Kabayan

MediCard offers a new and innovative product that aims to give everyone access to quality healthcare. MediCard Kabayan, a product specifically designed for overseas Filipinos, provides flexibility because it allows the sponsor to enroll practically everyone – not just immediate family members. With this product, beneficiaries will have coverage for hospitalization, outpatient, preventive, emergency and dental care. The plan also provides members pre-existing condition coverage up to a certain limit.

Note: Information on this online store is valid until updated.

[Last update: May 15, 2022]

The following no-charge Preventive Health Care Services will be provided to members by designated MEDICARD Medical Service Unit:

• Annual Physical Examination (APE) upon approval and by appointment basis only to include:

1. 1. Complete Blood Count
   2. Urinalysis (urine examination)
   3. Fecalysis (stool examination)
   4. Chest X-ray
   5. Electrocardiogram (for members 40 years old and above, or if prescribed)
   6. Pap smear (for women 40 years old and above, or if prescribed)

• Management of Health Problems
• Routine Immunization (except cost of vaccines)
• Counselling on health habits, diets and Family Planning
• Record Keeping of Medical History

OUTPATIENT SERVICES

The following Outpatient Services will be provided to members in any MediCard-accredited hospitals/clinics:

• Referral to specialists
• Regular Consultations and treatment (except prescribed medicines)
• Eye, Ear, Nose and Throat treatment
• Treatment of minor injuries and surgery not requiring confinement
• X-ray and laboratory examinations prescribed by MediCard physician

The member can go directly to the Primary Physician of any accredited hospital or at the Head Office clinic for out-patient consultation. The Primary Physician will request for laboratory or diagnostic examinations or refer the member to a specialist. The member may avail of services form any accredited hospital of his/her choice. All procedures or benefits are subject to the limitations on pre-existing conditions.

DENTAL CARE SERVICES

Members may avail of the following dental care services form any of the accredited dental clinics:

• Once a year oral prophylaxis (after having paid the annual premium)
• Consultation 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 and burns

HOSPITALIZATION CONFINEMENT BENEFIT

The following hospitalization (in-patient) services will apply when MediCard physicians prescribe the hospitalization of members in any MediCard Accredited Hospitals/Clinics:

• No deposit upon admission
• Room and Board according to type of enrolment
• Use of operating Theatre and Recovery Room
• Services of MediCard specialists like anaesthesiologists, internists, surgeon, 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 up to the dreaded disease limit up to the annual benefit limit
• Modern therapeutic modalities and interventional surgical procedures such as, but not limited to laparoscopic procedures and lithotripsy/EWSL, up to P20,000.00 each per individual/family unit (once a year)
• CT Scan, MRI and ultrasound up to P20,000.00 each per beneficiary/co-beneficiaries per year
• New modalities and/or diagnostic and treatment procedures for conditions with established etiologies and its use only as an alternative to the conventional methods up to P 20,000.00 per individual/family unit per year
• Laboratory/ancilliary services for conditions whose pathogenesis or subsequent clinical improvement is not yet fully established in Medical Science up to P20,000.00 per individual/family unit per year
• The following complex diagnostic examination up to P20,000.00 each per individual/family unit per:

1. 1. 1. Angiography (e.g. coronary, cerebral, retinal, pulmonary, GI, etc.)
      2. Serum chemistry panels (e.g. Chem 23, Spec M, etc.)
      3. Pulmonary perfusion scan
      4. Tests involving use of Nuclear Technologies (e.g. Radionuclide Ventriculography/Thallium stress testing/ Radionuclide (Isotope) Scanning, Pyrophosphate Scintigraphy, etc.)
      5. Electromyography, Nerve Conduction Velocity Studies
      6. 24-Hour Holter Monitoring, 2-D Echo and Doppler
      7. Treadmill Stress Test
      8. Myelogram
      9. Diagnostic Endoscopy including one of video
      10. Diagnostic Arthroscopy
      11. Diagnostic Hysteroscopy
      12. Adrenocortical Function, Plasma/Urinary Cortisol, Plasma Aldosterone, etc.
      13. Mammogram and Sonomammogram
      14. Bone densitometry scan (Dexascan)
      15. Immunologic studies, Anti-nuclear antibody (ANA), C-Reactive Protein, Lupus cell exam
      16. Genetic studies

