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MEDICard
Philippines, Inc.
9th Floor, Sagittarius Bldg., H.V. Dela Costa Street,
Salcedo Village, Makati City, Philippines
Trunkline: (02) 884-9999 / Fax. No.: (02) 810-3855
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 What is MEDICard?
MEDICard is a Health Maintenance Organization (HMO) that provides Comprehensive Health Care Coverage for its members with the use of accredited hospitals and accredited doctors.
- Preventive Health Care Service
- Out-Patient Services
- Dental Services
- Emergency Care Services
- Hospital confinement Benefits
- Member's Financial Assistance
Who are eligible as members?
PRINCIPAL MEMBERS
Salaried personnel at least 18 years old and up to 60 years old employed by the company on a permanent basis.
DEPENDENT MEMBERS
For married employees:
- Legal spouse up to 60 years old
- Legitimate and or legally adopted children from 90 days old and up to 21 years old who are unmarried
For Single employees:
- Parents up to 60 years old
- Brothers and sisters from 90 days old up to 21 years who are unmarried
All applicants for membership both principal and dependents, aged 40 and above are subject to prior medical evaluation and approval by the MEDICard Medical Department.
What are the benefits and how do we go about the availment?
In availing of all the benefits enumerated, the MOST IMPORTANT THING IS TO HAVE WITH YOU YOUR MEDICard ID.
PREVENTIVE HEALTH CARE
- Periodic Medical Check-up
- Annual Physical Examination
- Management of Health problems
- Administration of Immunization (except cost of vaccines)
- Counseling on health habits, diets and family planning
- Record keeping of Medical history
Annual Physical Examinations will be done at the MEDICard Head Office, 9th floor Sagittarius Bldg., H.V. dela Costa St. Salcedo Village, Makati City or it may be done at the company premises provided that the corporate account is composed of at least 50 principal members.
Included in the Annual Physical Examination are the following:
- Complete blood count
- Urinalysis
- Fecalysis
- Chest X-ray
- Electrocardiogram (for adults aged 40 and above, or if indicated)
- Pap smear (for women aged 40 and above, or if indicated)
When is a pre-existing condition covered?
All pre-existing conditions shall be deemd covered by MEDICard only AFTER ONE (1) year of continuous membership and shall be covered up to a maximum limit of P 5,000 per year.
For corporate accounts with 100 or more principal members, all Pre-existing conditions shall be covered immediately upon effective date of coverage up to maimum limit of P 5,000 per year.
What are considered pre-existing conditions?
- Dreaded Diseases, if such are present upon enrolment
- Hypertension
- Goiter (Hyperthyroidim)
- Cataracts/Glaucoma
- ENT conditions requiring surgery
- Bronchial Asthma
- Tuberculosis
- Chronic Cholecystitis/Cholelithiasis (gall bladder stones)
- Acquired Hernias
- Prostate disorders
- Hemorrhoids and Anal Fistulae
- Benign tumors
- Uterine myoma, Ovarian Cyst, Endometriosis
- Buergher's Disease
- Varicose Veins
- Arthritis
- Migraine headache
- Gastritis/duodenal or gastric ulcers
What is a dreaded disease?
These are illnesses which may or may not be life threatening or catastropic, but may require prolonged or recurrent hospitalization as adjudged by the MEDICard Medical Director.
Example of which are the following:
- CVA (Cerebro-vascular disease)
- Cancers of any form
- Cardio-vascular diseases
- Chronic Obstructive Pulmonary Disease
- Diabetes Mellitus
- Sepsis from any cause
- Injuries from accident or assault
- Respiratory/Renal or any form of Multiorgan failure
- Blood dyscracias
- Chronic liver Parenchymal disease
- Collage Vascular Diseases
- Any illness that may require an ICU confinement
- Complications of morbities that may arise from a previous surgical procedure
- Any complications related to above mentioned illness
MEDICard shall pay for the hospitalization of dreaded disease up to the maximum amount or limit according to their room and board category.
If any of the above illnesses are discovered to be existing even after a year of continuous membership, a retroactive waiver should be executed by the member or otherwise termination of membership shall be effected and all benefits shall be cancelled.
What are not covered by MEDICard?
A. OTHER MEDICAL PROCEDURES AND SERVICES/WORK-UPS
- Hospitalization and Medical /Surgical Services a member receives attended to by a non-MEDICard accredited physician, from a non-MEDICard accredited hospital or other provider of care, except as described in the emergency care in non-MEDICard accredited hospitals.
- Hospital bills for the following hospital service shall be charged to the account of the MEDICard patient member : Services of a private nurse or doctor , use of extra food, bed, T.V., electric fan, betamax, ID bracelet, thermometer, and all other items not directly related to the medical management of the patient.
- Hospitalization and treatment outside the Philippines.
- Plastic and reconstructive surgery for cosmetic purposes and for congenital deformities and abnormalities. Cosmetics services (e.g. cautery of facial warts, breast augmentation, injection of steroids for keloids etc)
- Diagnostic procedure to determine sources of allergy (e.g. Patch Test)
- Physical examinations required for obtaining or continuing employment or gov't licensing.
- Experimental medical procedures and acupuncture.
- Service to diagnose and/or reverse infertility or fertility.
- Purchase or lease of durable medical equipment, oxygen dispensing equipment and oxygen except during hospital confinement under the hospital confinement benefit.
- Corrective appliances and artifical aids and prosthetic devices.
- Human blood products like platelets, packed RBC, plasma etc.
- Psychiatric care, rehabilitation treatment, physio-therapy and speech therapy.
- Treatment for alcoholism and drug addiction or abuse.
