Philhealth Exclusions — Medical Conditions

Not Covered
NOT ALL medical conditions are covered by Philhealth.
HINDI LAHAT ng pagkaka-ospital o pagpapagamot ay sasagutin ng Philhealth.
Maraming medical cases na HINDI SASAGUTIN ng Philhealth, kaya pinakamaigi
talaga ang mag-ingat, mag-alaga sa katawan, umiwas sa mga nakaka-stress
sa isip, magkaroon ng masayahing disposisyon, at magdasal palagi sa
Panginoon.
Here are conditions that are NOT Covered by Philhealth:
1. Hospitalizations without definite diagnosis and without treatment.
Example: You had a terrible stomach pain and you were confined. They
performed expensive diagnostic tests. You stayed in the hospital for 3 days
while you wait for the results of the tests. But they did not find what is causing
your pain. Then you are discharged because your pain subsided. You paid
several thousands of pesos because of the tests, the room rates, and the
professional fees.
Even if you spent a lot, cases such as this will not be covered by Philhealth
because the doctor cannot write a definite diagnosis. They need to write on
the claim forms a code for your illness, but they cannot because they don’t
know what is your illness. They cannot prove your illness using the results of your
x-rays or blood tests.
2. Initial diagnosis which did not turn out as the final diagnosis
Examples:
Suspected dengue, pero hindi talaga dengue at fever lang
Suspected pneumonia, pero hindi talaga pneumonia at flu lang
Probable typhoid fever, pero hindi naman typhoid fever
3. Low risk illnesses
Examples:
Low-Risk Pneumonia
Community Acquired Pneumonia I
Asymptomatic Dengue Viral Infection
Asthma Not in Acute Exacerbation
Acute Gastroenteritis Without Signs of Dehydration or Only Mild Dehydration
4. Cesarean Section without Indication
Example: You chose to undergo CS even if you could have delivered your child
the normal way.
5. 5th Normal Delivery and Subsequent Normal Deliveries
All normal deliveries are counted, even deliveries not covered by Philhealth
Update 2016: All normal deliveries are now covered, as long as you have the
required number of prenatal checkups.
6. Outpatient Diagnostic Tests
Examples are allergy tests, biopsies, cerebral perfusion scanning, ECG, blood
tests and other diagnostic tests done as outpatient, whether self- prescribed or
prescribed by doctor.
Diagnostic tests performed in the emergency room are not covered if the
patient is not confined for treatment and is discharged in less than 24 hours.
Merong free diagnostic tests para sa OFWs under the Enhanced Out-Patient
Benefit (OPB) Package for OFWs sa selected government hospitals.
7. Emergency Room Treatments for Non-Emergency Cases
If you’re brought to the emergency room for treatment and discharged in less
than 24 hours, your ER costs will not be covered. Examples are treatment of light
wounds, suspected hypertension, allergies, stomach pains, severe headache,
low-risk asthma attacks, etc.
NOTE: There are certain emergency cases that are covered. Niri-research ko
pa yong specific cases. Stroke or cerebrovascular accident is one example. It’s
covered under the Case Rate payment scheme.
8. Costs at Referring Hospital when Transferred
When you are transferred to another hospital for further treatment, the costs of
initial treatment at the first hospital will not be covered. It’s your costs at the
second hospital that will be covered.
The sole exception is maternity care — when the delivering mother needs to be
transferred from a maternity clinic to a hospital.
9. The Same Illness Within 90 Days
If you are hospitalized for the same illness within 90 days, and you have already
claimed your benefit for the same illness within the 90-day period, you will no
longer be covered for your 2nd or 3rd confinement.
You are allocated only one set of benefits for the same illness or the same cause
of hospitalization within 90 days. The only thing that can still be covered is your
room and board, if you have not yet consumed your 45-day allowance for the
year.
