SBD –Classic Summary of Benefits

Rev.0
16 June 2013
Page 1 of 2

MEDICARD PHILIPPINES, INC.

HEAD OFFICE: 9th Floor, The World Centre Building, 330 Sen. Gil Puyat Avenue, Makati City 1200

HOSPITALIZATION CONFINEMENT BENEFITS

Members may avail of services in any of the 650 accredited hospitals and more than 14,000 medical professionals and specialists accredited by MediCard. The member
must be admitted under the services of the primary physician in the accredited hospital to avail of the following benefits:
 No deposit upon admission  CT Scan, MRI and ultrasound guided procedures are covered up to
 Room and board according to type of enrollment P20,000.00 per member per year*
 X-ray and laboratory examinations
 Services of MediCard specialist like anaesthesiologists, internists,  Arthroscopically and Endoscopically guided procedures guided
surgeons, etc. procedures excisions / treatments are covered up to P20,000.00 per
 Surgery and anaesthesia, dressings, sutures and plaster casts, etc. member per year*
 Transfusion (including screening/processing) of fresh whole blood,  Complex diagnostic procedures such as, but not limited to MRI, CT scan
human blood products (excluding gamma globulin) and intravenous and ultrasound, are covered up to P 5,000 each per member per year
fluids subject to the pre-existing conditions coverage*
 Admission kit including wee bag  New diagnostic and treatment procedures for conditions with
 Chemotherapy, radiotherapy and dialysis are covered up to ten (10) established etiologies and its use is only as alternative to the
sessions up to the maximum limits subject to pre-existing conditions conventional methods is covered up to P 5,000.00 each per member
coverage per year subject to the pre-existing conditions coverage*
 Modern therapeutic modalities and interventional surgical  All other items related to the management of the case
procedures such as, but not limited to laparoscopic surgery and  Assistance in administrative requirements through the liaison officers
lithotripsy, are covered once a year up to P 20,000.00 each per * Inclusive of room and board, operating room charges, professional fees
member per year subject to the pre-existing conditions coverage* and other incidental expenses relative to the procedure.

OUT-PATIENT SERVICES
 Referral to specialists  Cataract Extraction (excluding lens), including phacoemulsification, is
 Regular consultations & treatment (except prescribed medicines) covered up to the dreaded disease limit per member per year subject
 Treatment of minor injuries and surgery not requiring confinement to the pre-existing conditions coverage*
 X-ray and laboratory examinations  Laser Treatment of Glaucoma and retinal detachment (excluding lens)
 Eye, Ear, Nose & Throat treatment is covered up to P 20,000.00 per member per year subject to the pre-
 Physical and Speech Therapy is covered up to ten (10) sessions existing conditions coverage*
 Cauterization of Warts including facial warts up to P1,000.00  First Dose of anti-tetanus is covered up to P1,000.00
 Tuberculin Test (except screening) is covered up to P800.00  Consultations for Chronic Dermatoses
 Consultations for Scabies is covered at MediCard clnics only
The member can go directly to the primary physician of any accredited hospital or at the Head Office clinic for out-patient consultations. 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.
* Inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure

PREVENTIVE HEALTH CARE SERVICES

 Annual Physical Examination (APE), to include  Management of Health Problems
- Complete Blood Count  Routine Immunization (except administered medicine)
- Urinalysis  Counselling on Health
- Fecalysis (stool exam)  Record keeping of medical history
- Chest X-Ray
- Electrocardiogram (adults age 40 and above, or if prescribed)
- Pap Smear (Women age 40 and above, or if prescribed)
APE may be conducted at any MediCard Stand-alone Clinics or at the company premises through a MediCard mobile medical team on a scheduled basis for a minimum
of 50 principal members and after having paid at least the semi-annual or three quarters premium.

EMERGENCY CARE BENEFITS

EMERGENCY CARE IN ACCREDITED HOSPITALS EMERGENCY CARE IN NON-ACCREDITED HOSPITALS
MediCard agrees to reimburse 80% of the total hospital bills and doctor’s
When a member in an emergency case ends up at the emergency room of an professional fees based on MediCard relative values up to P 30,000.
accredited hospital or clinic, the following are provided:
 Doctor's services EMERGENCY CARE IN FOREIGN HOSPITALS
 Medicines used during treatment or for immediate relief MediCard agrees to reimburse 100% of the total hospital bills and doctor’s
 Oxygen and intravenous fluids professional fees based on MediCard relative values up to P 30,000.
 Dressings, casts and sutures
 Laboratory, X-ray and other diagnostic examinations directly related AMBULANCE SERVICE
to the emergency management of the patient Accredited to Accredited: Covered up to the dreaded disease limit
Non-Accredited Hospital to Accredited: Covered up to P2,500 per conduction
DENTAL SERVICES
Members may avail of the following dental care services from any of the accredited dental clinics’.
 Annual Prophylaxis (after having paid at least the semi-annual
 Emergency out-patient dental treatment
premium)
 Consultations and Oral Examinations  Temporomandibular Joint (TMJ) consultations
 Simple tooth extractions  Restorative and Prosthodontic consultations
 Temporary fillings  Dental Nutrition & Dietary Counseling
  Gum treatment and Adjustment of dentures  Dental Health Education
 Recementation of loose jackets, crowns, in-lays and on-lays  Treatment of mouth lesions, wounds and burns
SBD –Classic Summary of Benefits
Rev. 12
16 June2013
Page 2 of 2

