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This is the Health Care Agreement for the following products. The complete terms and conditions of the benefits under these products are contained in this guide.

MedConsult Series
MedConsult	For Kids
MedConsult	For Adults
MedConsult	For Seniors
ER Care Series
ER Care Basic 50	For Adults		Without Access to Top Hospitals
ER Care Booster 60	For Adults		Without Access to Top Hospitals
ER Care Booster 80	For Adults		Without Access to Top Hospitals
ER Care Booster 100	For Adults		Without Access to Top Hospitals
ER Care All-In 60		For Kids	Without Access to Top Hospitals
ER Care All-In 80	For Adults	For Kids	Without Access to Top Hospitals
ER Care All-In 100	For Adults	For Kids	Without Access to Top Hospitals
ER Care Basic 50	For Adults		With Access to Top Hospitals
ER Care Booster 60	For Adults		With Access to Top Hospitals
ER Care Booster 80	For Adults		With Access to Top Hospitals
ER Care Booster 100	For Adults		With Access to Top Hospitals
ER Care All-In 60	For Adults	For Kids	With Access to Top Hospitals
ER Care All-In 80	For Adults	For Kids	With Access to Top Hospitals
ER Care All-In 100	For Adults	For Kids	With Access to Top Hospitals

In general, the MedConsult Series cover the professional fees of accredited doctors, of selected specializations, who are consulted face-to-face, unlimited telemedicine service and a dental plan that provides for oral prophylaxis, permanent fillings and unlimited consultation on dental concerns. The MedConsult Series allow consultation on pre-existing conditions and/or chronic conditions. For face-to-face consultation on acute or chronic conditions, in-clinic procedures and tests and outpatient medicines are not covered.

The ER Care Series are generally suitable for those who are relatively healthy and would like to be covered for emergency care medically necessary for accidents, viral and bacterial illnesses and specific conditions related to anaphylactic shock, amoebiasis, malaria, acute appendicitis and acute gastritis. These are the health risks to which most everyone is exposed, only in varying degrees. We want to offer coverage to those who need it while in the Philippines, so these products are also available to non-Filipinos. Please note that the emergency care will be rendered by medical professionals and facilities within the Philippines.

Persons experiencing chronic conditions, now or in the past, should carefully review the services offered by these products. The ER Care Series do not cover pre-existing conditions and/or chronic conditions. Many persons with pre-existing and/or chronic conditions control and manage their illnesses while leading active lifestyles. If they will benefit from coverage that provides emergency medical care arising from accidents, viral and bacterial illnesses and the specific conditions mentioned above, they may consider availing of this product for themselves for those contingencies.

Please refer to Section 3 for the details on your coverage and benefits

How to use this information

There are several benefits under each health care product and the information contained in this booklet includes full details of them all. To understand your coverage, first identify the product under which you are or will be registered, and then read this booklet alongside your personalized Voucher and the Frequently Asked Question (FAQ). If there is any discrepancy between this Health Care Agreement and FAQ, the Health Care Agreement will prevail.

By reading this, you will understand:

• The accidents and illnesses that are covered by the above-mentioned Insular Health Care products
• How to purchase products under the Insular Health Care ER Care and MedConsult Series
• How to register a person under the Insular Health Care ER Care and MedConsult Series
• When is it medically appropriate to seek emergency care
• Where you should go to avail of emergency care
• What to expect at the Emergency Room of a hospital accredited by Insular Health Care
• What to do if the medical diagnosis/diagnoses is/are covered
• What to do if the medical diagnosis/diagnoses is/are not covered
• With which medical professional and where to seek non-emergency medical consultation
• How to self-generate a Letter of Authorization for the consultation
• How to ensure that a person is always covered under the Insular Health Care ER Care product

By registering or using this product yourself, you certify that you have read, understood and agree to this Health Care Agreement and the Return, Replacement and Refund Policy which can be viewed at shop.insularhealthcare.com.ph/return-replacement-refund-policy.

If you did not submit information about yourself, but you subsequently received an email with your Personal Information and Sensitive Personal Information and you confirmed their accuracy and further provided consent to Insular Health Care, consistent with Section 5 – Data Privacy in this guidebook, you certify that you have read, understood and agree to this Health Care Agreement and the Return, Replacement and Refund Policy which can be viewed at shop.insularhealthcare.com.ph/return-replacement-refund-policy.

Section 1 – Definition of Terms

The words below are used in various parts of the Health Care Agreement. Where it is indicated, please refer to the other sections of the Health Care Agreement to gain greater understanding of the meaning of the words and the context in which they are used.

