MEMBERSHIP BENEFITS AND PRIVILEGES

PREVENTIVE HEALTH CARE SERVICES

  1. 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:

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

      For those with monthly mode of payment, APE may be availed after having paid at least 6 monthly premiums.

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

OUT-PATIENT SERVICES

  1. The following Out-Patient 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
  2. 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

  1. 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

For those with monthly mode of payment, oral prophylaxis may be availed after having paid at least 6 monthly premiums.

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. 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

    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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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

  1. 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.
  2. 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:

White Plan
Year of membership Amount of Coverage
1st year Up to P5,000 aggregate limit per beneficiary per year.
2nd year of continuous membership onwards up to 50% of the annual benefit limit per beneficiary per year.

For Blue Plan
Year of membership Amount of Coverage
1st year Up to P10,000.00 aggregate limit per beneficiary.
2nd year of continuous membership onwards up to 50% of the annual benefit limit per beneficiary per year

For Purple Plan
Year of membership Amount of Coverage
1st year Up to P15,000.00 aggregate limit per beneficiary.
2nd year of continuous membership onwards up to 50% of the annual benefit limit per beneficiary per year