INHealth BiZ Comprehensive Health for SMEs

Plan I (Any accredited Hospital including top 9 major Hospitals)

• Asian Hospital Medical Center (AHMC) 
• Makati Medical Center (MMC) 
• Cardinal Santos Medical Center (CSMC) 
• St. Luke’s Medical Center – Quezon City (SLMC-QC) 
• The Medical City (TMC) 
• St. Luke’s Medical Center – Global (SLMC-GC) 
• Cebu Doctor’s Hospital (CDH),
• Chong Hua Hospital (CHH) 
• Davao Doctor’s Hospital (DDH)

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(For Plan b, click here talk to our Registered Financial Planner to know more)

Plan features applicable to all plans

• For primary care (non-emergency cases), entry point to accredited/preferred hospitals SHOULD BE THE COORDINATOR’S OFFICE. During off-clinic hours, and only for genuine emergency cases (as defined in the Agreement), a member may go to the Emergency Room for treatment. Unless stipulated in the Agreement, accredited clinics are not used for health care service availments.
• During genuine emergencies (as defined in the Agreement), a member may use any hospital nearest him. If a member uses an accredited hospital, we afford him full coverage according to his benefits classification. If a member uses a non-accredited hospital, reimbursement of expenses will be governed by the Emergency Benefits provision of the Agreement.
• Some accredited Metro Manila and provincial hospitals no longer have ward and  semi-private rooms or no longer admit HMO patients to ward or semi-private rooms. For members who select the ward or semi-private room accommodation plan and/or use hospitals without ward or semi-private rooms for in-patient benefits, please be advised that these hospitals will automatically admit the member to the next higher room accommodation on a step-ladder basis.
  • For genuine emergency cases (as defined in the Agreement), Insular Health Care takes care of the difference in upgraded costs for the first 24 hours. After the first 24 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 difference in upgraded costs from day one of his confinement prior to his discharge from the hospital. Please see provision “b” under Room and Board of In-Patient Benefits.

The Maximum Benefit Limit (MBL) per person per illness or injury per year will depend on the member’s Room Accommodation / Plan Category (which will be established at the start of the coverage period based on the client’s requirements, e.g., Officer, Supervisory, Rank & File, with or without dependents) and shall apply to dreaded and non-dreaded diseases.

 

MBLs may vary according to the client’s requirements. However, as much as possible, the company applies the following standard MBLs for the following Room Accommodation / Plan Categories:

Accommodation

Benefit Limit

Semi-Private 150,000

Private 80,000

Ward 70,000

DEPENDENT

Semi-Private 150,000

Private 80,000

Ward 70,000

*Note: Maximum Benefit Limit (MBL) per illness per injury per year

Outpatient Benefits

A. An illness or condition shall be considered pre-existing if before the Effective Date of the Agreement:

Any professional advice or treatment was given for such illness or condition

Such illness or condition was in any way evident to the member

The pathogenesis of such illness or condition has already started (which the member may not be aware of).

B. PECs are not covered in the first year of coverage.

C. After the member has been continuously covered with Insular Health Care for 12 months and the agreement is renewed, the following provisions on PECs shall apply:

PECs are covered provided that the PECs are not considered part of the “Permanent Exclusions to Health Care Coverage”, and that

such PECs were declared by the member in the original application;

such PECs are unknown to the member (without established medical history);

Undeclared PECs with established medical history are excluded from coverage. However, said PECs may be evaluated for possible future consideration.

In case an application is disapproved due to an adverse medical condition, an applicant may still avail of the Insular Health Care program by executing a “waiver” relinquishing or limiting coverage for the particular adverse condition/s (as stated in the provision on Enrollment / Approval of Application).

D. Examples of PECs: (inclusive of complications)

Hernias

All tumors and malignancies involving any body organ or system

Endometriosis, Dysfunctional Uterine Bleeding

Hemorrhoids

Diseased tonsils requiring surgery

Pathological abnormalities of the nasal septum and turbinates

Thyroid Dysfunction/Goiter

Cataract

Sinus condition requiring surgery

Asthma / Chronic Obstructive Pulmonary Disease

Cirrhosis of the liver

Tuberculosis

Anal Fistula

Cholelithiasis / Cholecystitis

Calculi of the urinary system

Gastric or Duodenal Ulcer

Hallux Valgus

Diabetes Mellitus

Hypertension

Collagen Disease / Auto Immune Disease

Cardiovascular Disease

Hormonal Dysfunction

Seizure Disorder / Cerebral Insufficiency / Stroke

E. The following health conditions may be covered (either fully or up to certain amounts) provided pre-existing conditions of an account are likewise covered:

Organ transplants and/or open-heart surgery / angioplasty and all services (e.g., coronary angiogram) related thereto (except organ donor services)

AIDS and AIDS-related diseases except when sexually transmitted

Congenital abnormalities and conditions are covered up to Php 25,000.

Chronic glomerulonephritis, gullain-barre syndrome

Scoliosis, Spinal Stenosis and Kyphosis are covered up to Php 25,000. For all other physical deformities, only consultations are covered.

For Vitiligo and Psoriasis, only consultations are covered.

Confirmatory Tests are covered up to the MBL provided the tests are done for valid diagnoses. Coverage shall be extended only up to the time the condition in question has been ruled in/out. Confirmatory tests are not applicable to health conditions listed under Permanent Exclusions.

Membership fees are based on a specific number of principal-enrollees that were culled from the client’s employee census.

• Our program is integrated with benefits under Philhealth and/or Employees Compensation Commission (ECC); therefore such Philhealth and / or ECC benefits to which the member is entitled to shall be deducted from the claim cost in the computation of benefits under our program, unless agreed otherwise through a special endorsement in the contract.
• All covered members are assumed to be Social Security System (SSS) members. In case a member and/or any dependent is not an SSS member, he shall be charged the amount equivalent to the Philhealth benefit in case he is hospitalized. Insular Health Care shall pay only all hospital bills in excess of the Philhealth benefits.

• An applicant applying for coverage is required to accomplish an enrollment form otherwise there will be no coverage despite having paid a deposit for membership fees.
• Changes in the application may be done prior to the underwriting process or the issuance of the ID card. Exceptions, if any, will be handled on a case-to-case, non-precedent setting basis.
• It is understood that Insular Health Care reserves the absolute right to approve or disapprove any application for membership. In case an application is disapproved due to an adverse medical condition, an applicant may still avail of the Insular Health Care program by executing a “waiver” relinquishing or limiting coverage for the particular adverse condition.
• Non-compliance of underwriting requirements within the prescribed period will mean the exclusion from coverage of the condition for which an underwriting requirement has been prescribed.
• In case of pre-termination of coverage or resignation/deletion of members, the client should return the ID card(s) of its members. Any misuse of the ID card by a member will be for the account of the client and / or the member.

 

Motor Vehicular Accidents

Coverage for newer modalities (up to Php 5,000 per member, per year)

Unprovoked Assault (Up to MBL)

Work-related Illnesses or Injuries – ECC Cases (Up to MBL)

Congenital Conditions (Up to Php 25,000 per member, per year)