1. Accident. A visible, external, sudden and violent event occasioned by a physical or natural cause and occurring entirely beyond the Member’s control causing damage to the health of the Member. An accident may or may not result in a medical emergency.
2. Accredited Clinic shall mean a duly licensed medical health care facility included in the list of accredited medical clinics of Insular Health Care which has an existing and valid accreditation agreement with Insular Health Care and where a Member can avail of medical services pursuant to this Agreement.
3. Accredited Doctor refers to a doctor qualified by degree and duly licensed or registered to practice in the Philippines and who has an existing and valid accreditation agreement with Insular Health Care. This person must not be a relative of the Member up to the third degree of consanguinity and affinity. Under the MedConsult Series, a Member can consult with an accredited doctor. Under the ER Care Series, a Member can seek inpatient emergency care under an accredited doctor at an accredited hospital.
4. Accredited Hospital shall mean a duly licensed hospital included in the list of accredited hospitals of Insular Health Care with which Insular Health Care has an existing and valid service agreement and where a Member can avail of medical services pursuant to this Agreement.
5. Adults refer to individuals aged 18 years old to 64 years old.
6. Benefit Limit refers to the maximum liability that Insular Health Care shall cover and assume under the specific ER Care product you are registered. The basis of the limit applies to the single incidence of the diagnosis rather than from where it started and the medical treatment that follows to make you better. For more context, please refer to Section 2 – Your Benefits, Inclusions and Exclusions – Emergency Care in the Emergency Room of Accredited Hospitals.
7. Buyer refers to the person who purchased the products through the e-commerce store of Insular Health Care at www.shop/insularhealthcare.com.ph.
8. Congenital Condition or Developmental Condition refers to a medical abnormality existing at the time of birth. It also includes physical and/or mental abnormalities that develop due to factors or conditions present at the time of birth.
9. Consultation refers to the confidential exchange between a licensed medical professional and a Member about a medical concern. Under the MedConsult Series, a Member can seek face-to-face consultation with accredited doctors or seek a telemedicine consultation with the accredited telemedicine provider of Insular Health Care.
10. Dental care is the combination of dental advice and treatment that a Member can avail at an accredited dental health care provider or dental clinic of the Dental Partner of Insular Health Care. Please refer to Section 2 – Your Benefits, Inclusions and Exclusions – MedConsult Series for more information on dental care benefits and services covered under the MedConsult Series.
11. Dental Partner refers to the company accredited with Insular Health Care that in its turn, accredits and maintains a network of dental health care providers and dental clinics. The name of the dental partner of Insular Health Care is listed under Section 2 – Your Benefits, Inclusions and Exclusions – MedConsult Series. Under the MedConsult Series, a Member can avail of dental benefits under the nationwide network of dental clinics and dental health care.
12. Diagnosis, Initial or Final refers to the diagnosis of the accredited doctor. An initial diagnosis is the working diagnosis of the doctor. Tests and further observation of the doctor may confirm the initial diagnosis as final. It’s also possible that an initial diagnosis may be revised, in the course of medical treatment. A diagnosis is considered final when it is confirmed by the doctor as such. The final diagnosis shall be the basis for a member’s eligibility to emergency care benefits under the ER Care Series.
13. Disability refers to an illness or injury, including their symptoms, sequelae or complication thereof that require medical attention and treatment.
14. Emergency shall mean the sudden, unexpected onset of illness or injury having the potential of causing immediate disability or death or requiring the immediate alleviation of severe pain and discomfort. Examples of such emergency cases, but not limited to, are the following: (a) Massive bleeding; (b) Acute appendicitis; (c) Acute myocardial infarction (heart attack); (d) Hypertensive crisis (e.g. stroke, Hypertensive coma); (e) Fractures/injuries secondary to accidents. For the purpose of implementation, the final diagnosis shall be the basis for a member’s eligibility to emergency care benefits under the Agreement. The key words are life-threatening and/or has the potential to cause immediate disability if no medical care is provided. Another key condition is the presence of pain and discomfort that a patient cannot tolerate. Only a doctor can determine if there is a medical emergency. Please refer to Section 2 – Your Benefits, Inclusions and Exclusions – ER Care Series to better understand how the ER Care Series provides coverage for emergency care.
15. Emergency Care is the combination of medical advice and treatment that a Member can avail at accredited hospitals. It includes medically necessary treatment required by a Member in a case of a medical emergency. Under the ER Care Series, emergency care can be covered as an outpatient or inpatient, depending on the specific ER Care product under which a Member is registered. Please refer to Section 2 – Your Benefits, Inclusions and Exclusions – ER Care Series for more information on emergency care benefits and services covered under the ER Care Series.
16. Kids refer to individuals aged 1 year old to 17 years old
17. Letter of Authorization (LoA) refers to a document duly issued by Insular Health Care to, and signed by, the Member which shall serve as the authority of the latter to avail of the medical services.
18. Medical specialization refers to the particular field of medicine completed by a physician licensed to practice in the Philippines. Under the MedConsult Series, consultation with accredited doctors with a few medical specializations are not covered. Please refer to the list of these excluded medical specializations under Section 2 – Your Benefits, Inclusions and Exclusions – What are the face-to-face medical consultations that are not covered?
19. Medically Necessary Service/s is/are medical service/s, as determined by Insular Health Care, which is (a) consistent with the diagnosis and customary medical treatment of treatment of the condition, (b) in accordance with the standards of managed care and good medical practice, (c) not for the convenience of the Member or the Accredited Physician, (d) performed in the most cost effective manner required by the medical condition and (e) consistent with the terms and conditions of this Agreement.
20. Member refers to a person who has been successfully registered under a product. A member can avail of the benefits and services under a product, consistent with the terms and conditions contained in this Health Care Agreement.
21. One-Time Use refers to the singular time that the products under the ER Care Series can be availed by a Member. Upon availment, the ER Care product is considered as terminated.
22. Pre-Existing Condition are illnesses or conditions for which a Member received professional advice or treatment prior to the start date of coverage; or was in any way evident to the Member prior to the start date of coverage; or the pathogenesis of which had already started prior to the start date of coverage, regardless if the Member was not aware of it. Generally, the ER Care Series do not provide coverage for pre-existing conditions. They also do not cover viral and bacterial illnesses that are related to the pre-existing condition. For the telemedicine service under the ER Care Series and the MedConsult Series, a Member may seek consultation for medical concerns including pre-existing conditions.
23. Registration is the process by which a person’s details are submitted to Insular Health Care. Through this process, a person is registered for coverage under a specific product. Successful registration is required for coverage under a specific Insular Health Care product.
24. Seniors refer to individuals aged 65 years old and older.
25. Specific Conditions specifically refers to anaphylactic shock, acute appendicitis, acute gastritis and malaria. These specific conditions are covered for emergency care under the ER Care All-in product.
26. Telemedicine is the confidential exchange between a licensed medical professional and a Member about a medical concern. The exchange is executed over a communication line such as a wired phone, mobile phone, through a digital application and any other means that Insular Health Care allows. Please refer to Section 2 – Your Benefits, Inclusions and Exclusions – MedConsult Series for more information on telemedicine benefits and services covered under the MedConsult Series. The name of the partner of Insular Health Care that provides the telemedicine service is listed in this section.
27. Viral and Bacterial Illnesses refers to diseases caused by a virus or bacteria. The disease may or may not have the potential to cause a medical emergency.
28. Waiting Period is the number of calendar days that a person waits before his or her coverage begins under the product that he or she has been successfully registered.
29. With Access to Top Hospitals means that the ER Care product under which a Member is registered allows availment of emergency care services at all hospitals accredited with Insular Health Care including the ‘Top Hospitals’ in Metro Manila, namely, Asian Hospital and Medical Center, Cardinal Santos Medical Center, Makati Medical Center, St. Luke’s Medical Center in Quezon City and in Bonifacio Global City (BGC) and The Medical City.
30. Without Access to Top Hospitals means that the ER Care product under which a Member is registered allows availment of emergency care services at all hospitals accredited with Insular Health Care except the ‘Top Hospitals’ in Metro Manila, namely, Asian Hospital and Medical Center, Cardinal Santos Medical Center, Makati Medical Center, St. Luke’s Medical Center in Quezon City and in Bonifacio Global City (BGC) and The Medical City.

Section 2 – Purchasing and Registering

You can purchase the Insular Health Care ER Care Series and MedConsult Series on-line by visiting shop.insularhealthcare.com.ph/. We offer a range of products and services on the shop. You should read and understand each product before selecting it to purchase. Please be mindful of:

• The service/s that it offers
• The places where the service/s can be availed
• The medical diagnosis/diagnoses that is/are covered and not covered
• The age requirement, if any
• The gender requirement, if any
• The information about the person to be covered required for registration
• Other limitations of the product

For the ER Care Series and the MedConsult Series, the definition of the age is as follows:

Insular Health Care Product	Kids	Adult	Senior
MedConsult	1 to 17 years old	18 to 64 years old	65 years old and older
ER Care Series	1 to 17 years old	18 to 64 years old

If you want to seek advice on the medically appropriate health care product for your requirements and those of your family, please feel free to chat with us on-line, send a Private Message on Facebook or request for a return call via a Facebook Private Message.

On-Line Purchase: Purchaser, Buyer’s Web-Based Account

When you have made your selection and are ready to check-out, you, as the ‘Purchaser’, will be asked to open a free Insular Health Care Buyer’s web-based account to proceed. We will use the information you submit to us through this account to fulfill your purchase; e.g. send you an email to confirm your purchase. You will also use this account when you purchase from the Insular Health Care store again. As the Purchaser, you will be able to see all of the products you’ve purchased and the status of each. You will be able to view the following information.

• If a person has been registered under a specific product
• If the product is expired
• If a person has been registered, you will see if the coverage is inactive or active
• If a product is used

In the process of check-out, select your payment method and make your payment. After we have confirmed receipt of your payment, we will send you an email to confirm your purchase. This email contains the product serial code that you need to be able to register the person to be covered by the product.

As the Purchaser, you can be registered under a product. To do so, you must register yourself under a specific product. You are not covered under any product unless you are registered under it.

