not be liable for the same within the first twelve (12) months from the effectivety of this MMA or from the date of the latest reinstatement or reissuance thereof, as the case may be except for consultations with the Designated Physician and the Medical Service Units/Teams of the MEMBER which consultation shall be rendered free of charge. However, in the event the MEMBER suffers from any of the said pre-existing conditions, MEDICARD shall assist the MEMBER arrange for and avail of such medial services as may be needed at MEDICard accredited Hospitals and/or designated clinics, or render such services at discounted rates and preferential professional fees.
SEC. 15.2 COVERAGE WITH WAIVER
  1. MEDICard reserves the absolute right to disapprove all applications for membership on grounds including but not limited to adverse medial conditions other than those indicated in the provisions for exclusions and limitations and “pre-existing conditions’. In cases of a disapproved application or member renewal due to an adverse medial condition, an applicant or member could still avail of the MEDICard program benefits be executing a WAIVER. Such WAIVER in effect is an intentional relinquishment of medial coverage for the particular adverse medical condition.
SEC. 15.3 HOSPITALIZATIONS
  1. All confinement shall be upon recommendation of the corporate health program holder’s MEDICard accredited, or the MEDICARD Medical Director or the Emergency Room Resident Physician of the MEDICARD accredited Hospital who decides to admit MEDICARD patient-member in cases of the threatening emergencies.
  2. Hospital bills for the following hospital services shall be charged to the account of the MEDICARD patient-member services to a private nurse or doctor, use of extra food and/or bed, T.V. electric tan, VCD, ID bracelet, thermometer, admission kit, and all other items not directly related to the medical management of the patient.
  3. Hospitalization and treatment outside the Philippines is not covered.
  4. MEDICARD is not responsible and will not recognize any hospital bills incurred by a corporate health program holder in hospitals not accredited by MEDICARD, except for emergency care services.
  5. Cost of hospitalization, medical services, medicine and other expenses incurred as a result of a member’s decision to avail of such hospitalization, medical services, treatment or procedure, not contrary to what has been prescribed by the attending MEDICARD provider, or without Medicard’s express written report.
SEC. 15.4 OUT-PATIENT SERVICES
  1. Prescribed medicines on an out-patient basis are not provided by MEDICARD Medical Center or Medical Service Units.
  2. The absolutely no charge out patient medical and healthcare services are provided only during clinic hours of medical Service Units.
  3. Second opinions and cost of treatment incurred in non-accredited hospital or clinic should the member unilaterally decide to seek such recourse.
SEC. 15.5 EXCLUSIONS
  1. Services a member receives from a non-MEDICARD Physician, non-MEDICARD Accredited Hospital or other provider of care, except as described in the emergency care in non-MEDICARD hospitals, as provided for in the Agreement
  2. Hereditary and/or congenital defects of whatever form
  3. Sensorineural hearing impairments except those acquired during time of membership
  4. Plastic and reconstructive surgery for cosmetic purposes and for physical congenital deformities and abnormalities
  5. Dermatological care for aesthetic purposes such as electrocautery or chemical treatment for skin tags, xanthelasma, milla, keloids scars, etc. on any exposed areas of the body
  6. Gullain-BArre syndrome, multiple scierrosis, demyelinating disease, Parkinson’s disease, Aizheimer’s disease. Myasthenia Gravis, epilepsy, seizure disorder, and other autoimmune neurological disease
  7. Slipped disc. Herniated disc. Scoliosis spinal stenosis and spondylosis
  8. AV malformation and aneurysms which are considered congenital except only those unequivocably proven to be acquired secondarily
  9. Corrective eye for error of refraction including laser surgery for correction of myopia and hypermyopia
  10. Psoriasis vintiligo
  11. Experimental medical procedures, acupuncture, reflexology, and chiropractics
  12. Services to diagnose and/ reverse fertility and virility/potency (erectile dysfunction)
  13. 0pen heart surgeries, angioplasities, permanent pacemaker insertion, intra coronary thrombolysis ballon valvuloplasties, transvenous endocardial biopsy, percutaneous intraaortic ballon pump insertin, ballon atrial septostomy, previous craniotomy sequiae, organ transplanation and complicatona dnd other surgeries related to the heart
  14. Diagnostics for hypersensitivity and desensitization treatment
  15. Purchase or lease of durable medical equipment, oxygen dispensing equipment and oxygen except during hospital confinement under the Hospital Confinement Benefit
  16. Corrective appliances and artificial aids and prosthetic devices
  17. Human blood products like platelets packed RBC, plasma, gamma globulin, etc. and its processing
  18. Psychiatric and psychological illnesses including neurotic and psychotic behavior disorders
  19. Treatment for alcoholic intoxication and drug addiction or overdose reaction to us of prohibited drugs including illnesses directly related to it and other injuries attributed as a result of it
  20. Rehabilitation treatment physical speech, occupational and hormonal therapies
  21. Developmental disorders, metabolic diseases, sleep and eating disorders
  22. Sexually transmitted diseases such as aids, Hepatitis B, condyloma, gonorrhea, syphilis, herpes etc. and their attendant complications
  23. Hazardous job-related illnesses and/or injuries
  24. Physical examination required for obtaining or continuing employment, insurance or government licensing
  25. Injuries or illnesses resulting from participation in war-like or combat operations, riots insurrection, rebellion, strikes and other civil disturbances
  26. Treatment of self-inflicted injuries or injuries attributable to the MEMBERS own misconduct. Gross negligence, use of alcohol and/or drugs. Vicious or immoral habits participation in act of crime violation of a law or ordinance, unnecessary exposure to imminent danger or hazard to health, and hazardous sports related injuries
  27. Maternity care and other conditions as a result of pregnancy unless specifically provided
  28. Custodial, domiciliary care, convalescent, and intermediate care.
  29. Oral surgery for purposes of beautification, temporomandibular joint disease (TMJ) surgery done by dental practitioner
  30. Circumcision, except for correction of Phimosis
  31. Treatment of injuries sustained in a motor vehicle accident if the member or his guardian fails or refuses to execute the deed of Subrogation specified in Article VII hereof
  32. Professional fees of medico-legal officers
  33. Diagnosis of unknown etiology or the absence of any organic dysfunction
  34. Cost of vaccines for active and passive immunization
  35. Laboratory examination for screening sexually related illnesses and injuries
  36. Any condition or illness waived upon membership except as otherwise provided for in this Agreement
SEC. 15.6 LIMITATION IN SERVICES: MEDICARD is not not responsible for the following:
  1. Delay or failure to render services due to major disasters, brownouts or epidemics affecting facilities or personnel.
  2. Unusual circumstances such as complete or partial destruction of facilities, war, riots, disability of a significant number of MEDICARD personnel or similar event which result in delay to provide services
  3. Conditions for which a member has refused recommended treatment for personal reasons, for which MEDICARD physicians believe no professionally acceptable alternative treatment exists.
  4. Sudden change of hospital policies