- Open heart surgery and organ transplant.
- Treatment of self-inflicted injuries attributable to the member's own misconduct, gross negligence, use of alcohol and/or drugs, vicious or immoral habits, participation in acts of crime, violation of a law or ordinance, and unnecessary exposure to imminent danger hazard to health.
- Maternity care and other conditions as a result of pregnancy unless specifically provided.
- Custodial, domiciliary care, convalescent and intermediate care.
B. OTHER ILLNESS AND/OR DISEASES
- Congenital defects and hearing impairment.
- Slipped disc, spinal stenosis, scoliosis, and spondylosis
- All physical deformities prior to enrolment.
- Guillain-Barre syndrome, multiple sclerosis, and other auto immune neurological disease.
- Epilepsy
- Psoriasis, vitiligo
- Previous craniotomy sequelae
- Sexually transmitted disease, including gonorrhea, syphilis, herpes
- AIDS
- Injuries or illnesses resulting from participation in warlike or combat operations, riots, and civil disturbance
- Hazardous job-related illnesses
- Medico-legal Fees
What happens to my PhilHealth?
PhilHealth benefit is integrated with MEDICard. When you are admitted, you will be asked by rhe MEDICard Liaison Officer to file your PhilHealth Reimbursement form. The PhilHealth reimbursement that is due you shall be deducted by the hospital from their bill to MEDICard.
Does this plan cover hospitalization as a result of a vehicular accident?
YES, MEDICard Medical and Hospital services are extended to a member in case of injuries arising from vehicular accidents that require hospitalization.
However, if the member's bodily injuries and fractures are claimed to have been caused by any act or commission of third party through a motor vehicle, the same will be covered provided 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. The agreement to subrogate from may be obtained from the MEDICard head office.
Member's Financial Assistance
Aside from the standard benefits to which a MEDICard member is entitled to, MEDICard Philippines, Inc., also hereby agrees to give/provide the heirs and/or assigns of any member who is enrolled in this health care program in the event of death or injuries through natural causes or accidental means.
SCHEDULE OF FINANCIAL ASSISTANCE
Natural Death................................................ P 10,000.00
Accidental Death ............................................ P 20,000.00
Loss of sight, or two limbs.................................. P 10,000.00
Loss of one eye, one hand or foot........................ P 5,000.00
Provided, that the death of injury results from causes that are covered and are not under the exclusions or pre-existing conditions as stated in the MEDICard Membership contract. PEC coverage under the HMO program does not entitle the member to MFA benefits unless disclosed in the original application or specifically negotiated for prior to contract effectivity.
What are the documents needed in availing reimbursement?
IN-PATIENT
- Emergency confinement in non-accredited hospital attended by a non-accredited doctor.
Payments shall be 80% of approved charges not to exceed the maximum reimbursable limit.
- Emergency confinement in an accredited hospital attended by a non-accredited doctor.
Payments shall be 100% of approved charges on hospital bills portion and 80% of professional fees based on MEDICard relative values
- Maternity claim
Payment shall be 100% of approved charges on hospital bills and professional fees based on MEDICard relative value not to exceed the maximum reimbursable limit.
OUT-PATIENT
- Out-Patient emergency consultation/treatment by a non-accredited doctor/hospital in areas where there are accredited hospitals/clinics.
Payment of claims shall be 80% of professional fees and approved laboratory expenses based on MEDICard relative value.
- Out-Patient emergency or non-emergency consultation/ treatment by a non-accredited doctor/hospital in areas where there are no hospitals/clinics.
Payment of claims shall be 100% of professional fees and approved laboratory expenses based on MEDICard relative value.
Members Financial Assistance
Natural Death P10,000.00
Accidental Death P20,000.00
Loss of sight, or two limbs P10,000.00
Loss of sight of one eye, one hand or foot P 5,000.00
Provided, that the death or injury results from causes that are covered and are not under the exclusions or uncovered pre-existing conditions as stated in the MEDICard Membership Contract.
Also, total annual premium for the contract year should have been paid at the time of availment. Otherwise, all remaining unpaid premium will be deducted from the amount of assistance.
Medicine Reimbursement
100% not to exceed maximum allowable limit
Eyeglasses wear Reimbursement
100% not to exceed maximum allowable limit
PhilHealth Refund
100% of actual payment made for the Philhealth portion
PhilHealth Refund – PhilHealth Incentive
Actual Philhealth Benefit (hospital bills portion) multiply to the Allowed Incentive Rate
How long will it take to get my reimbursement?
Normally, processing of reimbursements is 15 working days after receipt of the complete documents; it includes evaluation of the bills, investigation, approval of doctor, premium payment verification with Revenue Management Department and check preparation. All claims without outstanding premium balance MUST be released within the 15-working day period.
Reimbursements that were initially given an action/disapproved memo will be processed 7 working days after receipt of the complete documents.
Grace Period
Please take note that 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 so shall invalidate the claim, except if it can be shown in writing that it was not reasonable/ possible to furnish all the necessary documents in availing reimbursement.
Claims that was initially given an action memo MUST be complied with the necessary requirements not later than thirty (30) calendar days from the date of the memo.
How to deal with Denied claims?
If a request for payment was denied, the Member may appeal the decision by filing a written request with MEDICard Head Office within thirty (30) days after receiving the decision. The request must indicate why the Member believes that the decision merits a reconsideration. The Member may submit additional documents and/or written statements to support the appeal.
The letter of appeal will be presented to the Reconsideration Committee headed by our Medical Director, scheduled every Tuesday of the week at 4 P.M.
Upon completion of the procedure, the Member will receive a written notice stating the final MEDICard decision and the reason for such.
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