On-Line Registration of the Person to be Covered: Becoming a Member, Waiting Period, Start Date of Coverage, Coverage Period

Registering is the process by which you identify and submit the details of the person to be covered by the Insular Health Care product. This person who will be covered is called the Insular Health Care ‘Member’. Without a successful registration, no coverage can be provided by the Insular Health Care product to a Member. You must register a person under the product you have purchased as soon as possible so that the registration process can begin. There is a maximum of 90 calendar days from purchase date to register the person; after which, a person can no longer be registered under the product. We will send confirmation of the successful registration and details thereof to the Member.

If you register yourself or your child below 18 years old, you will receive the Product Voucher through the email address you provided. If you submitted the data of an adult, an email will be sent to that person through which he/she will confirm and provide his/her consent to submit the data to Insular Health Care. After he/she has given his/her consent, the Product Voucher will be sent to his/her provided email address.

Please see below for the waiting period applicable to each product. Waiting period is the number of calendar days from the date of successful registration to the start date of coverage. Waiting period applies to everyone and cannot be waived for anyone. Waiting period starts from the day after successful registration; after it ends, coverage begins.

Please see below for the coverage period applicable to each product. The coverage period is defined by a start date and an end date and within this period, as long as the product has been successfully registered and is not terminated prematurely (see below Section 4 on ‘Availment’), the product is available for use by the registered Member, subject to the terms of coverage.

Product	Registration Period	Waiting Period	Coverage Period
			Start Date	End Date
MedConsult Series	Within 90 calendar days from purchase date	3 calendar days	12:01am of Day 1 of the coverage period	11:59pm of Day 365 of the following year
ER Care Series		10 calendar days	12:01am of Day 1 of the coverage period	11:59pm of Day 365 of the following year

Please see below for a sample illustration of registration, waiting period and coverage period. Once we have confirmed that a person has been successfully registered, coverage will automatically begin according to the waiting period applicable to the product registered. Insular Health Care may send you a further notice that the coverage has begun.

Once a person has been successfully registered under a product, it cannot be un-done and the product can no longer be exchanged or refunded.

Product Registration Timeline	Sample Date for Illustration Purposes Only
Day 0 is the day of successful registration	31st of March
Days 1-10 are the waiting period	1st to 10th of April
Day 11 is the start date of coverage	11th of April
Product Coverage Timeline
Day 1	12:01am, 11 April
Day 365	11:59pm, 10 April of the following year

Product Voucher

Once you successfully register yourself under a product, you will receive a confirmation via email. You will also receive the email if you registered your child below 18 years old. The email contains the important details concerning your coverage. It also includes the Product Voucher you need to present at the clinics of our accredited doctors and dentists for consultations, or to accredited hospitals to be able to seek emergency medical care. The Product Voucher also contains the Member ID you need to give to the telemedicine provider to allow them to validate your telemedicine privilege, if applicable.

The email confirmation summarizes your benefits under the specific product you have registered. The Product Voucher contains the product name, your complete name, your Insular Health Care Member ID and the start and end dates of coverage. We recommend that you print the Product Voucher and keep a copy in an accessible place, like your wallet. You will need to present the Product Voucher, personalized with your details, together with your valid government-issued ID. If the covered person is a child without a school ID, the responsible adult accompanying him/her should present their government-issued ID.

Product Coverage Period and Termination Schedule

Once successfully registered, and after the waiting period, the product coverage period begins.

For the MedConsult Series, the product coverage period is 12 months.

For the ER Care Series, the product coverage period is 12 months or until availed, whichever comes first. Please see below for the termination schedule of the Insular Health Care products.

Product	Termination Schedule
This schedule applies to any variant of the products listed above
If the MedConsult is availed during the coverage period	11:59pm on Day 365 from the start date of coverage.
If the MedConsult is not availed during the coverage period	11:59pm on Day 365 from the start date of coverage.
If the ER Care product is availed during the coverage period	Coverage terminates when Insular Health Care issues a Letter of Authorization corresponding to the ER Care product
If the ER Care product is not availed during the coverage period	11:59pm on Day 365 from the start date of coverage.

Insular Health Care may send you a further notice that the coverage has terminated. In any case, we urge you to record and monitor the end date of your coverage so that you can renew it on time and your coverage will be without interruption.

Below is a summary of the product timelines relative to the waiting period, coverage period and termination period.

Insular Health Care Product	Waiting Period	Coverage Period and Termination Schedule
		Start Date	End Date
MedConsult Series
MedConsult	3 calendar days	1 year that starts from 12:01am on Day 1 of coverage to 11:59pm on Day 365	11:59pm on Day 365
ER Care Series
ER Care Basic 50	10 calendar days	1 year that starts from 12:01am of Day 1 of coverage to 11:59pm of Day 365	Terminates on the day when Insular Health Care issues a Letter of Authorization corresponding to the ER Care product   If not availed, it terminates at 11:59pm on Day 365
ER Care Booster 60	10 calendar days
ER Care Booster 80	10 calendar days
ER Care Booster 100	10 calendar days
ER Care All-In 60	10 calendar days
ER Care All-In 80	10 calendar days
ER Care All-In 100	10 calendar days

 

Renewal of ER Care and MedConsult Coverage

You can always stay covered with these Insular Health Care products. Simply visit shop.insularhealthcare.com.ph/ and log in to the account you previously created to avoid having to input your buyer details again. Select and purchase the products and make your payment. As soon as you have received the email from us confirming your purchase, register the person to be covered according to the Product Renewal Schedule below.

For the MedConsult Series, you can register as early as 3 calendar days prior to the end date of coverage.

For the ER Care Series, you can register as early as 10 calendar days prior to end date of coverage. If the ER Care product has been availed, you can register for another product as soon as the day following the availment of emergency care under the ER Care product. If you have been confined, you can still register the day following the date of admission.

Remember that after successful registration, there is a waiting period before coverage begins anew.

For concerns or queries relating to registration, please feel free to chat with us or send us an email or PM.

Section 3 – Your Benefits, Inclusions and Exclusions

One benefit of a Filipino citizen is universal PhilHealth coverage under Republic Act No. 7875, as amended; you can visit its implementing rules and regulations by clicking https://www.philhealth.gov.ph/about_us/IRR_NHIAct_2013.pdf. We cannot emphasize too much that it is to your greatest benefit to ensure that you are covered by PhilHealth and that, you make regular contributions, as necessary, to be able to complement your HMO coverage.

These are the services and benefits that you can avail under the ER Care Series and MedConsult Series. Please read carefully how your PhilHealth coverage may help in covering your medical expenses.