• Angiography (e.g. coronary, cerebral, retinal, pulmonary, GI, etc.)
• Serum chemistry panels (e.g. Chem 23, Spec M, etc.)
• Pulmonary perfusion scan
• Tests involving use of Nuclear Technologies (e.g. Radionuclide Ventriculography/Thallium stress testing/ Radionuclide (Isotope) Scanning, Pyrophosphate Scintigraphy, etc.)
• Electromyography, Nerve Conduction Velocity Studies
• 24-Hour Holter Monitoring, 2-D Echo and Doppler
• Treadmill Stress Test
• Myelogram
• Diagnostic Endoscopy including one of video
• Diagnostic Arthroscopy
• Diagnostic Hysteroscopy
• Adrenocortical Function, Plasma/Urinary Cortisol, Plasma Aldosterone, etc.
• Mammogram and Sonomammogram
• Bone densitometry scan (Dexascan)
• Immunologic studies, Anti-nuclear antibody (ANA), C-Reactive Protein, Lupus cell exam
• Genetic studies
• Professional fee of the assisting physician in surgical procedures
• Assistance in administrative requirements through the liaison officers
• All other items related to the management of the case

Above limits are inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure. The maximum benefit limit shall be inclusive of consultations, diagnostic procedures and hospitalization. All procedure or benefits are subject to the limitation on pre-existing conditions.

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 member to other physicians or specialists for further opinions as needed so as to protect the interest of both the member and MediCard.

In case a member is simultaneously covered under more than one health maintenance agreements with MediCard, the premiums for which are paid by the Sponsor Member, 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/her confinement will be governed by the terms and conditions and the limits of the agreement of his/her choice. The provision is without prejudice to the member availing himself/herself of other benefits under another agreement which may apply for other confinements.

Hospitalization or in-patient coverage of a member will depend on his/her final diagnosis. All diagnostic procedures will only be covered if results are within inclusions.

Services availed by a member in excess of the coverage or allowable limit shall be settled by the member directly with the hospital. Failure of the member to settle the excess charges shall necessitate MediCard to bill the Sponsor, all excess charges with corresponding twenty percent (20%) service fee, payable within ten (10) working days from receipt of billing. Otherwise, a corresponding penalty of 3% per month will be incurred. If the bills remain unpaid after thirty (30) days, the concerned member shall cease to be entitled for coverage until after bills have been settled in full.

For purposes of determining the amount utilized by the member of his/her “per disease, per year limit,” it shall be understood that any Disease Complication shall share the same limit as the primary disease which caused it, and any amount expended for the treatment of the Disease Complication shall be included in the total amount expended for the said primary disease for the year. Similarly, the exclusion of a primary disease from coverage by MediCard shall cover any Disease Complication that may have been caused by the said excluded primary disease. This provision shall be applicable to all benefits provided by MediCard under this Agreement, especially those provided for under this Article VIII.

EMERGENCY CARE BENEFITS

a. In case of emergency where the member avails of the services of MediCard Accredited Hospitals/ Clinics, 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.

b. Emergency Care in Non-MediCard Accredited Hospitals

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- MediCard accredited hospital for treatment, MediCard agrees to reimburse eighty percent (80%) of the approved total hospital bills and of professional fees, based on MediCard relative values for accredited hospitals, but not to exceed the amount of annual benefit limit.

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 hospitals 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 is follow up care.

PRE-EXISTING CONDITIONS PROVISIONS

Pre-existing conditions coverage shall be based on the year of membership as follows:

1. HOSPITALIZATION
   • All confinement shall be upon recommendation of the MEMBER’s MediCard accredited Physician, 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 life threatening emergencies.
   • Hospital bills for the following hospital services shall be charged to the account of the MediCard patient‑MEMBER: services of a private nurse or doctor, use of extra food and/or bed, T.V., electric fan, video/audio disc player, ID bracelet, thermometer and all other items not directly related to the medical management of the patient.
   • Hospitalization and treatment outside the Philippines is not covered except where there is a coverage for “Emergency Care Services in Foreign Countries”, explicitly indicated in “Schedule A – Benefit Coverage” of this Agreement.
   • MediCard is not responsible and will not recognize any hospital bills incurred by a MEMBER in hospitals not accredited by MediCard, except for emergency care services under the terms provided in this Agreement.
   • 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 prescribed or contrary to what has been prescribed by the attending MediCard attending physician, or without MediCard’s express written report shall not be shouldered by MediCard.

    

2. OUT-PATIENT SERVICES
   • Prescribed medicines on an out‑patient basis are not provided by MediCard-owned Clinics or Medical Service Units.
   • The absolutely no charge out‑patient medical and health care services are provided only during clinic hours of Medical Service Units.
   • Second opinions and cost of treatment incurred in non-accredited hospital or clinic should the MEMBER unilaterally decide to seek such recourse.

