iCare Medical Plans for Families

Nationwide Access with access to Top 6 Hospitals

• Top 6 Hospitals – Asian Hospital and Medical Center, Cardinal Santos Medical Center, Makati Medical Center, St. Luke’s Medical Center (QC and BGC) and The Medical City

Nationwide Access without access to Top 6

Luzon Access only (excluding NCR)

VisMin Access only

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 and shall apply to dreaded and non-dreaded diseases.

• Minimum of Php 10,000 in coverage
• Maximum of Php 50,000 in coverage

In accordance with Insular Life Group Term Policy No. G – 014175 dated 15 January 1999 and all of its succeeding endorsements, any individual with adverse medical findings shall automatically be covered for one-half (1/2) of coverage of a standard risk for deaths due to natural causes and one hundred percent (100%) of coverage for deaths due to accident.

1. Dental Benefits

To avail of this outpatient benefit, 100% participation of all qualified enrollees is required.

• Any number of consultations on dental problems including but not limited to lesions, wounds, burns, and gum problems (during clinic hours and by appointment)
• Annual Oral Prophylaxis (mild to moderate cases)
• Unlimited simple tooth extractions, except surgery for impaction or extraction of impacted tooth or complicated extractions involving the use of other dental instruments aside from pliers and/or the re-administration of anaesthesia
• Unlimited temporary fillings
• Unlimited re-cementation of fixed bridges, jacket crowns, inlays and onlays (limited to 4 abutments)
• Dental education and counseling during consultations
• Simple adjustments of denture clasps
• Any number of consultations/dental examinations including treatment of lesions, wounds, burns, gum and other dental problems except diagnostics, prescribed medicines, surgeries and “root canal” procedures
• No limit as to the number of abutments covered (on item 5 above)
• Orthodontic consultations
• Aesthetic dental consultations
• Emergency desensitization of hypersensitive teeth
• Option to choose between three (3) surfaces of amalgam fillings or two (2) lightcure filling

The following procedures and modalities are subject to the inner limits when specified, otherwise Actual Cost, subject to MBL.

Coverage is subject to the Maximum Benefit Limit per person per illness or injury per year.

1. Neurological disorder
2. Blood dyscracia
3. Collagen/Immunological disorder
4. Liver Cirrhosis
5. Chronic Pulmonary/Renal disorder
6. Cardiovascular disorder
7. Cancer
8. Any condition which necessitates the use of Intensive Care
9. Unit subject to other limitations
10. Accidental injuries
11. Other conditions causing partial or total organ damage or failure

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

1. Any professional advice or treatment was given for such illness or condition
2. Such illness or condition was in any way evident to the member
3. 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:

1. PECs are covered provided that the PECs are not considered part of the “Permanent Exclusions to Health Care Coverage”, and that
   1. such PECs were declared by the member in the original application;
   2. such PECs are unknown to the member (without established medical history);
2. Undeclared PECs with established medical history are excluded from coverage. However, said PECs may be evaluated for possible future consideration.
3. 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

1. Hernias
2. All tumors and malignancies involving any body organ or system
3. Endometriosis, Dysfunctional Uterine Bleeding
4. Hemorrhoids
5. Diseased tonsils requiring surgery
6. Pathological abnormalities of the nasal septum and turbinates
7. Thyroid Dysfunction/Goiter
8. Cataract
9. Sinus condition requiring surgery
10. Asthma / Chronic Obstructive Pulmonary Disease
11. Cirrhosis of the liver
12. Tuberculosis
13. Anal Fistula
14. Cholelithiasis / Cholecystitis
15. Calculi of the urinary system
16. Gastric or Duodenal Ulcer
17. Hallux Valgus
18. Diabetes Mellitus
19. Hypertension
20. Collagen Disease / Auto Immune Disease
21. Cardiovascular Disease
22. Hormonal Dysfunction
23. 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:

1. Organ transplants and/or open-heart surgery / angioplasty and all services (e.g., coronary angiogram) related thereto (except organ donor services)
2. AIDS and AIDS-related diseases except when sexually transmitted
3. Congenital abnormalities and conditions are covered up to Php 10,000.
4. Chronic glomerulonephritis, gullain-barre syndrome
5. Consultations for Scoliosis, Spinal Stenosis and Kyphosis are covered.
6. For Vitiligo and Psoriasis, only consultations are covered.