MedConsult Series
· Within the 12-month coverage period, you can avail of consultation benefits under the following services: o Face to face medical consultations o Unlimited 24×7 telemedicine consultations o Unlimited dental consultations and annual oral prophylaxis and permanent fillings · Please refer below for the complete details on your benefits
Face-to-Face Medical Consultation
Your face-to-face medical consultation benefit		You have a maximum of four (4) out-patient face-to-face medical consultations with accredited doctors in a clinic setting. The benefit covers the professional fee that the medical doctor charges for consultation. You can consult with more than 10,000 accredited doctors throughout the Philippines Consultations with non-accredited doctors, consultations with accredited doctors whose medical specialization are excluded under ‘What are the face-to-face medical consultations that are not covered?’, Consultations falling under the exclusions mentioned under ‘What are the other exclusions to the face-to-face medical consultation?, are not covered by this product. If you decide to proceed with any of these types of consultation and pay for his or her consultation fee and any other fees, you cannot seek reimbursement, regardless of amount. You may consult symptoms and illnesses that are acute or pre-existing with accredited doctors who are general practitioners and those with the following specializations: Family Medicine Pediatrics Obstetrics-Gynecology Cardiology Gastroenterology Pulmonology Endocrinology Infectious Medicine Nephrology Urology Rheumatology · Oncology Hematology Allergology Geriatrics General Surgery Orthopedics Rehabilitation Medicine Dermatology Ophthalmology Otorhinolaryngology (ENT)
What are the face-to-face medical consultations that are not covered?		Consultation with accredited doctors with these medical specializations are not covered Neurology Neurosurgery Sleep Medicine Developmental and Behavioral Pediatrics
What are the other exclusions to the face-to-face medical consultation?		Please take note of the following exclusions to this benefit. Consultation in emergency room facilities Consultation with non-accredited doctors Consultation with an accredited doctor in a non-accredited hospital Dermatological consultation and procedures for purposes of beautification; examples are those cases of acne, warts, hyperpigmentation and milia Consultation about a condition secondary to all pregnancy and/or fertility-related illnesses and/or treatments. Consultation about sexually transmitted infections such as but not limited to syphilis, gonorrhea, chlamydia, human papillomavirus infection and HIV/AIDS Consultation for complications resulting from sterilization of either sex or reversal of such, artificial insemination, sex transformation and circumcision Consultation with psychiatrists and consultation related to psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, stress-related conditions, adjustment disorders, childhood and developmental disorders, alcoholism and its complications or conditions related to substance or drug abuse, addiction and intoxication Consultation for cardio-pulmonary (CP) clearance required prior to surgery or medical procedures Physical examination required for obtaining employment, medical certification, insurance or government license Consultation for injuries or illnesses due to military, paramilitary, police service, high-risk activities or those suffered under conditions of war Consultation for injuries which are self-inflicted, caused by attempt at suicide or incurred as a result of or while participating in a crime or acts involving the violation of the law, administrative order or ordinances Consultation for diseases declared as an ‘epidemic’ by the Department of Health Medico-legal consultation
What are not covered by the face-to-face consultation benefit?		All In-clinic procedures, tests, therapy and medicines such as but not limited to: Ophthalmology procedures like visual acuity, refraction, slit lamp exam, fundoscopy, tonometry, etc. Ears, nose, throat (ENT) procedures like ear irrigation/cleaning, ear/nasal suctioning, rhinoscopy, laryngoscopy, etc. Surgical procedures like incision and drainage, wound cleaning, debridement, suture removal, etc. Administration of injection Pap smear Dermatologic procedures for purposes of beautification like those relating to acne, warts, hyperpigmentation and milia Hypersensitivity and allergy tests Physical therapy Out-patient medicines, whether prescribed or not by an accredited doctor
Unlimited 24×7 Telemedicine Consultation powered by MyPocketDoctor Telemedicine has been widely practiced in many parts of the world for the past 30 years or so. It has positively impacted millions of people and it’s time for Filipinos to significantly benefit from this kind of service. The practice of telemedicine is as rigorous as that of a face-to-face medical consultation. First, the doctors and nurses are licensed practitioners in the Philippines and have undergone specific training on telemedicine consultation. Second, the nurses and doctors follow an approach, specifically designed for telemedicine, that has been calibrated and enhanced over the years by millions of calls worldwide. Third, in case of any doubt, the privacy of the telemedicine calls is protected to the standards required by our data privacy laws.
Your unlimited telemedicine medical consultation benefit		You can consult through the telephone, 24×7 You may consult about symptoms or complaints you may have, about medicines, about treatment plans, about any medical-related concerns you may have You may consult about pre-existing or chronic conditions You may consult without limit You may call from anywhere in the Philippines or anywhere in the world Most likely, in almost 90% of the cases, the doctor will be able to assist you By the end of the consultation, the doctor will either have an impression and prescribe a treatment plan or order for diagnostic tests to help determine your condition The doctor will provide you with a prescription for medicines and/or diagnostic tests through email Further, the nurse and/or doctor will conduct follow-up calls to monitor your progress If the doctor finds that your case is emergency in nature, you will be advised to proceed to a hospital to seek emergency care The telemedicine service can help in finding the nearest hospital and coordinating with the receiving hospital, as necessary
Unlimited Dental Consultation with Oral Prophylaxis and Permanent Filling Insular Health Care’s dental partner is Reliant Health Med Alliance Corporation. They maintain a nationwide network of dental clinics and dental health care providers who offer diagnostic and therapeutic dental services. Your dental benefits can be availed at the dental clinics that have been accredited by Reliant Health Med Alliance Corporation.
		You can consult with an accredited dental professional You can avail of the benefits described below under the following services
Preventive Services		You can consult without limit on dental-related concerns Your dentist can educate and provide instruction on oral hygiene You can avail of one (1) oral prophylaxis per 12-month coverage, for mild to moderate cases for dental cleaning You can avail of one (1) dental examination per 12-month coverage
Restoration Services		You can avail of temporary fillings, without limit You can avail of Amalgam filling for three (3) surfaces or Light Cure fillings for two (2) surfaces Your dentist can re-cement jacket crown inlays and onlays Your dentist can perform simple tooth extraction, without limit
Dentures & Orthodontics		Your dentist can help with the adjustment of dentures Your dentist can also provide advice on orthodontic and aesthetic dentistry
Treatments		You can seek the dentist to treat and alleviate dental-related pain though prescribed medicines are not covered Your dentist can help you find relief and/or issue a prescription for acute dental pain Your dentist can provide treatment for lesions, wounds and burns in the dental area Your dentist can provide emergency desensitization of hypersensitive teeth
ER Care Series
First, identify the product under which you have been registered. Carefully note if you are covered for accidents only. If so, determine if you are covered under ER Care Basic for outpatient emergency care only or ER Care Booster with outpatient and inpatient emergency care. If you are covered under ER Care Booster, confirm the room type and the corresponding limit for your outpatient and inpatient emergency care benefit. If your coverage is under ER Care All-In, you have outpatient and inpatient coverage for accidents, viral and bacterial illnesses and specific conditions enumerated under this Section. Confirm the room type and the corresponding limit for your outpatient and inpatient emergency care benefit. Lastly, determine if your coverage includes the Top 6 hospitals in Metro Manila, namely, Asian Hospital and Medical Center, Cardinal Santos Medical Center, Makati Medical Center, St. Luke’s Medical Center in Quezon City and in Bonifacio Global City (BGC) and The Medical City. For the same type and limits of coverage, the benefits are the same for Kids and Adults relative to the outpatient and inpatient emergency care services they can avail. Proceed to read and understand about emergency care and the inclusions and exclusions of coverage.
What are the benefits of each of the ER Care products?	Carefully note under which ER Care product you are registered as each of them have different benefits. The number beside the Product name refers to the Benefit Limit and corresponding room type that applies if you are hospitalized. Please see below the details on the benefits of the different products under the ER Care Series.
Coverage for Accidents only
Product	Emergency Care Service		Adult
ER Care Basic 50	Outpatient emergency care only		Emergency Room only with Php50,000 Benefit Limit
ER Care Booster 60	Outpatient or inpatient emergency care		Ward Room with Php60,000 Benefit Limit
ER Care Booster 80			Semi-Private Room with Php80,000 Benefit Limit
ER Care Booster 100			Regular Private Room with Php100,000 Benefit Limit
Coverage for Accidents, Viral and Bacterial Illnesses and Specific Conditions
Product	Emergency Care Service		Accident Coverage only
			Kids	Adult
ER Care All-In 60	Outpatient or inpatient emergency care		Ward Room with Php60,000 Benefit Limit	Not available
ER Care All-In 80			Semi-Private Room with Php80,000 Benefit Limit	Semi-Private Room with Php80,000 Benefit Limit
ER Care All-In 100			Regular Private Room with Php100,000 Benefit Limit	Regular Private Room with Php100,000 Benefit Limit
Hospital Cash Allowance
ER Care Booster 60	Adult		Upon admission, you can receive a one-time cash allowance of Php1,000
ER Care Booster 80	Adult
ER Care Booster 100	Adult
ER Care All-In 80	Adult
ER Care All-In 100	Adult
