PROVISIONS UNDER CONTRACTS ISSUED PRIOR TO JANUARY 1, 2020

PROVISIONS UNDER CONTRACTS ISSUED STARTING JANUARY 1, 2020

This Agreement, together with the Data Page, amendments, the attached Client’s application and the individual application, if any, of the persons enrolled, constitute the entire Agreement between the parties.

The Agreement may at any time be amended and changed by written agreement between Insular Health Care and the Client. Any such amendment shall take effect only upon endorsement on this Agreement and shall be binding on all persons enrolled under this Agreement whether they become enrolled prior to or on or after the effective date of the amendment.

Only the chairman of the Board, the President or any persons authorized by the Board of Directors may alter/modify this Agreement and only in writing.

Insular Health Care, Inc. (“InLife Health Care”), as a duly registered Health Maintenance Organization under the Insurance Commission (IC), has offered and the Client has agreed to engage the services of InLife Health Care to extend healthcare and health maintenance services to its employees and their dependents, as the case may be, upon enrollment and payment of the appropriate Membership Fees in such amount and manner as stated in this Agreement.

This Agreement together with the attached Coverage Proposal/Renewal Proposal with signed Conformé, Summary of Benefits (SOB), Riders or rider clauses, Application Forms if applicable, and any other endorsement(s) as indicated in the Data Page which is also attached to this Agreement, constitute the entire Health Care Agreement. All statements and information contained in the Application Form shall be deemed representations and warranties made by the applicant himself for purposes of applying the provisions of this Agreement.

Only the Chairman of the Board, the President, or any persons authorized by the Board of Directors of InLife Health Care may effectuate the amendment/modification to this Agreement and such shall only be done in writing.

Definition of Terms

“Client” shall mean the owner of this policy or the person with whom this Agreement is entered into.

“Member” shall mean any person who is enrolled and eligible for the health care benefits under this Agreement.

“Maximum Benefit Limit”- shall mean the maximum amount payable for the period of the Agreement, per Member per illness or injury per year (as stated in the Data Pages).

“Accredited Hospital” shall mean any (other) hospital as may be recognized by Insular Health Care from time to time for the purpose of the Agreement.

“Physician” shall mean any person legally authorized to render medical and surgical services in the geographical area of his/her practice.

Definition of Terms

“Client” shall refer to the legally existing corporate or group entity which is actually the owner of this Agreement.

“Member” refers to a Principal Member and/or Dependent who is eligible, has been accepted by InLife Health Care after complying with the Eligibility provisions and is currently enrolled under this Agreement.

“Maximum Benefit Limit (MBL)” refers to the maximum liability that InLife Health Care shall cover and assume per covered Illness or injury of a Member per year as stated in the Data Page. The MBL is replenished upon renewal of this Agreement but not during extension.

“Accredited Hospital” refers to a duly licensed hospital included in the list of accredited hospitals of InLife Health Care with which InLife Health Care has an existing and valid service agreement and where a Member can avail of medical services pursuant to this Agreement.

“Physician or Surgeon” refers to the person qualified by degree and duly licensed or registered to practice medicine in the geographical area in which he serves. This person must not be a relative of the Member up to the third degree of consanguinity and affinity.

Additional definitions:

“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.

“Accredited Clinic” refers to a duly licensed medical health care facility included in the list of accredited medical clinics of InLife Health Care which has an existing and valid accreditation agreement with InLife Health Care and where a Member can avail of medical services pursuant to this Agreement.

“Actively at Work” ordinarily refers to a circumstance where an employee is actually ready, available, and able to perform work, but it shall also refer to those who: (i) is on a regular paid vacation leave as certified by the Client or on paid non-working day; (ii) is not absent from work due to sickness, injury or other form of Disability; (iii) was actively at work on the last preceding regular working day prior to the Effective Date of this Agreement.

“Annual Benefit Limit (ABL)” refers to the maximum liability that InLife Health Care shall assume for all covered services rendered to a Member within the one-year term of this Agreement. The ABL is replenished upon renewal of this Agreement but not during extension.

“Benefits Classification” refers to the program type, room accommodation and Maximum Benefit Limit/Annual Benefit Limit stated in the Data Page.

“Contributory Member” refers to a Member whose Membership Fee is fully or partially paid for by the Member.

“Custodial Care” refers to the care which is primarily for the purpose of assisting the Member in the activities of daily living or in meeting personal rather than medical needs, which is not specific therapy for an illness or injury and is not skilled care.

