SCHEDULE OF BENEFITS INDIVIDUAL AND FAMILY PLAN

c. shall pay for the difference in room rate as well as difference in

ancillary expenses between the higher room category and the original
room category.
Insular Life Health Care, Inc. d. Room amenities vary according to actual hospital set-up.'
A Subsidiary of The Insular Life Assurance Company, Ltd. 2. Services of physicians and surgeons, including surgery
3. General nursing services
INDIVIDUAL & FAMILY PLAN 4. Use of operating room
(Effective 1-1-2004) (to form part of the application) 5. Use of recovery room
Plan A (Open Access to Accredited Hospital System) 6. Anesthesia and its administration
Under this Plan, a member may use any I-Care accredited Hospital nationwide. 7. Drugs and medication for use in the hospital
Plan B (preferred Hospital system) 8. Oxygen and its administration
Under this plan, a member will have to select and strictly use his preferred 9. Dressing plaster and cast
hospital except during genuine emergencies (as defined in the "Agreement" 10. Transfusion of blood and other blood elements
whereby he may use any hospital nearest him. If a member uses an accredited 11. Chemotherapy/radio therapy (including out-patient)
hospital, we afford him full coverage according to his benefits classification. If a 12. ICU confinement (maximum of 14 days but not to exceed benefit limit)
member uses a non-accredited hospital, reimbursement of expenses will be 13. Dialysis (maximum of 10 treatment but not to exceed benefit
governed by the Emergency provisions of the Agreement. limit)(inclusive of out-patient dialysis )
Plan features applicable to both Plan A & Plan B/ Out/In-patient Services 14. Physical therapy (maximum of 7 sessions but not to exceed benefit limit,
1. For primary care (non-emergency cases), entry point to all accredited inclusive of out-patient therapy)
hospitals SHOULD BE THE COORDINATOR'S OFFICE. During off- 15. Services and supplies related to the medical management of the patient
clinic hours, and only for genuine emergency cases (as defined in the 16. Other hospital charges deemed necessary by the I-Care accredited Physician
Agreement), a member may go to the Emergency Room for treatment. in the treatment of the patient subject to program provisions
2. Makati Medical Center (MMC) users will have to pass through the I-Care 17. Ambulance services (hospital to hospital transfers, limited to P 2,500 per
Clinic (at the I-Care Building in Makati City) and avail of its services. conduction), if requested by an I-Care physician.
When the member requires services that are only available in MMC will he EMERGENCY BENEFITS
be referred to the hospital. During genuine emergencies (as defined in the 1. No charge emergency care services administered in any I-Care accredited
Agreement), a member may use any hospital nearest him. If a member uses hospital/clinic for genuine emergency cases as defined in the agreement.
an accredited hospital, we afford him full coverage according to his benefits 2 In case of emergency treatment/confinement in a non-accredited
classification. If a member uses a non-accredited hospital, reimbursement clinic/hospital, I-Care shall reimburse up to 80% of the usual and customary fees
of expenses will be governed by the Emergency Benefits provision of the which the I-Care preferred clinic/hospital would charge for such
agreement. treatment/confinement in accordance with the Benefits Classification of the
3. Some accredited Metro Manila and provincial hospitals no longer have member; or P10,000.00 for clinic/hospital charges and P5,000.00 for professional
semi-private rooms or no longer admit HMO patients to semi-private rooms fees (or a total of P15,000.00), whichever is less, provided that the illness or
(e.g. Makati Medical Center, The Medical City, UST Hospital, Chong Hua condition is covered under the contract and provided further that the member
Hospital, Mary Chiles General Hospital, and Dr. Jesus Delgado Memorial follows the Benefit Availment Procedures of the I-Care.
Hospital). For members who select the semi-private room accommodation MAXIMUM BENEFIT LIMIT (MBL)
plan and/or uses hospitals without semi-private rooms for in-patient The Maximum Benefit Limit per person per illness or injury per year will depend
benefits, please be advised that these hospitals will automatically admit the on the member’s Room Accommodation:
member to the next higher room accommodation on a step-ladder basis. For Suite P150,000.00
genuine emergency cases (as defined in the Agreement), I-Care takes care Private P120,000.00
of the difference in upgraded costs for the first 24 hours. After the first 24 Semi-private P100,000.00
hours, the member pays for the difference in upgraded costs prior to his
discharge from the hospital. For elective cases, the member pays for the PHILHEALTH/EMPLOYEES COMPENSATION COMMISSION (ECC)
difference in upgraded costs from day one of his confinement prior to his Our program is NOT integrated with benefits under Philhealth and/or ECC
discharge from the hospital. Please see provisions "b" under Room and benefits. If the member is entitled to such benefits, he/she should file for
Board of In-Patient Benefits. reimbursement directly with Philhealth or ECC.