10. Major Surgeries Performed at Level 1 Hospitals or Clinics
Surgeries such as CS, Hysterectomy, and Appendectomy are not covered if they
are done at Level 1 hospitals. These should be done at Level 2, Level 3 and
Level 4 hospitals
The only surgical procedures covered at Level 1 hospitals are:
D & C or Raspa and Normal Delivery of Child
Procedures Covered at Ambulatory Surgical Clinics:
D & C or Raspa
Cataract
Laparoscopic cholecystectomy
Herniorrhaphy
Procedure Covered at Free-Standing Dialysis Centers:
Hemodialysis
Radiotherapy is covered only if done at Level 3 or 4 hospitals
11. Treatment for Alcohol Abuse and other Dependencies Cosmetic Surgery
12. Optometric Services
Example:
Pagpagawa ng graded eyeglass
13. Medicines Taken as Out-Patient, Even those Prescribed by Doctors
Examples:
Mga gamot na binili pagkatapos lumabas sa ospital, kahit prescribed by
doctors at kahit continuation ng pagpapagamot sa hospital.
Mga gamot na binili pagkatapos magpakonsulta sa doctor
14. Ordinary Dental Services or Cosmetic Dental Treatments
Examples:
Tooth extraction
Teeth cleaning
Braces
Teeth bleaching
15. Outpatient Consultations with Doctors
Sabi ng Philhealth, magpakonsulta sa health centers o sa government hospitals
para libre ang consultation o magbigay lang ng donasyon.
Merong free consultation services for OFWs and their dependents sa selected
government hospitals. Pero free din naman ang consultations sa mga kahit
hindi OFWs, basta sa OPD-Charity.
16. Psychiatric or Mental Illnesses or Behavioral Disorders That Do Not Require
Hospital Admission
Patient’s aggressive behavior or manic depression is not a danger to others and
to himself or herself and medication side effects are not potentially life
threatening.
17. Second or 3rd Surgical Procedure Performed at the Same Site of Primary
Surgical Procedure in a Single Operative Session
For 2 or more different surgeries (under the Case Rate scheme) performed in
one operative session, Philhealth covers only the main surgical procedure or the
one with the highest Case Rate package.
Examples: CS with Bilateral Tubal Ligation, CS with incidental appendectomy or
CS with adhesiolysis is paid as CS (coverage is the same as plain CS, which is 19k;
no additional coverage)
18. Second or 3rd Illness that Occur During Hospitalization or After Surgery (for
Case Rate Conditions)
Examples:
– Diabetes that occur during hospitalization for hypertension — Only
hypertension is covered
– Hypertension that occur during hospitalization for diabetes — Only diabetes is
covered
– Complications after Surgery (Surgeries Under Case Rate)
19. Maternity Services for Special Cases Performed at Non-Hospital Facilities
The following conditions are not covered if they are treated at maternity clinics,
lying-in centers, health centers or birth clinics:
– pregnancy under the age of 19
– first pregnancy at age 35 or older
– multiple pregnancies
– ovarian abnormality, such as ovarian cyst
– uterine abnormality, such as myoma uteri
– placental abnormality, such as placenta previa
– abnormal fetal positions, such as breech position
– history of 3 or more miscarriages or abortions
– history of 1 stillbirth
– history of major obstetric or gynecologic operation, such as CS or uterine
myomectomy
– history of medical conditions, such as pre-eclampsia, eclampsia, heart –
disease, hypertension, moderate to severe asthma, diabetes, epilepsy, renal
disease, thyroid disorder, bleeding disorder, and morbid obesity
– conditions during pregnancy such as premature contractions and vaginal
bleeding
18. Animal Bites Treated at Facilities Not Accredited by the Department of
Health (DOT) as Centers for Animal Bite Treatment
Outpatient Treatments Covered by Philhealth
NOTE: I am not a doctor and I am not a Philhealth employee. I based my list on
Philhealth circulars and publications and on the comments of people who
shared their experiences about their Philhealth claims.
Sources of information:
Philhealth Circular No. 011-A-2011 – Selected Medical Case Rates – Additional
Implementing Guidelines
Philhealth Circular No. 011-B-2011 – Selected Surgical Case Rates – Additional
Implementing Guidelines
Philhealth presentation titled “The Formal Sector and Universal Health Care”