ARTICLE XVI. DELINGQUENCY, GRACE PERSION AND LAPSATION
SEC. 16.1 This MMA shall automatically lapse and be considered terminated if the membership fee remains unpaid alter fifteen (15) days from the due date, which is the grace period for payment of membership fees. As such, the membership lapsed and the member is no longer entitled to the benefits and privileges or membership under the MEDICard health care program, or this MMA.
SEC. 16.2 During the 15-day grace period within which the MEMBER is given time to update his account, all benefits will still be covered, except fro emergency care and hospital confinement which will cease to be covered after seven (7) days of non-payment of the membership fees from due date.

ARTICLE XVII. CONSIDERATION
SEC. 17.1 The application made by the MEMBER to the MEDICard Health Care Program, the information and representations furnished bye the MEMBER to MEDICard upon the latter’s request in connection with the application for membership, all amendments and endorsement and endorsement duly made by MEDICard after the date of effectivity hereof, due payment of the membership fees and all charges, and the terms and conditions specified herein constitute the consideration on the part of MEDICard for this MMA.

ARTICLE XVIII. PRE-TERMINATION OF MMA
SEC. 18.1 This MMA may be pre-terminated by MEDICard and the fees forfeited in favor of MEDICard if the MEMBER:
  1. Fails to maintain a satisfactory hospital-patient or doctor-patient relationship with the Designated Physician. The Medical Service Units/|Teams, Designated Hospital, or Accredited Hospital.
  2. Fails to pay or arrange of applicable charges within fifteen (15) days from due date.
  3. Knowingly furnishes MEDICard incorrect or incomplete enrolment information, or fails to inform MEDICard on other changes that may affect the MEMBER’s eligibility for membership.
  4. Permits the use of his/her MEDICard I.D. by any other person.
SEC. 18.2 In all cases of pre-termination, MEDICard shall send appropriate notice of the existence of the ground for pre-termination to the MEMBER AND ALLOW THE MEMBER to explain his side. Termination shall take effect upon final notice sent to the MEMBER at his address of record.

ARTICLE XIX. NON-ASSIGNABILITY OF MMA
SEC. 19.1 The medical benefits under this MMA are non-assignable and non-transferable on the part of the MEMBER. Any violation of this provision would entitled MEDICard to the remedy of pre-termination under this MMA

ARTICLE XX. ARBITRATION AND VENUE
SEC. 20.1 In the event of any different arising between the MEMBER and MEDICard as to the construction, interpretation, application of any provision of this MMA, or as to the rights, obligations, and responsibilities of the parties hereto, all questions shall be determined primarily by the parties themselves in the spirit of amicable settlement, failing which the parties hereby agree to submit the determination of their differences to arbitration in accordance with Arbitration Law of the Philippines which decision shall be final. Pending such arbitration between the parties, there shall be no cancellation or forfeiture of the effectivity of any other provisions under this MMA otherwise unaffected by the dispute.
SEC. 20.2 It is further stipulated and agreed that the venue for the submission of all actions and questions in the course of the arbitration, including a proper appeal of the award, which may be presented before the courts in accordance with the law shall be the courts at Makati City, Metro Manila.

/  URG-MMA
REV.2
01 JUNE 2002