When is it medically necessary to seek emergency care and when is it covered by the ER Care product?	Please do seek emergency care when you need it. For more life-saving information, visit icare.com.ph/need-medical-attention-where-to-go. Under the ER Care Series, you can avail of emergency care with benefits at the hundreds of hospitals accredited with Insular Health Care. Availment of emergency care in non-accredited hospitals is not covered and there is no reimbursement option. Only emergency care is covered by the ER Care Series. Non-emergency care is not covered so it is important that you only seek emergency care at the hospital when it is a valid emergency. For example, a 7-year child with cough and colds should be brought to the pediatrician during clinic hours rather than to the emergency room.
What does Emergency Care mean?	For clarity, ‘emergency’ means the sudden, unexpected onset of illness or injury having the potential of causing immediate disability or death or requiring the immediate alleviation of severe pain and discomfort. The key qualifiers here are that illness or injury must be life-threatening and/or has the potential to cause immediate disability if no medical care is provided. Or, there is pain and discomfort that you are not able to tolerate. It is the doctor who will determine if your case qualifies as a medical emergency. Again, if the case is evaluated by the doctor as a non-medical emergency, the ER Care product will not provide coverage.
What is an accident?	ER Care Basic, ER Care Booster cover emergency medical care to individuals involved in an accident. Aside from the coverage of accidents, ER Care All-In provides emergency care coverage to individuals suffering from viral and bacterial illnesses and specific conditions relating to anaphylactic shock, acute appendicitis, acute gastritis, amoebiasis and malaria. In the case of ‘accident’, it shall mean a visible, external, sudden and violent event that causes damage to the health of a person. This visible, external, sudden and violent event is the result of a physical or natural cause that was entirely out of the control of the person. Though accidents are unexpected, we can take measures to avoid them. Accidents occur in our homes, offices, roads and just about anywhere – let’s all apply common sense and be more mindful to avoid accidents wherever we may be so that we can all be safer. In case of accidents that require emergency medical care, you should present yourself at the emergency room of the hospital as soon as possible. Generally, you must be at the emergency room within 24 hours so that injuries resulting from accidents requiring emergency are coverable by the ER Care products. Below are descriptions of common accidents requiring emergency care at the hospital. These examples do not preclude you from seeking emergency care if you believe that you need the attention of a medical professional. Vehicular accidents on the road either as a driver, passenger, pedestrian or bystander where there are visible wounds, and/or you experience shock When a child slips and their body makes contact with an object or another person that causes injury, like an arm fracture When you accidentally cut off your finger while working in the kitchen
What are viral and bacterial illnesses?	Aside from the coverage of accidents, ER Care All-In provides emergency care coverage to individuals suffering from viral and bacterial illnesses and specific conditions relating to anaphylactic shock, acute appendicitis, acute gastritis, amoebiasis and malaria. Viral and bacterial illnesses are diseases caused by viruses and/or bacteria. Thankfully, our doctors practice advanced medical health care management so that many illnesses caused by virus and bacteria do not require hospitalization. Doctors will evaluate whether a viral or bacterial illness requires hospitalization. In cases where hospitalization is required for viral and bacterial illnesses, ER Care will provide inpatient and outpatient coverage. See below for examples of these viral and bacterial illnesses that may require hospitalization. Dengue Hemorrhagic Fever Cellulitis Measles with complications Chicken pox with complications Acute pancreatitis Hepatitis A For more samples, please click icare.com.ph/faq
What are the specific conditions covered by the ER Care All-In product?	Aside from the coverage of accidents, ER Care All-In provides emergency care coverage to individuals suffering from viral and bacterial illnesses and the following specific conditions: Anaphylactic shock Acute appendicitis Acute gastritis Amoebiasis Malaria Doctors will evaluate whether your specific case requires hospitalization. In cases where hospitalization is required for your case, ER Care All-In will provide inpatient and outpatient coverage.
What accidents, viral and bacterial illnesses, or specific conditions would be excluded from coverage?	The ER Care All-In product provide coverage for acute cases of viral and bacterial illnesses and the specific conditions mentioned above. It also provides coverage for accidents that have just occurred. The incidence of the viral and bacterial illnesses and accidents must be within the start and end dates of the coverage period. Generally, the ER Care Series do not provide coverage for pre-existing conditions. They also do not cover viral and bacterial illnesses that are related to the pre-existing condition. An illness or condition is considered pre-existing if, prior to start date of coverage, any of these conditions was present: Any professional advice or treatment was given for such illness or condition; or Such illness or condition was in any way evident to the Member; or The pathogenesis of such illness or condition had already started, of which the Member may not be aware Please visit icare.com.ph/faq for a sample list of viral and bacterial conditions considered as pre-existing conditions. For reference, we are also sharing the sample list of pre-existing conditions that are not viral or bacterial in nature. Examples of viral and bacterial illnesses considered as pre-existing conditions are Tuberculosis, Gastric or Duodenal Ulcer, and Hepatitis B, Hepatitis C & Hepatitis D. These would not be covered by the ER Care product. Examples of viral and bacterial illnesses relating to pre-existing conditions are below. These would not be covered by the ER Care product. Pneumonia related to heart failure Cellulitis related to diabetes Urinary Tract Infection (UTI) related to urinary/kidney stones The following cases would also not be covered by the ER Care product. If the viral or bacterial illness or injuries resulting from accidents commenced or occurred, respectively, prior to the start date of coverage like a fracture that occurred prior to the start date of coverage If the injury occurred within the coverage period but was only brought to the emergency room after 24 hours from incidence like back pains that can be traced to a fall that happened six months ago
What are the other conditions for non-coverage of accidents, viral and bacterial illnesses and specific conditions?	This is a list of other conditions that are non-coverable under the ER Care Series. It should be read and interpreted in view of the specific ER Care product under which you are registered. 1. Viral and bacterial illnesses that are complications of or contracted due to a compromised or impaired immune system. The following are examples but not limited to: Patients with malnutrition Patients with uncontrolled diabetes mellitus Recipients of organ transplant Patients with hematologic malignancies Patients undergoing radiation, chemotherapy and immunosuppressive therapy Patients with HIV / AIDS infection Patients with foreign objects/implants such as venous or urinary catheters Patients with auto-immune diseases such as Systemic Lupus Erythematous (SLE), Rheumatoid Arthritis, Multiple Sclerosis, Guillain-Barre syndrome 2. Viral infections like: Hepatitis B, C, D & E Herpes infections like Epstein-Barr and Cytomegalovirus 3. Accidents and viral / bacterial illnesses that are secondary to or contracted due to having a degenerative disease such as but not limited to Alzheimer’s disease, Amyotrophic Lateral Sclerosis (ALS) and Parkinson’s disease 4. Conditions secondary to all pregnancy and fertility-related illnesses and/or treatments 5. Lithiasis/stones of the gallbladder and genito-urinary system 6. Sexually transmitted infections such as but not limited to syphilis, gonorrhea, chlamydia, human papillomavirus infection, HIV/AIDS 7. Chronic viral and bacterial illnesses 8. Congenital illnesses acquired through viral and bacterial infections 9. All dental related conditions and services 10. Complications from sterilization of either sex or reversal of such, artificial insemination, sex transformations, and circumcision 11. Rest cures, custodial, domiciliary, or convalescent care 12. Complications arising from cosmetic surgery, dental/oral surgery and dermatological procedures for the purpose of beautification, including reconstructive surgery to treat a dysfunctional defect due to a disease or accident 13. Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, stress related conditions, adjustment disorders, alcoholism and its complications or conditions related to substance or drug abuse, addiction and intoxication 14. Medical and/or surgical procedures which are not generally accepted as standard treatment by the medical profession like acupuncture 15. Procurement, lease/rent or use of corrective appliances, artificial aids and durable equipment, and orthopedic prosthesis and implants 16. Surcharges resulting from additional personal (luxuries/accommodation) request or service including special nursing services 17. Injuries or illnesses due to military, paramilitary, police service, high risk activities, or suffered under conditions of war 18. Injuries or illnesses which are self-inflicted, caused by attempt at suicide or incurred as a result of or while participating in a crime or acts involving the violation of law, administrative order or ordinances 19. Professional sports, high-risk sports/activities 20. Outpatient or Take-Home medicines 21. Valvular Heart Disease and/or Rheumatic Heart Disease. 22. All hospital expenses and professional fees incurred by a Member when discharged against medical advice 23. Professional fees of assistant surgeons 24. Diseases declared by the Department of Health as “epidemic”. 25. Miscellaneous Fees not related in the diagnosis and treatment of a member’s condition such as, but not limited to, “nursing fee”, waste/biologic hazard disposal fee, management fee, local taxes, and other analogous fees 26. Professional fees of medico-legal officers, consultations and confinement 27. Medical certificates 28. All expenses incurred in the process of organ donation and transplantation, as donor or recipient
Emergency Care in the Emergency Room of Accredited Hospitals