OUT-PATIENT BENEFITS ADDITIONAL BENEFITS
ANNUAL PHYSICAL EXAMINATION (To be availed at the I-Care Clinic in PRESCRIPTION MEDICINE BENEFIT
Makati City or at designated facilities) Up to P 1,000 worth of prescription medicine for immediate relief and/or
1. Taking of medical history treatment of illness provided the illness or condition is covered under the
2. Physical examination Agreement and medication is prescribed by an I-Care physician.
3. Chest X-ray LIFE (GROUP TERM) INSURANCE with INSULAR LIFE
In accordance with Insular Life Group Term Policy No. G-014175 dated 15
4. Laboratory medical examination January 1999 and all its succeeding endorsements, each individual shall be
• Complete Blood Count insured in accordance with the following benefit schedule:
• Stool Examination Room Accommodation Standard Risk Sub-standard Risk
• Urinalysis Suite P50,000 P 25,000
5. Electrocardiogram for members 35 years of age and above Private 25,000 12,500
6. Pap smear for female members 35 years of age and above. Semi-private 15,000 7,500
PREVENTIVE HEALTH CARE (to be availed at the I-Care Clinic, Accredited Any individual with adverse medical findings shall automatically be covered for
or Preferred Hospital) one-half (1/2) of coverage of a standard risk for deaths due to accident. However,
1. Immunization (does not include cost of vaccine and determination of the insurance of a child below five (5) years old will be subject to "Child's Lien"
susceptibility) as follows:
2. Consultation and advice on diet, exercise and other healthful habits Age of Dependent Child at the Amount payable
3. Periodic monitoring and management of health problems time of Death
4. Family planning counseling 3 mos. to less than 1 yr One-tenth of the amount of insurance
5. Health education and wellness program 1 yr to less than 2 yrs. One-fifith of the amount of insurance
6. Medical information dissemination through clinics, newsletters, seminars, 2 yrs. To less than 3 yrs. Two-fifths of the amount of insurance
etc. 3 yrs. To less than 4 yrs. Three-fifiths of the amount of insurance
OUT-PATIENT SERVICES (to be availed at the I-Care Clinic, Accredited or 4yrs. To less than 5 years Four-fifiths of the amount of insurance
Preferred Hospital) 5 years and above The full amount of insurance
1. Consultation, including specialist's evaluation OPTIONAL BENEFITS
2. First-aid treatment of injury or illness DENTAL BENEFITS
3. Laboratory examination and all other diagnostic procedures prescribed by To avail of this out-patient benefit at the member's preferred dental clinic (for
the I-Care Physician, subject to program provisions those who select strict preferred dental facilities) or at any dental clinic (for those
4. Minor surgery not requiring confinement who select open-door dental facilities) 7under the Filipino Doctors Health
5. Eye, ear, nose and throat care Alliance, 100% participation of all qualified enrollees (by category, i.e.,
IN-PATIENT BENEFITS officer/Supervisory/Rank & File, with or without their dependents) is required.
1. Room and Board 1. Any number of consultations during clinic hours (by appointment)
a. In case hospitalization arises either through the advise of the I-Care 2. Annual examination and oral prophylaxis
Medical Coordinator or by way of an "emergency" situation, I-Care 3. Unlimited simple tooth extraction except surgery for impaction and
shall secure the room chosen by its member using a "step-ladder" complicated extractions involving re-administration of anesthesia
system (lowest to highest). (Complicated extractions involve the use of dental instruments except
b. For genuine emergency cases (as defined in the agreement) in the pliers)
event that the room accommodation pre-selected by the member under 4. Lesions, wounds, burns and gum or dental problems requiring dental
his I-Care package is nor readily available, the member shall be management surgeries.