    

3. EXCLUSIONSThe following shall be excluded in the coverage given by MediCard:
   • Services which a MEMBER receives from a non‑MediCard Physician, non‑MediCard Accredited Hospital or other provider of care, Accredited Physician in non‑MediCard Accredited Hospital or other provider of care, except as described in the emergency care in non‑MediCard hospitals, as provided for in this Agreement;
   • Hereditary and/or congenital defects of whatever form;
   • Sensorineural hearing impairments except those acquired during time of membership;
   • Plastic and reconstructive surgery for cosmetic purposes and for physical congenital deformities and abnormalities;
   • Dermatological care for aesthetic purposes such as electrocautery or chemical treatment for skin tags, xanthelasma, milia, keloids, scars, etc. on any exposed areas of the body;
   • Guillain‑Barre syndrome, multiple sclerosis, demyelinating disease, Parkinson’s disease, Alzheimer’s disease, Myasthenia Gravis, epilepsy, seizure disorder and other autoimmune neurological disease;
   • Slipped disc, scoliosis, spinal stenosis and spondylosis;
   • AV malformation and aneurysms which are considered congenital except only those unequivocably proven to be acquired secondarily;
   • Corrective eye surgery for error of refraction including laser surgery for correction of myopia and hypermyopia;
   • Psoriasis, vitiligo;
   • Experimental medical procedures, acupuncture, acupressure, reflexology and chiropractics;
   • Services to diagnose and/or reverse infertility or fertility and virility/potency (erectile dysfunction);
   • Open heart surgeries, angioplasties, valvuloplasties, permanent pacemaker insertion, intracoronary thrombolysis, balloon valvuloplasties, transvenous endocardial biopsy, percutaneous intraaortic balloon pump insertion, balloon atrial septostomy, previous craniotomy sequelae, organ transplantation and complication and other surgeries related to the heart;
   • Diagnostics for hypersensitivity and desensitization treatment;
   • Purchase or lease of durable medical equipment, oxygen dispensing equipment and oxygen except during hospital confinement under the Hospital Confinement Benefit;
   • Corrective appliances and artificial aids and prosthetic devices;
   • Gamma globulin;
   • Psychiatric and psychological illnesses including neurotic and psychotic behavior disorders;
   • Treatment for alcoholic intoxication and drug addiction or overdose reaction to use of prohibited drugs including illnesses directly related to it and other injuries attributed as a result of it;
   • Rehabilitation treatment, physical, speech, occupational and hormonal therapies;
   • Developmental disorders, metabolic diseases, sleep and eating disorders;
   • Sexually transmitted diseases such as Hepatitis B, condyloma, gonorrhea, syphilis, herpes, etc. and their attendant complications;
   • Pelvic inflammatory disease, tubo-ovarian abscess, pyosalpingitis, etc.;
   • HIV/AIDS;
   • Hazardous job‑related illnesses and/or injuries;
   • Physical examinations required for obtaining or continuing employment, insurance or government licensing, health permit, requirement in school and other similar purposes;
     1. Injuries or illnesses resulting from participation in war‑like or combat operations, riots, insurrection, rebellion, strikes and other civil disturbances;
     2. Treatment of self‑inflicted injuries or injuries attributable to the MEMBER’S 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;
     3. Maternity care and other conditions as a result of pregnancy unless specifically proided;
     4. Custodial, domiciliary care, convalescent and intermediate care;
     5. Oral surgery for purposes of beautification, temporomandibular joint disease (TMJ) surgery done by dental practitioner;
     6. Circumcision, except for correction of Phimosis;
     7. 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 XI, Section 16 of this Agreement;
     8. Professional fees of medico-legal officers;
     9. Diagnosis of unknown etiology or the absence of any organic dysfunction;
     10. Cost of vaccines for active and passive immunization except as otherwise provided for in this Agreement;
     11. Laboratory examinations for screening sexually related illnesses and injuries; and
     12. Any condition or illness waived upon membership except as otherwise provided for in this Agreement.

    

4. LIMITATION IN SERVICES: MediCard is not responsible for the following:
   • Delay or failure to render services due to major disasters, brownouts or epidemics affecting facilities or personnel.
   • Unusual circumstances such as complete or partial destruction of facilities, war, riots, disability of a significant number of MediCard personnel or similar events which result in delay to provide services.
   • Conditions for which a MEMBER has refused recommended treatment for personal reasons, for which MediCard physicians believe no professionally acceptable alternative treatment exists.
   • Sudden change of hospital policies.

AHMC – Asian Hospital and Medical Center
CSMC – Cardinal Santos Medical Center
MMC – Makati Medical Center
SLMC – Global City – St. Luke’s Medical Center – Global City
SLMC – QC – St. Luke’s Medical Center – Quezon City
TMC – The Medical City

Note: A Family Unit is a group of related beneficiaries who are enrolled at the same time. The table below outlines the eligibility. A separate fee will apply to those who are outside the grouping.

Above rates are for new members. Renewals are subject to actuarial computation.

Note: Family Unit Members should be enrolled at the same time. Otherwise, a separate membership fee will apply.