Benefit Limit	The maximum amount of services that you can avail as a benefit corresponds to the Benefit Limit (BL ) of the ER Care product under which you are registered. The same limit applies to your journey whether it starts in the Emergency Room or with a doctor’s visit and whether you are directly discharged from the emergency room or continues onto a hospital confinement. The basis of the limit applies to the single incidence of the diagnosis rather than from where it started and the medical treatment that follows to make you better. For the ER Care Basic, coverage is limited to outpatient emergency care. In case you need to be admitted, your benefit limit will be used to settle the coverable hospital charges in the emergency room only. You will shoulder all the hospital charges while confined. For the ER Care Booster and ER Care All-In, coverage includes the emergency room and when admitted, the coverable hospital charges while you are confined . If you consult with an accredited doctor and are advised to be admitted, your benefit limit will be used to settle the coverable hospital charges while confined.
Coverable Hospital Charges	At the emergency room, your benefits will cover the hospital’s fees for the emergency room, professional fees of accredited doctors who attend to you in the emergency room, hospital services and supplies that the doctors say that you need to recover and be discharged. Hospital services and supplies include general nursing care and the drugs and medicines, and supplies prescribed with therapeutic effect while in the emergency room. Notwithstanding, we apply sub-limits on specific services relating to specific tests – which you can view by visiting icare.com.ph/prepaid/standardprovisions. In addition, in the case of animal bites, we will only cover the first dose of anti-rabies/anti-venom/anti-tetanus, up to a maximum of Php20,000.
PhilHealth Coverage	For certain outpatient procedures done in the emergency room, based on their own rules, PhilHealth will provide coverage in PhilHealth accredited hospitals. If your case qualifies, you must submit the necessary PhilHealth-mandated documents to be able to claim the benefit. If you are not yet a PhilHealth member or are unable to complete the document requirements because your contributions are not sufficient and/or updated, you will have to shoulder the portion that PhilHealth would have covered. Your total hospital bill will be reduced by PhilHealth’s coverage. If there are any discounts, like Senior Citizen or PWD discount, that will be applied, it will be deducted after PhilHealth’s coverage. Insular Health Care will cover the coverable charges in the hospital bill, net of the PhilHealth coverage and other discounts. If the total coverable charges, net of PhilHealth and discounts, are less than or equal to the available benefit limit, the ER Care product will cover the whole amount. In case that the net coverable hospital charges are greater than your available benefit limit, you will shoulder 100% of the excess.
InPatient Care in Accredited Hospitals
Benefit Limit	The maximum amount of services that you can avail as a benefit corresponds to the Benefit Limit (BL) of the ER Care product under which you are registered. The same limit applies to your journey whether it starts in the Emergency Room or with a doctor’s visit and whether you are directly discharged from the emergency room or continues onto a hospital confinement. The basis of the limit applies to the single incidence of the diagnosis rather than from where it started and the medical treatment that follows to make you better.
Hospital Room Amenities	You can avail of a hospital room and board according to the room type of the ER Care product you are registered. The room amenities that are included as standard in the specific hospital where you are admitted forms part of the room and board; as such, it does not cost you. Amenities not part of the standard that you request will be for your account. Please note that room amenities differ by room type and by hospital and Insular Health Care has no influence over the room amenities that are specified by each hospital.
Importance of Room Type Selection	You may not have known it before that hospitals practice socialized pricing; the higher the room type, all hospital products and services and even professional fees, also increase in cost. This is why it is important that you select a room type that corresponds or is lower in category to the ER Care product under which you are registered. Please note that hospitals have their own manner of categorizing their rooms. If a hospital has more than one type of Private room, the ER Care product provides for a Regular Private room type benefit, based on the hospital’s label. If you select a room higher than that of a Regular Private room, you will have to cover the difference between the upgraded room and Regular Private room rates plus the difference in the cost of the therapeutic treatment you receive while in the upgraded room versus what would have been charged if you were in the Regular Private room. If you expect that your hospital charges will be significant, and/or you want to avoid paying any coverable charges in excess of the benefit limit of the ER Care product under which you are registered, one way you can maximize the benefit limit is to choose a lower or the lowest room type. With us as your partner, we will help ensure that you will continue to receive the highest standard of medical care in the hospital regardless of your room type. Do note that in certain instances, particularly infectious cases, your doctor may require a private room. We have observed this particularly for children. In this instance, we suggest that you avail of the ER Care All-In corresponding to the Regular Private Room category to avoid having to room upgrade.
No Hospital Rooms Available and Staying Beyond Discharge	If the doctor has admitted you for inpatient emergency care, and there is no room available that corresponds to your ER Care product, you can still be admitted into a room type lower or higher than that of your product room. In case of a choice of a lower and higher room type, Insular Health Care will select the lower room type to better manage your benefit limit. If there is no choice in room type, you will be admitted into the available room type. In case of a lower room type, Insular Health Care will cover the room rate and all the coverable hospital charges as if you were admitted to a room type corresponding to your product. You can choose to stay in this room throughout your confinement as a way of conserving your benefit limit for coverable charges relating to the medically necessary treatment you need for your recovery and healing. Refer to Importance of Room Type Selection for more insight on why room selection is important. In case of a room upgrade, we will cover the first 24 hours of your admission from the room rate and all the therapeutic treatment you receive. If a room type that corresponds to your product becomes available within the first 24 hours or immediately after the first 24 hours, Insular Health Care will help arrange for your transfer to the room type corresponding to your product. You will not shoulder any charges for the room or coverable hospital charges in this scenario. If there is still no appropriate room type available that corresponds to your product after the first 24 hours, you can choose to transfer to a room type lower than that of your product; in this case, you will not have to shoulder any difference in the rates of the room and the coverable hospital charges. If there is still no room type that corresponds to your product after the first 24 hours, and you choose to stay in the upgraded room, you will have to cover the difference in room rates between the upgrade and your product’s corresponding room plus the difference in the cost of the therapeutic treatment you receive while in the upgraded room versus what would have been charged if you were in your product’s corresponding room type. It is certain that you will have out-of-pocket expenses to settle in this scenario. For your own reasons, if you choose to stay confined in the hospital after you have been discharged by the accredited doctor, you will be responsible for all hospital charges and professional fees starting from the time of the discharge order. It is certain that you will have out-of-pocket expenses to settle in this scenario.
Coverable Hospital Charges and Special Modalities of Treatment	Aside from your room and board, your benefits will cover the professional fees of accredited doctors and hospital services and supplies that the doctors say that you need to recover and be discharged. Hospital services and supplies include general nursing care and the drugs and medicines prescribed with therapeutic effect. Your benefits will also cover the services and supplies related to the surgery you may need and confinement in the Intensive Care Unit. Notwithstanding, we apply sub-limits on specific services relating to specific tests and procedures which we call collectively as special modalities – you can view by visiting icare.com.ph/faq. In addition, in the case of animal bites, we will only cover the first dose of anti-rabies/anti-venom/anti-tetanus, up to a maximum of Php20,000. In one hospital stay, there will be tens to hundreds of items that will be used to help you recover. The guiding rule is that your benefits will cover those that are prescribed by an accredited doctor with therapeutic effect relative to the diagnosis/diagnoses that is covered by the ER Care product under which you are registered. Services and supplies that are not medically necessary in your medical management are not covered; examples of these are blood donor screening services, additional meal trays for your companion or a TV unit if it was not a standard amenity of the room you selected.
PhilHealth Coverage	For certain medical cases, based on their own rules, PhilHealth will provide coverage in PhilHealth accredited hospitals. If your case qualifies, you must submit the necessary PhilHealth-mandated documents to be able to claim the benefit. If you are not yet a PhilHealth member or are unable to complete the document requirements because your contributions are not sufficient and/or updated, you will have to shoulder the portion that PhilHealth would have covered. Your total hospital bill will be reduced by PhilHealth’s coverage. If there are any discounts, like Senior Citizen or PWD discount, that will be applied, it will be deducted after PhilHealth’s coverage. Insular Health Care will cover the coverable charges in the hospital bill, net of the PhilHealth coverage and other discounts. If the total coverable charges, net of PhilHealth and discounts, are less than or equal to the available benefit limit, the ER Care product will cover the whole amount. In case that the net coverable hospital charges are greater than your available benefit limit, you will shoulder 100% of the excess.