1. Care by non-accredited Physician and/or in a non-preferred hospital/ clinic, except in emergencies wherein the emergency provision of the Agreement will apply
2. All pregnancy related conditions requiring medical/surgical care and screen tests related thereto
3. All dental related services not expressly stipulated in the Dental Rider Endorsement
4. Sterilization of either sex or reversal of such, artificial insemination, sex transformations or diagnosis and treatment of infertility, and circumcision
5. Rest cures, custodial, domiciliary or convalescent care
6. Cosmetic surgery, dental/oral surgery and dermatological procedures for the purpose of beautification except reconstructive surgery to treat a dysfunctional defect due to disease or accident
7. Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, stress related conditions, adjustment disorders, alcoholism and its complications or conditions related to substance or drug abuse, addiction & intoxication
8. Sexually transmitted diseases
9. Medical and surgical procedures which are not generally accepted as standard treatment by the medical profession like acupuncture
10. Procurement or use of corrective appliances, artificial aids, durable equipment, and orthopedic prosthesis and implants
11. Surcharges resulting from additional personal (luxuries/ accommodation) request or service including special nursing services
12. Physical examination required for obtaining employment, certification for whatever legal purpose it may serve, insurance or a government license
13. Injuries or illnesses due to military, paramilitary, police service, high risk activities, or suffered under conditions of war
14. Reimbursement of procedures obtained through government programs
15. 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 laws, administrative order or ordinances
16. Take-home medicines
17. Valvular Heart Disease and Rheumatic Heart Disease
18. Medico-legal consultations and confinement
19. When a member is discharged against medical advice, current and all subsequent benefits/services related thereto
20. Blood/Organ-Donor screening/other screening procedure that are purely diagnostic or for screening purposes including, among others, Purified Protein Derivative (PPD), and procedures conducted prior to hormonal replacement therapy
21. All hospital charges and professional fees after the day and time the hospital discharge had been duly authorized
22. Professional fees of Assistant Surgeon
23. All confirmatory tests used to document health conditions not covered under the Agreement
24. Conditions excluded by medical underwriting
25. Concealment cases
26. Diseases declared by the Department of Health (DOH) as Epidemic
27. Use of Emergency room Facilities on non-emergency cases or by reason of conditions/injuries not falling under the term “Emergency”. 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 & discomfort. For the purpose of implementation, the final diagnosis shall be the basis for a member’s eligibility to emergency care benefits under the Agreement
28. 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

15 days old to below 60 years old

FOR FAMILY PLAN:

A. Principal members: at 18 years old to below 60 years old.

B. Dependents: (Following Hierarchy Guidelines)

• For single principal: Parent(s) first who is/are less than 60 years old and not gainfully employed; followed by the eldest sibling down to the youngest who is/are 15 days to less than 21 years old, unmarried and not gainfully employed.
• For single parent: Eldest child down to the youngest, 15 days to less than 21 years old, unmarried and not gainfully employed.
• For married individuals: Spouse first who is less than 60 years old; followed by the eldest child down to the youngest, 15 days to less than 21 years old, unmarried and not gainfully employed.

• 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, the client should return the ID card(s). Any misuse of the ID card by a member will be for the account of the member.

• Payment should be on or before due dates corresponding to a mode pre-selected by the client.
• Non-receipt (by the client) of a billing notice does not constitute a valid reason for non-payment of membership fees.
• Non-payment of Membership Fees for 31 days from due date will automatically void the “Agreement”.
• Benefits under the “Agreement” are allowed only if membership fees have been paid PRIOR to availment of such benefits.
• If for any reason the Insular Health Care membership is pre-terminated, the member must surrender to Insular Health Care his ID card.

Effective date of coverage for InHealth Persona is every 1st and 16th of the month.