I. OUT-PATIENT BENEFITS

As a PhilamCare member, you are entitled to the following out-patient benefits. You may avail of these benefits starting on the day of the effectivity date of your Agreement.

A. ANNUAL PHYSICAL EXAMINATION

1. Taking of Medical History
2. Physical Examination
3. Chest X-ray
4. Urinalysis
5. Stool Examination
6. Complete blood count
7. ElectroCardiogram (ECG) for members above 35
8. Pap Smear for female members above 35

B. PREVENTIVE HEALTH CARE

1. Wellness program
2. Immunization and allergy desensitization ( cost of vaccines, allergens and determinations of susceptibility are not included)
3. Health education and counseling on diet or exercise
4. Periodic monitoring of health problems
5. Family Planning, and Counseling

C. OUT-PATIENT SERVICES

The following services are provided for treatment of illness or injury which does not require hospitalization.
1. Consultation, including specialist's evaluation
2. First aid treatment of injury or illness
3. Necessary x-rays and laboratory examinations
4. Minor surgery not requiring confinement
5. Eye, ear, nose and throat care
6. Pre-natal and post-natal consultation at PhilamCare Clinics with OBGYN.

All out-patient benefits shall be provided only at PhilamCare clinics by PhilamCare physicians except for emergency cases wherein the Emergency Provision of the Agreement shall apply. Out-patient treatments may also be provided in affiliated medical clinics or hospitals, and by affiliated physicians or specialists only when referred by a PhilamCare authorized physician.

II. IN-PATIENT BENEFITS

In case you suffer from an ailment which will require hospitalization, you shall be entitled to the hospitalization benefits listed below:

1. Services of physician and surgeon, including surgery
2. Room and Board according to the type of room accommodation and subject to maximum rate of Daily Room and Board as stated in the Member's Benefit Classification and maximum room rate allowance
3. General nursing service
4. Use of operating room and recovery room
5. Anesthesia and its administration
6. Drugs and medications for use in the hospital
7. Oxygen and its administration
8. Dressing, plaster casts and other medical supplies
9. Laboratory tests, x-rays and other necessary diagnostic services
10. Transfusion of blood and other blood elements
11. Dialysis/ ICU coverage up to the maximum limit of the plan

These hospitalization benefits shall be available subject to the following conditions except for emergency illness or injury wherein the Emergency Provisions of the Agreement shall apply:

1. The hospitalization must be arranged or approved by a PhilamCare authorized personnel prior to the confinement.
2. The confinement shall be in an affiliated hospital and the type of hospital room accommodation shall be in accordance with the Member's Benefit Classification and maximum room rate allowance.
3. Professional services shall be provided only by PhilamCare physician(s) or affiliated physician(s),
4. If discharge from the hospital has been authorized by a physician and the member shall fail or refuse to do so, PhilamCare shall not be responsible for any charges for hospital service rendered after the day and time for which discharge has been authorized.

 

III. P10,000 GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

Each enrolled member may be covered by P10,000 Group Life and Accidental Death and Dismemberment Insurance provided for by Philamlife at a certain minimal additional fee. This benefit is optional.

IV. DENTAL BENEFITS

Notwithstanding the provision of General Exclusion No. 6 of the Agreement, the member shall be entitled to the dental services listed below from the affiliated dentist assigned to the member :

1. Annual dental examination
2. Annual oral scaling and polishing
3. Simple tooth extraction
4. Treatment of pain, lesions, wounds and burns
5. Gum treatment, except alveolectomy and gingivectomy
6. Recementation of fixed bridges, crowns, jackets, inlays and onlays
7. Temporary fillings
8. Consultations

In case the member would require dental services other than those in the above list, such member may avail of these other services at a cost no higher than the rates indicated in the Schedule of Dental Fees attached with your Agreement, provided these other services are given by the assigned affiliated dentist.

V. POINT-OF-SERVICE (POS) OPTION

If you are entitled to the POS option, you may avail of health services outside the PhilamCare Network and be reimbursed for a percentage of the health care expenses that you incurred. This means that:

1. Hospitalization: (whether emergency or non-emergency)
- Your confinement in a hospital need not be authorized by a PhilamCare authorized physician
- Your attending physician during confinement in a hospital need not be affiliated with PhilamCare
- You may be confined in a non-affiliated hospital

2. Specialist Consultations
- You may consult a PhilamCare affiliated physician directly without an authorization from a PhilamCare authorized physician.

In all the above cases, the member shall initially shoulder the health care expenses and request for reimbursement. Further, the member may be charged by an affiliated physician according to the rates that he charges his private patients.

PhilamCare, on the other hand, shall reimburse the member 80% of the coverable health care expenses. The amount reimbursable however is subject to a maximum of 80% of what PhilamCare would have spent had the Member been treated by an affiliated physician in an affiliated facility and had the usual procedures for availment of services been followed.

To claim your reimbursement , please refer to "Claim Procedures: Reimbursement of Expenses " of this guide book.

PAYMENT OF MEMBERSHIP FEES

To avoid problems in your availment of benefits as a PhilamCare member, you are advised to be up-to-date in your membership fee payment whether or not you receive a billing notice prior to your payment due date.

The Membership Fee stated in the Schedule is due and payable on the Effective Date unless a mode other than single payment is chosen, in which case, only the first installment is due on the Effective Date. Succeeding installment payments are payable in advance on the due date corresponding to the mode selected. Membership Fees are payable at the Head Office of PhilamCare and other Philamlife offices.

The member is given a grace period of 31 days from due date within which to pay the Membership Fee due. No benefits shall be available to the member during this 31-day grace period. However, if the Member pays the Membership Fee due within said 31-day period prior to availment, his benefits resume from the date the fee is paid. The Agreement shall automatically end and be void if the Membership Fee remains unpaid 31 days from due date.