automatically be upgraded to the next higher room classification for 5. Unlimited temporary fillings
the first TWENTY FOUR (24) HOURS and the ancillary price 6. Unlimited recementation of fixed bridges (limited to 2-4 abutments), jacket
difference shall be borne by I-Care with absolutely no obligation on crowns, inlays and onlays
the part of the member. After the first twenty-four (24) hours and 7. Dental education and counseling during consultations
there is still no room available under the member's original room 8. Unlimited adjustments of dentures (limited to adjustment of clasp)
classification, in the succeeding days of his confinement, the member 9. Two (2) permanent amalgam fillings (surfaces)
For open-door plan, add: 4. Chronic glomerulonephriitis, gullain-barre syndrome
10. Orthodontic & Aesthetic dental consultations 5. Physical deformities (e.g., scoliosis, spinal stenosis, vitiligo, psoriasis,
11. Emergency sesensitization of hypersensitive teeth etc.) Only consultation are covered
LATEST MODALITIES OF TREATMENT (examples of) PERMANENT EXCLUSION (examples of)
1. Laparoscopic Cholecystectomy (LapChole) is covered up to MBL 1. Care by non-accredited Physician and/or in a non-preferred hospital/clinic
All other laparoscopic procedures for therapeutic purposes (except except in emergencies wherein the emergency provision of the agreement
LapChole, Hyteroscopic D&C and Hysteroscopic Myomectomy) are will apply.
covered up to P20,000 per session 2. All pregnancy related conditions requiring medical/surgical care.
2. Lithotripsy (limited to one session per year) up to P 30,000.00 3. Sterilization of either sex or reversal of such, artificial insemination, sex
3. Magnetic Resonance Imaging (MRI) / Magnetic Resonance Antiogram transformations or diagnosis and treatment of infertility and circumcision.
(MRA) / Computerized Tomography (CT Scan) are covered up to 4. Rest cures, custodial, domiciliary or convalescent care
P5,000.00 per session. 5. Cosmetic surgery, dental/oral surgery, and dermatological procedures for
4. All nuclear medicine procedures (e.g. Thallium Scintigraphy, Radioactive the purpose of beautification except reconstructive surgery to treat
Isotopic Scan, etc are covered up to P5,000 per session. dysfunctional defect due to disease or accident.
5. Cryosurgery up to Maximum Benefit Limit. 6. Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome,
6. Electrocautery for wars - P1,000.00 per year adjustment disorders, alcoholism and its complications or conditions related
7. Endoscopic procedure (except FESS) is covered up to MBL, for diagnostic to substance or drug abuse, addiction and intoxication.
purposes; and P 5,000 per session for therapeutic purposes. 7. Sexually transmitted disease
8. Functional Endoscopic Sinus Surgery -(FESS) is covered up to MBL. 8. Medical and surgical procedures which are not generally accepted as
9. Gamma Knife is covered up to MBL standard treatment by the medical profession.
10. Percutaneous Ultrasonic Nephrolithotomy (PUN) with electro Shock Wave 9. Procurement or use of corrective appliances, artificial aids, durable
Lithotripsy is covered up P30,000.00 (one session per year). equipment, and orthopedic prosthesis and implants.
11. Stereotactic Brain Biopsy is covered up to P20,000.00 per session. 10. Surcharges resulting from additional personal (luxuries/accommodation)
12. Transurethral Microwave Therapy of Prostrate is covered up to P30,000.00 request or service.
per year 11. Physical examination required for obtaining employment, insurance or a
13. Laser Eye Procedures (one session per eye per year) is covered up to government license, and procedures for purely diagnostic purposes.
P5,000.00 except Photorefractive Keratectomy 12. Injuries or illness due to military, para-military, police service, high risk
14. Speech theraphy - maximum of seven sessions activities or suffered under conditions of war
15. Positron Emission Tomography Scan (PET Scan) up to P 5,000 per session 13. Reimbursement of procedures obtained through government programs.
16. Sleep Studies up to P 5,000 per year 14. Injuries or illnesses which are self-inflicted, caused by attempt at suicide or
17. Pain Management up to P 3,000per year. incurred as a result of, or while participating in a crime.
DREAD DISEASE (examples of) 15. Out-patient/take-home medicines.