“Developmental / Congenital Condition” refers to a medical abnormality existing at the time of birth as well as neonatal physical or mental abnormalities developing thereafter because of causal factors or conditions present at the time of birth.

“Disability” refers to an illness or injury and any symptoms, sequelae, or complication thereof requiring treatment.

“Expiry Date” refers to the date the Agreement is scheduled to terminate which is one (1) year from the Effective Date.

“Letter of Authorization” refers to a letter duly issued by InLife Health Care to, and signed by, the Member which shall serve as the authority of the latter to avail of the medical services.

“Material Information” An information is deemed material if its disclosure would have resulted in the (a) declination of the application for Membership of the applicant (b) the assessment of a higher Membership Fee or (c) the inclusion of additional restrictions and exclusions to the benefits of the Member under this Agreement.

“Medically Necessary Service/s” is/are medical service/s, as determined by InLife 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.

“Membership Card” refers to the card issued by InLife Health Care to a Member containing the latter’s name, ID number and other matters pertaining to his Membership.

“Membership Fees” shall refer to the fees for the enrollment of the Members, as specified in the Data Page – Membership Fees of this Agreement.

“Non-Contributory Member” refers to a Member whose Membership Fee is fully paid for by the Client.

“Plan A” refers to a program type which has open access to accredited hospitals. Under this program type, a member may use any InLife Health Care accredited hospitals nationwide.

“Plan B” refers to a program type of a preferred hospital. Under this program type, a Member will have to select and strictly use his preferred hospital except during emergencies (as defined in this Agreement) whereby he may use any InLife Health Care accredited hospitals nationwide. Use of non-accredited hospital for emergency care shall be governed by the Emergency Benefits provision of the Agreement.

“Professional Fees” refers to the fees paid to licensed medical professionals including but not limited to an Occupational Therapist, Physiotherapist, Attending Physician’s visits or Pathologist.

“Room Accommodation” refers to the pre-assigned type of hospital room accommodation by InLife Health Care to the Member based on the benefit stated in the Data Page.

“Specialist” refers to a Physician who has completed the prescribed training in a particular field of medicine.

“Statement of Account / Billing Statement / Billing Letter ” refers to the document duly issued by InLife Health Care on or before the due date of payment reflecting Membership Fees and other monetary obligations, if any, payable by the Client.

“Surgery” refers to that branch of medicine dealing with manual or operative procedures for the correction of deformities and defects, repair of injuries, diagnosis and cure of certain diseases. This includes surgery performed in an outpatient setting for a covered Illness or Injury.

Enrollment/Approval of Application

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 Membership 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.

 Enrollment/Approval of Application

Each eligible person applying for coverage is required to accomplish an application form. Otherwise, there will be no coverage despite having paid a deposit for membership fees. It is understood that InLife Health Care reserves the absolute right to approve or disapprove any application for membership. Enrollment of Dependents must be simultaneous with the Principal. Further, such Dependents’ coverage should be equal to or lower than the Principal’s Room Accommodation/ Program Type (Plan A or Plan B).

In case an application or membership renewal is disapproved due to adverse medical condition, an applicant or member may still avail of the InLife 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 result to exclusion of the condition for which an underwriting requirement has been prescribed.

Membership Fee

Membership fee is due and payable on the Effective Date of the Agreement. However, when Membership fee is payable on a modal scheme, payment thereof should be made on or before the Due Date 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 thirty-one (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.

Membership Fees

The Membership Fees are due on the effective date of this Agreement and every month thereafter for monthly mode of payment, every quarter thereafter for quarterly mode of payment and every semester thereafter for semi-annual mode of payment. The Membership Fee due on any due date shall be the aggregate of the Membership Fees for all Members enrolled under this Agreement.

The Membership Fees of members added after any due date and any adjustments in the Statement of Account (SOA), such as addition or deletion of members, upgrading or downgrading of plan, errors and changes still under process, shall be reflected in another SOA to be given within thirty (30) days from the date the advice from Client is received by InLife Health Care.

Should there be any dispute, contest or conflict regarding the SOA on any substantial matter appertaining thereto, Client shall pay twenty percent (20%) of the sum demanded on or before the due date, notwithstanding such dispute, contest or conflict, unless Client shows proof of significant error on any substantial matter stated in the SOA. For this purpose, significant error means an error that would affect at least 25% of the total amount due. Upon resolution of the dispute, contest or conflict, the adjustment, if any, shall be reflected in another statement of account to be given within seven (7) days from the date of dispute, contest or conflict was settled by Client and InLife Health Care. In this regard, a full payment of such adjusted SOA shall be made fifteen (15) days from the time of receipt of such adjusted SOA.