Section 4 – Important Information on How to Avail of your Benefits

Availment of Medical and Dental Consultation and Services: Online Letter of Authorization, Dental Consultation

Throughout the coverage period of one (1) year, you can avail of face-to-face, tele-medical and dental consultation. You may also avail of the additional benefits under the dental plan like the annual oral prophylaxis and permanent fillings. Please refer to Section 2 for more details.

You will need to self-generate a Letter of Authorization to seek face-to-face medical consultation. Please prepare your Product Voucher on which you will find your Insular Health Care Member ID. You will need this Member ID to generate the Letter of Authorization. 

Telemedicine consultation is as easy as sending an SMS and waiting for the call of the doctor. Please click www.insularhealthcare/telemedicine for more information.

Visiting the dentist of your choice is just as simple. Please click www.insularhealthcare/dentist for more information.

Availment of Emergency Medical Care for Accidents: Police Report, Notarized Affidavit

Accidents at home are most unfortunate and for those accidents that result in injuries that require emergency attention at the hospital, you can avail of the medical care through the ER Care Series. We will require a notarized affidavit from you for home accidents and accidents involving yourself. We will need this document at the point that the hospital bill is being settled, regardless if you were treated at the emergency room only or admitted.

We are also exposed to the risk of motor vehicle accidents, as a bystander, pedestrian, passenger or driver. In situations where you are unfortunate enough to be involved in a motor vehicle accident in any capacity, involving a person other than yourself, we will require a police report. We will need this document at the point that the hospital bill is being settled, regardless if you were treated at the emergency room only or admitted.

The purpose of the affidavit and police report is to determine if you acted in your own best interest in protecting yourself from harm. For example, you need to have been wearing a helmet or seatbelt if you were riding a motorcycle or vehicle, respectively, at the time of the accident. You also should not have been intoxicated or under the influence of illegal drugs while involved in an accident. Or you should not have been driving against traffic in a one-way street when you collided with another vehicle. In these situations, when it has been found out that you did not act in accordance with the law and other prescribed rules and regulations, the ER Care product cannot respond to your need for emergency medical care.

Availment of Emergency Medical Services: Telemedicine, ER at Accredited Hospitals, Letter of Authorization

A medical professional will be able to determine if you need emergency medical care. Please do visit icare.com.ph/need-medical-attention-where-to-go to know when it is medically necessary to seek emergency care and why you should avoid the emergency room for non-emergency situations.

ER Care All-In for Kids comes with a special service – it also provides 24/7 telemedicine consultation powered by MyPocketDoctor. Emergency or not, you can avail of a telemedicine consult about any health concern you have for your child within the coverage period. And when you think that your child needs emergency care, it becomes even more important that you seek telemedicine consultation before going to the emergency room. It is to your best advantage to telemedicine consult before you go to the emergency room because you will receive a lot of useful and practical information from the doctor that will help you make a better informed decision to proceed or not proceed to the emergency room.

• Be properly advised if it is medically necessary to seek emergency care
• Assistance in calling for an ambulance
• Receive first aid instructions on your way to the hospital
• Be advised on the nearest accredited hospital
• The doctor can brief the destination hospital on your pending arrival with the details of your medical case
• If the case does not require emergency care, you can proceed to a telemed consultation, receive a prescription for medicines or diagnostic procedures and even a treatment plan – there is no additional cost to you for these services
• Post-diagnostic test, you can share your results with the doctor and proceed with a consultation

At the emergency room, if the doctor determines that your case is non-emergency in nature and/or the diagnosis is not coverable under the ER Care product, you will shoulder all the hospital charges.

Also, it is the medical professionals who will attend to you who will provide the medical diagnosis/diagnoses of your case. They may be able to diagnose you within a short period of time or it may take longer, depending on the factors affecting the case. It is not common but it can also happen that they may provide a diagnosis in the beginning and eventually change it as your condition develops. In the end, it is the final medical diagnosis/diagnoses that we will use to determine if it is covered by the ER Care product under which you are registered.