DREADED DISEASES
Dreaded diseases are potentially or actually life threatening conditions or illnesses which may require prolonged or repeated hospitalization or intensive care
management. MediCard shall pay for hospitalization services up to the maximum limit subject to the pre-existing conditions coverage.
The following are considered dreaded disease:
a. Cerebrovascular Accident (stroke) h. Diabetes Mellitus and its complications
b. Central nervous system lesions i. Malignancies and Blood Dyscrasias (Cancer, Leukemia, Idiopathic
(Poliomyelitis/Meningitis/Encephalitis/Neurosurgical conditions) Thrombocytopenic Purpura)
c. Cardiovascular Disease(Coronary/Valvular/Hypertensive Heart j. Injuries from accidents or assaults, frustrated homicide or frustrated
Disease/Cardiomyopathy) murder
d. Chronic Obstructive Pulmonary Disease (Chronic Bronchitis/Emphysema), k. Complications of an apparent ordinary illness including MODS and SIRS
Restrictive lung disease Liver Parenchymal Disease [Cirrhosis, Hepatitis (e.g. sepsis due to pneumonia, typhoid ileitis, cerebral malaria, etc.)
(except type A), New growth] l. Single or multiple organ dysfunction and failure (MODS and MOF)
e. Chronic Kidney/Urological disease (Urolithiasis, Obstructive Uropathies, m. Conditions that may require dialysis
etc.) n. Chronic pain syndrome (greater than six weeks)
f. Chronic Gastrointestinal Tract Disease requiring bowel resection and/or o. Any illness other than the above which would require Intensive Care Unit
anastomosis confinement
g. Collagen diseases (Rheumatoid Arthritis, Systemic Lupus Erythematosus) p. Et cetera

PRE-EXISTING CONDITIONS
1. Any illness, injury or any adverse medical condition shall be considered pre-existing if during the entire period prior and within the first twelve (12) months from
the effectivity date of this Agreement:

a. Any professional advice or consultation and/or treatment was made given as a result of such illness, injury or adverse medical condition; or
b. The MEMBER was aware or should reasonably have been aware of the signs or symptoms of such illness, injury or adverse medical condition; or
c. The pathogenesis or onset of such illness, injury or adverse medical condition has been started during the contestability period for membership in this
Corporate Health Program as determined by MediCard 's Medical Director or accredited physicians.

2. 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:
a. Dreaded Diseases listed above except for letters k & l j. Prostate disorders
b. Hypertension k. Hemorrhoids and Anal Fistulae
c. Goiter (Hypo/Hyperthyroidism) l. Benign Tumors
d. Cataracts/Glaucoma m. Uterine Myoma, Ovarian cysts, Endometriosis
e. ENT conditions requiring surgery n. Buergher's Disease
f. Bronchial Asthma/Allergy/Urticaria o. Varicose Veins
g. Tuberculosis p. Arthritis
h. Chronic Cholecystitis/Cholelithiasis (gall bladder stones) q. Migraine headache
i. Acquired Hernias r. Gastritis/duodenal or gastric ulcers
NOTE: All limits mentioned in this proposal are subject to the Pre-Existing Condition limit, if applicable, based on the given diagnosis

MEMBERSHIP ELIGIBILITY
PRINCIPAL
Salaried personnel at least 18 years old up to age 60 and employed by a COMPANY on a permanent basis.
DEPENDENTS
For Married Employees
 The legal spouse at least 18 years old up to age 60
 Legitimate and/or legally adopted children 30 days up to 21 years of age and living under the same roof as the principal member
For Single Employees
 Parents up to age 60, unemployed and dependent upon the principal member
 Brothers and sisters 30 days up to 21 years of age who are not gainfully employed and are living under the same roof as the principal member
For Single Parent Employees
 Legitimate and/or legally adopted children 30 days up to 21 years of age and living under the same roof as the principal member (Please provide Birth Certificate)

Enrollees age 41 and above are required to undergo a medical evaluation at MediCard Stand-alone clinics with a minimal fee of P 450.00 per head.

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
married personnel. For single personnel, the parents must be enrolled first followed by eldest brother/sister and so on.

At least 75% of the total number of principal members shall enroll all their immediate dependents to be able to avail of dependent’s coverage. If the above condition is
not met, dependents would be subject to a separate program and/or premium rate as may be determined from their exact demographics.

PHILHEALTH
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 net of the member’s PHILHEALTH benefits. Computation of dreaded disease limit is net of Phil health
but the Company will give an authorization to MediCard to verify Phil health benefits.

OTHERS
1. An Emergency Assistance Response Service (E. A. R. S.) that operates on a 24-hour/day 365-day/year basis to respond your inquiries. Just dial: Trunk line: 884-
9999; 841-8080 Toll free Nos: 1-800-1888-9001
2. Direct access to a network of 650 accredited hospitals/clinics with 14,000 doctors/specialists nationwide plus fifteen (15) satellite medical clinics, one (1) mall-
based clinic and a Head Office Clinic.