Standard

• No deposit upon admission
• Room & Board according to type of enrolment
• Use of Operating Theatre 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 year subject to the pre-existing conditions coverage
• CT Scan, MRI and ultrasound are covered up to P5,000 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. 1. Angiography (e.g. coronary, cerebral, retinal, pulmonary, GI, etc.)
   2. Pulmonary perfusion scan
   3. Tests involving use of Nuclear Technologies (Radionuclide Ventriculography/Thallium stress testing/Radionuclide/Thyroid scan, etc.), nuclear technologies such as Pyrosphosphate Scintigraphy, Positron Emission Tomography, Radio Isotope Scanning, etc.)
   4. Electromyography, Nerve Conduction Velocity Studies
   5. 24-Hour Holter Monitoring, 2-D Echo and Doppler
   6. Treadmill Stress Test
   7. Myelogram
   8. Endoscopy including one of video
   9. Orthopedic Arthroscopy
   10. Adrecortical Function (e.g. Primary Aldosteronism, Cushings 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. New modalities and / or diagnostic and treatment procedure 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: Mentioned limits are inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure.

Excess Charges and Incremental Costs

1. Excess charges, more appropriately called excess in room and board are charges payable to the hospital when a member is confined in a room rate higher than his actual coverage, but within the same level or category. On top of the common excess of disapproved charges that a member might incur during confinement, incremental costs can be incurred by a member when he is confined in a room higher category or level than what his plan entitles him to. (e.g. availment of private room instead of a semi-private).
2. 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.
3. The maximum benefit limit shall be inclusive of consultations, diagnostic procedures, and hospitalization.
4. 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. 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. 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.

Out-Patient Care

The Following outpatient services will be provided to members in MediCard accredited hospitals or clinics:

• Referral to specialist(s)
• Regular consultations and treatment (except prescribed medicines)
• Eye, ear, nose and throat treatment
• Treatment of minor injuries and surgeries 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 outpatient consultations. The primary physician will request for laboratory or diagnostic examinations or refer the member to a specialist.

Preventive Health Care

Preventive healthcare services are provided to members to assure that their health status is regularly and properly monitored.

The following no-charge Preventive Health Care Services will be provided to members at MediCard Head Office Clinic or at any designated MediCard Medical Service Units:

1. 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)

2. Management of Health
3. Routine Immunization (except cost of vaccines)
4. Counselling on health habits, diets and Family Planning
5. Record Keeping of Medical History

*APE may be availed at the MediCard Lifestyle Center or at MediCard mall clinic in Festival Super Mall, Alabang, Muntinlupa City.

Emergency Care

• Emergency Care in MediCard-Accredited Hospitals/Clinics – In cases of emergency where the MEMBER avails of the services of MediCard Accredited Hospitals/Clinics, the following will be provided:
  1. Doctor’s services
  2. Medicines used during treatment or for immediate relief
  3. Oxygen and intravenous fluids
  4. Dressings, plaster casts, and sutures
  5. Laboratory, X-ray and other diagnostic examinations directly related to the emergency management of the patient-MEMBER

• 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-MediCard accredited hospital for treatment.
  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 is follow up care.
  3. MediCard agrees to reimburse eighty percent (80%) of the approved total hospital bills and of professional fees, based on MediCard relative value for accredited hospitals, up to the amount of P30,000.00.

• Emergency Care in Foreign Countries – In cases of emergency where a MEMBER avails of services in a foreign territory. MediCard shall reimburse one hundred percent (100%) of the approved total hospital bills and of professional fees, based on the MediCard relative value and in Philippine currency, up to P30,000.00.

• Ambulance services (land transport) are covered on a reimbursement basis up to P2,500.00 per member per year.
• In cases of non-availability of room according to plan during emergency case, MEMBER may avail of the next higher room available except suite room within the first twenty-four (24) hours of confinement upon admission. All incremental costs incurred after the first twenty-four (24) hours shall be for the personal account of the MEMBER, except when the Accredited Hospital issues a certification of non-availability of the MEMBER’s room and board accommodation.

Dental Care

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 and burns

Dental care services availment procedures:

1. Call dentist to set up appointment (refer to list of dentists provided)
2. Visit dentist and present MediCard ID to avail of service
3. Sign all related documents and forms after treatment/procedure was done

1. Services which 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 this 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, milia, keloids, scars, etc. on any exposed areas of the body;
6. Guillain Barre syndrome, multiple sclerosis, demyelinating disease, Parkinson’s disease, Alzheimer’s disease, Myasthenia Gravis, epilepsy, seizure disorder and other autoimmune neurological disease;
7. Slipped 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 surgery for error of refraction including laser surgery for correction of myopia and hypermyopia;
10. Psoriasis, vitiligo;
11. Experimental medical procedures, acupuncture, acupressure, reflexology and chiropractics;
12. Services to diagnose and/or reverse infertility or fertility and virility/potency (erectile dysfunction);
13. Open heart surgeries, angioplasties, valvulaplasties, permanent pacemaker insertion, intra coronary 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;
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 use 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 Hepatitis B, condyloma, gonorrhea, syphilis, herpes etc. and their attendant complications;
23. Pelvic inflammatory disease, tubo-ovarian abscess, pyosalpingitis, etc.;
24. HIV/AIDS;
25. Hazardous job-related illnesses and/or injuries;
26. Physical examinations required for obtaining or continuing employment, insurance or government licensing;
27. Injuries or illnesses resulting from participation in war like or combat operations, riots, insurrection, rebellion, strikes and other civil disturbances;
28. 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;
29. Maternity care and other conditions as a result of pregnancy unless specifically provided;
30. Custodial, domiciliary care, convalescent and intermediate care;
31. Oral surgery for purposes of beautification, temporomandibular joint disease (TMJ) surgery done by dental practitioner;
32. Circumcision, except for correction of Phimosis;
33. 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;
34. Professional fees of medico-legal officers;
35. Diagnosis of unknown etiology or the absence of any organic dysfunction;
36. Cost of vaccines for active and passive immunization except as otherwise provided for in this Agreement;
37. Laboratory examinations for screening sexually related illnesses and injuries;
38. Any condition or illness waived upon membership except as otherwise provided for in this Agreement.