To facilitate your medical care and based on an initial diagnosis, we may already issue a Letter of Authorization (LoA) to the hospital on your behalf, corresponding to the ER Care product benefit under which you are registered. In the case that the initial medical diagnosis changes to one that is not covered under the ER Care product under which you are registered, we will advise you at the soonest possible time that we will withdraw the LoA from the hospital and that you will have to make your own arrangements with them. We will also reinstate your ER Care product as if it was not used so that it is still available for future medical availment.

The ER Care product is considered availed when Insular Health Care issues an LoA to the hospital. The LoA may be in an amount less than or equal to the maximum amount of benefits of the ER Care product under which you are registered. In which case, please refer below to the table on how the LoA works to address the coverable charges in the hospital bill. Please note that non-coverable charges in the hospital bill are for your account.

When the coverable charges in the hospital bill is less than the maximum amount of benefits	The LoA will act as the guarantee of Insular Health Care to the hospital that the coverable charges will be settled by them. The difference between the maximum amount of benefits and the lower amount of coverable charges will not be given to you, in cash or in kind. Non-coverable charges should be directly settled by you with the hospital
When the coverable charges in the hospital bill is equal to the maximum amount of benefits	The LoA will act as the guarantee of Insular Health Care to the hospital that the coverable charges will be settled by them. Non-coverable charges should be directly settled by you with the hospital
When the coverable charges in the hospital bill is greater than the maximum amount of benefits	The LoA will act as the guarantee of Insular Health Care to the hospital that the coverable charges will be settled by them. The difference between the maximum amount of benefits and the higher amount of coverable charges should be directly settled by you with the hospital. Non-coverable charges should be directly settled by you with the hospital

 

Availment of Hospital Cash Allowance

If you are an adult registered under the ER Care Booster or ER Care All-In product, you can also receive a one-time cash allowance of Php1,000.00 when you are admitted for confinement.

We will process your cash allowance soon after your discharge. When it’s ready, we will let you know so you can claim it.

Section 5 – Data Privacy

It is very important to be able to confirm the identity of the Insular Health Care Member to ensure that your benefits are availed by the correct person. Another important reason is that as your partner in your well-being, we need to be certain about your identity to review and validate the medical treatment requested by your doctor.

For these reasons, we will solicit specific information that we need to be able to record you as a Member and share with our partners, the doctors, clinics, hospitals and telemedicine staff, so that they in turn, can validate your identity. We will handle your data according the standards and requirements set by the Data Privacy Act of 2012.

During the registration process, if you are registering yourself under a specific Insular Health Care product, you shall provide information about yourself. By registering yourself, you certify that the information you provided is accurate and relates to your own identify. Further, you provide your consent to Insular Health Care to solicit, obtain, review and process your Personal Information and Sensitive Personal Information, including records you directly submit to us or as shared to us by our partners like medical professionals, clinics and hospitals. You authorize Insular Health Care to solicit, receive and process these records and information, such as medical and dental consultations, visits to the hospital as an outpatient or inpatient, your medical history, any treatment or any other information about you in relation to your availment of medical and other benefits.

If you registered another person, like a child or an adult under your authority like a specially-abled sibling, you certify that the data are accurate and that you have the legal authority to submit Personal Information and Sensitive Personal Information about them to Insular Health Care. On their behalf, you authorize Insular Health Care to solicit, obtain, review and process their Personal Information and Sensitive Personal Information, including records directly submitted to us or as shared to us by our partners like medical professionals, clinics and hospitals. You authorize us to solicit, receive and process these records and information, such as medical and dental consultations, visits to the hospital as an outpatient or inpatient, your medical history, any treatment or any other information about you in relation to your availment of medical and other benefits.

Section 6 – Disputes: Arbitration, Insurance Commission

We are committed to work with you to stay healthy and recover from any illness. We will handle the availment of your benefits in accordance with accepted Philippine medical standards and in cooperation with you and our medical partners. Should you believe that we were not able to correctly and accurately handle your request for availment of benefits, please do let us know so that we can review our procedures and correct them accordingly. Please feel free to communicate with us through phone, email or a private message on Facebook. We urge you to use any of these methods of communication to preserve your privacy.

As an HMO under the supervision of the Insurance Commission (https://www.insurance.gov.ph/), we comply with their requirements in handling customer concerns. One of the measures they specify is arbitration. After our review and if you still believe that we were not able to satisfy your expectations on the availment of your benefits, we would be happy to refer your complaint to an arbitrator whom we agree upon. If we cannot agree upon a single arbitrator, we can appoint one arbitrator each. If we are still not able to agree on the two arbitrators, the two arbitrators shall select an umpire. If the dispute relates to a medical expertise, we can require that the arbitrator be a licensed medical professional and the umpire would be a senior medical professional like a consultant Specialist or Surgeon. The decision of the arbitration is a condition necessary to any legal action against us.

You may also reach out to the Insurance Commission at any time. The Insurance Commission is the government office in charge of the enforcement of all laws related to Health Maintenance Organizations (HMO) and has supervision over them. It is always ready to assist the public in matters pertaining to HMO, pre-need and insurance. For any inquiries or complaints, please contact the Public Assistance and Mediation Division (PAMD) of the Insurance Commission at 1071 United Nations Avenue, Manila with telephone numbers +63(2) 523 8461 to 70 or email them at publicassistance@insurance.gov.ph. The Insurance Commission also has offices in Cebu and Davao. The official website of the Insurance Commission is www.insurance.gov.ph.

Section 7 – General Provisions, Future Taxes and Fees

FUTURE TAXES, LEVIES AND GOVERNMENT IMPOSITION. If during the effectivity of this Agreement, the fees and benefits are made subject to new taxes, levies or fees, and such law, regulation or its equivalent result in additional obligations on the part of Insular Health Care, any additional amount due shall be charged to the Buyer in addition to the applicable fees. Future taxes, levies or fees referred herein are only those that affect the computation of Membership Fees, other future taxes, levies or government impositions that do not affect the computation of Membership Fees are excluded.

CIVIL CODE, ARTICLE 1250 – WAIVER. The provisions of Article 1250 of the Civil Code of the Republic of the Philippines (Republic Act No. 386) which reads, “ln case an extraordinary inflation or deflation of the currency stipulated should supervene, the value of the currency at the time of establishment of the obligation shall be the basis of payment”, shall not apply in determining the extent of liability under the provisions of this Agreement.

RIGHT OF SUBROGATION. The coverage under this Agreement is extended to cover injuries of the Member caused by third party(ies) whether liability is determinable or not as in cases of vehicular accidents and other similar instances or related incidents including but not limited to all the claims, losses, damages which may be recovered by the Member or which may have been paid to or due him as a result of the illness or disability which have been paid by Insular Health Care pursuant to the Terms and Conditions of this Agreement and that the Member will subrogate his rights of recovery from any other party to Insular Health Care and will undertake to assist the latter in the successful recovery of the losses.

GOVERNING LAW. This Health Care Agreement shall be governed by and construed in accordance with the laws of the Republic of the Philippines.

Section 8 – Keeping in Touch

We always want to stay in touch with you. Please do add our email address to your directory o avoid our emails being classified as spam. Through email, through notices posted repeatedly on our website and social media accounts, we will communicate any information pertinent to the Insular Health Care products you have purchased. Please do update us of any change in your email address and other contact information so that you do not miss out on any important notices. Please find below a list of the notices we may send through email and possibly through SMS.

• Confirmation of your purchase
• Confirmation of your successful registration
• Confirmation of your availment
• Confirmation of your product’s termination
• Notification of your product’s upcoming expiry
• Changes in the Health Care Agreement

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