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
▪ Room and board according to type of enrollment
▪ X-ray and laboratory examinations
▪ Services of MediCard specialist like anaesthesiologists, internists, surgeons, etc.
▪ Surgery and anaesthesia, dressings, sutures and plaster casts, etc.
▪ Transfusion (including screening/processing) of fresh whole blood, human
blood products (excluding gamma globulin) and intravenous fluids
▪ Admission kit including wee bag
▪ Chemotherapy, radiotherapy and dialysis are covered up to ten (10) sessions up
to the maximum limits subject to pre-existing conditions coverage
▪ Modern therapeutic modalities and interventional surgical procedures such as,
but not limited to laparoscopic surgery and lithotripsy, are covered once a year
up to P 20,000.00 each per member per year subject to the pre-existing
conditions coverage*
▪ CT Scan, MRI and ultrasound guided procedures are covered up to P20,000.00
per member per year*
▪ Arthroscopically and Endoscopically guided procedures guided procedures
excisions / treatments are covered up to P20,000.00 per member per year*
▪ Complex diagnostic procedures such as, but not limited to MRI, CT scan and
ultrasound, are covered up to P 5,000 each per member per year subject to the
pre-existing conditions coverage*
▪ New diagnostic and treatment procedures for conditions with established
etiologies and its use is only as alternative to the conventional methods is
covered up to P 5,000.00 each per member per year subject to the pre-existing
conditions coverage*
▪ All other items related to the management of the case
▪ Assistance in administrative requirements through the liaison officers
* Inclusive of room and board, operating room charges, professional fees and other
incidental expenses relative to the procedure.

OUT-PATIENT SERVICES
▪ Referral to specialists ▪ Cataract Extraction (excluding lens), including phacoemulsification, is covered up
▪ Regular consultations & treatment (except prescribed medicines) to the dreaded disease limit per member per year subject to the pre-existing
▪ Treatment of minor injuries and surgery not requiring confinement conditions coverage*
▪ X-ray and laboratory examinations ▪ Laser Treatment of Glaucoma and retinal detachment (excluding lens) is covered
▪ Eye, Ear, Nose & Throat treatment up to P 20,000.00 per member per year subject to the pre-existing conditions
▪ Physical and Speech Therapy is covered up to ten (10) sessions 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
When a member in an emergency case ends up at the emergency room of an accredited MediCard agrees to reimburse 80% of the total hospital bills and doctor’s professional
hospital or clinic, the following are provided: fees based on MediCard relative values up to P 30,000.
▪ Doctor's services
▪ Medicines used during treatment or for immediate relief EMERGENCY CARE IN FOREIGN HOSPITALS
▪ Oxygen and intravenous fluids MediCard agrees to reimburse 100% of the total hospital bills and doctor’s professional
▪ Dressings, casts and sutures fees based on MediCard relative values up to P 30,000.
▪ Laboratory, X-ray and other diagnostic examinations directly related to the
emergency management of the patient AMBULANCE SERVICE
Accredited to Accredited: Covered up to the dreaded disease limit
Non-Accredited Hospital to Accredited: Covered up to P2,500 per conduction

MEMBERS' FINANCIAL ASSISTANCE (For Principal Members only)

Aside from the standard benefits to which a principal member is entitled to, MediCard PHILS., INC., also hereby agrees to give/provide the heirs and/or assigns of a principal member who is
enrolled in this health care program in the event of death or injuries through natural causes or accidental means, the following amounts by way of financial assistance:

SCHEDULE OF FINANCIAL ASSISTANCE

Type Rate of Coverage
Natural Death P 10,000
Accidental Death 20,000
Loss of sight, or two limbs 10,000
Loss of sight of one eye, one hand or foot 5,000

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.
 SBD –Classic Summary of Benefits
Rev. 12
16 June2013
Page 2 of 2

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 premium) ▪ Emergency out-patient dental treatment
▪ 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