Coverage is subject to the Maximum Benefit Limit per person per illness or 16. Cardio-valvular disease or Rheumatic Heart Disease.
injury per year. 17. Medico-legal consultations
1. Neurological Disorder 18. When a member is discharged against medical advise
2. Blood dyscrasia 19. Blood donor screening/other screening procedure
3. Collagen/Immunological disorder 20. All hospital charges and professional fees after the day and time hospital
4. Liver Cirrhosis discharge has been duly authorized
5. Chronic Pulmonary/ Renal disorder MEMBERSHIP ELIGIBILITY
6. Cardiovascular disorder A. PRINCIPAL
7. Cancer At least 18 years to less than 60 years old
8. Any condition which necessitates the use of Intensive Cate Unit
9. Accidental injuries B. Dependents: (Following hierarchy guidelines)
10. Other conditions causing partial or total organ damage or failure. • For single individual: Parent(s) first who is/are less than 60 years old
PRE-EXISTING CONDITIONS (PECs) and not gainfully employed; followed by the eldest sibling down to
A. An illness or condition shall be considered pre-existing if before the the youngest who is/are 15 days to less than 21 years old, unmarried
Effective Date of the Agreement: and not gainfully employed.
1. Any professional advice or treatment was given for such illness or
condition prior to effective date of coverage. • For married individuals: Spouse first who is less than 60 years old;
2. Such illness or condition was in any way evident to the member prior followed by the eldest child down to the youngest, 15 days to less than
to effective date of coverage. 21 years old, unmarried and not gainfully employed.
3. The pathogenesis of such illness or condition has already started prior DEPENDENT'S COVERAGE
to effective date of coverage (which the member may not be aware Accommodation/Plan of Dependents should be equal to or lower than the
of). principal's accommodation
B. After the member has been continuously covered with I-Care for 12 months ENROLLMENT/APPROVAL OF APPLICATION
and the agreement is renewed, PECs are covered provided that the PEC is An applicant applying coverage is required to accomplish an enrollment form
not considered part of the “Permanent Exclusions to Health Care Coverage" otherwise there will be no coverage despite having paid a deposit for membership
and that such PEC was declared by the member in the original application / fees. Changes in the application may be done prior to the underwriting process or
renewal application. Genuinely unknown (and therefore undeclared) PECs the issuance of the ID card. Exceptions if any, will be handled on a case-to-case
will be covered provided these are not concealment cases. basis. It is understood that I-Care reserves the absolute right to approve or
C. Examples of PECs (inclusive of complications) disapprove any application for membership. In case an application is
1. Hernias disapproved due to adverse medical condition, an applicant may still avail of the
2. All tumors involving any body organ or system I-Care program by executing a "waiver" relinquishing or limiting coverage for the
3. Endometriosis,Dysfunctional Uterine Bleeding particular adverse condition. Non-compliance of underwriting requirements
4. Hemorrhoids within the prescribed period will mean the exclusion from coverage of the
5. Diseased tonsils requiring surgery condition for which an underwriting requirement has been prescribed. It will
6. Pathological abnormalities of the nasal septum and turbinates likewise mean the non-issuance of the member’s ID card.
7. Hyperthyroidism/goiter MEMBERSHIP FEE/BILLING STATEMENT
8. Cataract Membership fee is due and payable on Effective Date of Agreement. Payment
9. Sinus condition requiring surgery should be on or before Due Dates corresponding to a mode pre-selected by the
10. Asthma/Chronic Obs. Pulmo. Disease client. Non-payment of Membership Fees for 31 days from Due Date will
11. Liver Cirrhosis automatically void the "Agreement". Benefits under the "Agreement" are
12. Tuberculosis allowed only if membership fees have been paid PRIOR to availment of such
13. Anal fistulae benefits,. If for any reason the I-Care membership is pre-terminated, the member
14. Cholethiasis/Cholecystitis must surrender his ID card.
15. Calculi of the urinary system EFFECTIVITY DATE OF COVERAGE
16. Gastric or duodenal ulcer Effectivity Date of coverage will either be 1st, 8th, 16th, or 24th of the month after
17. Hallux valgus receipt (and evaluation) of the application; receipt of the initial deposit for
18. Diabetes mellitus membership fees; and/or after underwriting requirements, if any, have been
19. Hypertension complied by the applicant.
20. Collagen disease
21. Cardio-vascular disease This is to certify that I have read and have been briefed on the salient features of
22. Hormonal dysfunction the I-Care Program and do hereby agree to its product features, terms and
23. Seizure disorder conditions
D. The following health conditions may be covered (either fully or up to
certain amounts) provided pre-existing conditions of an account are
likewise covered. Attested t Printed name and signature of applicant Date
1. Organ transplant and/or open heart surgery and all services related
thereto (except organ and donor services)
2. AIDS and AIDS-related diseases
3. Congenital abnormalities and conditions are covered up to Noted by: Printed name and signature of agent Date
P10,000.00.