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) i. Malignancies and Blood Dyscrasias (Cancer, Leukemia, Idiopathic Thrombocytopenic
b. Central nervous system lesions (Poliomyelitis/Meningitis/Encephalitis/Neurosurgical Purpura)
conditions) j. Injuries from accidents or assaults, frustrated homicide or frustrated murder
c. Cardiovascular Disease(Coronary/Valvular/Hypertensive Heart k. Complications of an apparent ordinary illness including MODS and SIRS (e.g. sepsis
Disease/Cardiomyopathy) due to pneumonia, typhoid ileitis, cerebral malaria, etc.)
d. Chronic Obstructive Pulmonary Disease (Chronic Bronchitis/Emphysema), Restrictive l. Single or multiple organ dysfunction and failure (MODS and MOF)
lung disease Liver Parenchymal Disease [Cirrhosis, Hepatitis (except type A), New m. Conditions that may require dialysis
growth] n. Chronic pain syndrome (greater than six weeks)
e. Chronic Kidney/Urological disease (Urolithiasis, Obstructive Uropathies, etc.) o. Any illness other than the above which would require Intensive Care Unit
f. Chronic Gastrointestinal Tract Disease requiring bowel resection and/or anastomosis confinement
g. Collagen diseases (Rheumatoid Arthritis, Systemic Lupus Erythematosus) p. Et cetera
h. Diabetes Mellitus and its complications

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 Philhealth but the Company will give an authorization to
MediCard to verify Philhealth 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: Trunkline: 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.
MediCard Healthcare Program
EXCLUSIONS

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;

MediCard Healthcare Program
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;

MediCard Healthcare Program
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;
 ORIENTATION CHECKLIST
SBD1 – Orientation Checklist
Rev. 0
11 January 2017

MediCard Philippines, Inc.

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

HOSPITALIZATION PEC LIMIT FOR INDIVIDUAL, FAMILY, & VIP PLANS

 Inner limits of Complex Diagnostic Procedures &
Modern Therapeutic Modalities INDIVIDUAL / FAMILY PLAN:
 Excess and Incremental Charges FIRST YEAR No Coverage
 Phil-health Benefits should be filed during SECOND YEAR Up to P5,000/illness/member/year, provided that
confinement and OP-OR cases of continuous the pathogenesis or onset of such illness, injury
membership or adverse medical condition started prior to or
onwards during the 1st year of membership, otherwise up
OUT-PATIENT SERVICES to DDL.
 All availed services should have a diagnosis
 Out-Patient Availing Procedures VIP PLAN Regular Private (DDL: 200,000):
FIRST YEAR up to P5,000/illness/member/year
PREVENTIVE HEALTHCARE SERVICES SECOND YEAR Up to P5,000 per illness per member per
 APE done at MediCard Clinics and services in of continuous year, provided that the pathogenesis or onset
satellite clinics membership of such illness, injury or adverse medical
 APE in provinces are done in designated hospitals onwards condition started prior to or during the 1st year
of membership; otherwise up to DDL.
(case to case basis)

EMERGENCY SERVICES VIP PLAN Regular Private (DDL: 250,000):

 Services in accredited hospitals FIRST YEAR up to P10,000/illness/member/year
Up to P10,000 per illness per member per
 Reimbursement for services done in a non-accredited SECOND YEAR
year, provided that the pathogenesis or onset
hospital of continuous
of such illness, injury or adverse medical
 Medicard Relative Values membership
condition started prior to or during the 1st year
 Reimbursement Procedure & Requirements onwards
of membership; otherwise up to DDL

MEMBER’S FINANCIAL ASSISTANCE (Principal Members Only) VIP PLAN Large Private:
 Benefit FIRST YEAR up to P15,000/illness/member/year
 Conditions on giving the claim Up to P15,000 per illness per member per
SECOND YEAR
year, provided that the pathogenesis or onset
of continuous
DENTAL SERVICES membership
of such illness, injury or adverse medical
 Benefits-Fillings and prophylaxis condition started prior to or during the 1st year
onwards
of membership; otherwise up to DDL
CATEGORY OF ILLNESSES AND ITS COVERAGE
 Coverage of each category VIP PLAN Suite up to 8,000:
 Examples of Ordinary Illnesses FIRST YEAR up to P20,000/illness/member/year
 Examples of Dreaded Diseases Up to P20,000 per illness per member per
SECOND YEAR
year, provided that the pathogenesis or onset
 Examples of Pre-existing Conditions of continuous
of such illness, injury or adverse medical
membership
condition started prior to or during the 1st year
EXCLUSIONS onwards
of membership; otherwise up to DDL
 LIST OF EXCLUSIONS & EXAMPLES
 MOTOR VEHICULAR LIABILITY

I have been clearly informed of the above items.

________________________________ __________________________________________________
CLIENT/ACCOUNT REPRESENTATIVE’S MediCard Representative (Signature over Printed Name)
SIGNATURE OVER PRINTED NAME
Designation: _______________________ Date: _____________________________
Date: _____________________________