The absence of any written notice to InLife Health Care regarding dispute, contest or disagreement in the details contained in the SOA seven (7) days from receipt thereof shall constitute Client absolute agreement thereof.

Non-Accredited Clinic/Hospital in the Philippines

In case of emergency treatment/confinement in a non-accredited hospital/clinic, Insular Health Care shall reimburse up to 80% of the usual and customary fees which the Insular Health Care preferred or accredited hospital would charge for such treatment or confinement in accordance with the Benefits Classification of the Member or P 10,000 for hospital charges and P 5,000 for professional fees (or a total of P 15,000), whichever is less, provided that the illness or condition is covered under the Agreement, and provided further, that the Member follows the Benefit Availment Procedures.

Non-Accredited Clinic/Hospital in the Philippines

In case of emergency treatment/confinement in a non-accredited hospital/clinic, InLife Health Care shall reimburse up to 80% of the usual and customary fees which the InLife Health Care preferred or accredited hospital would charge for such treatment or confinement in accordance with the  Benefits Classification of the Member or a standard limit of Php30,000 whichever is less, provided that the illness or condition is covered under the Agreement, and provided further, that the Member follows the Benefit Availment Procedures.

Medical Facility Outside the Philippines

In case of emergency treatment/confinement in a medical facility outside the Philippines during official business trips, Insular Health Care shall reimburse up to 80% of the usual and customary fees which the Insular Health Care preferred or accredited hospital would charge for such treatment or confinement in accordance with the Benefits Classification of the Member or P 10,000 for hospital charges and P 5,000 for professional fees (or a total of P 15,000), whichever is less, provided that the illness or condition is covered under the Agreement, and provided further, that the Member follows the Benefit Availment Procedures.

 Medical Facility outside the Philippines

In case of emergency treatment/confinement in a medical facility outside the Philippines during official business trips, InLife Health Care shall reimburse up to 80% of the usual and customary fees which the InLife Health Care preferred or accredited hospital would charge for such treatment or confinement in accordance with the Benefits Classification of the Member or a standard limit of Php30,000 whichever is less, provided that the illness or condition is covered under the Agreement, and provided further, that the Member follows the Benefit Availment Procedures. Any reimbursement shall be computed based on the exchange rate conversion at the date of availment.

Ambulance Services

Hospital to hospital ambulance services is available as part of emergency care benefits but is limited to a standard rate of Php3,500 per conduction.

Pre-existing Conditions Covered

Pre-existing Conditions are not covered in the first year. After the Member has been continuously covered with Insular Health Care for 12 months and this Agreement is renewed, Pre-existing Conditions (PECs) are covered, provided that, such 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. Only PECs unknown to the member (without established medical history) will be covered. Undeclared PECs with established medical history are excluded from coverage. However, said PECs may be evaluated for possible future consideration.

If there is a failure to disclose or if there is misrepresentation of any material information in the original application, this Agreement is automatically invalidated under the “Invalidation of Agreement” clause.

Pre-existing Conditions

Pre-existing Conditions are not covered within one year from Effective Date. After the Member has been continuously covered with InLife Health Care for twelve (12) consecutive months, and this Agreement is renewed, Pre-existing Conditions (PECs) may be covered, provided that, such 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 or renewal application. Only PECs unknown to the Member (without established medical history) will be covered. Undeclared PECs with established medical history are excluded from coverage. However, said PECs may be evaluated for possible future consideration.

This provision shall not however apply to illness or conditions specifically excluded by an endorsement which is made part of this Agreement.

The following health conditions may be covered (either fully or up to certain amount) provided that pre-existing conditions of a Member are likewise covered:

(a)   Organ Transplant and/or Open-Heart Surgery and all services related thereto (except organ donor services);

(b)   AIDS and AIDS-related diseases except when sexually transmitted;

(c)   Congenital Abnormality and/or Condition are covered up to Php 25,000 per year;

(d)   Chronic Glomerulonephritis, Gullain-Barre Syndrome;

(e)   Scoliosis, Spinal Stenosis and Kyphosis are covered up to Php 25,000 per year. For all other physical deformities, only consultations are covered;

(f)    For Vitiligo, Psoriasis, only consultations are covered.

Diagnostic procedures undertaken to determine the existence of a Pre-existing Condition is a covered expense provided that the result of diagnostic procedure is negative for the existence of the pre-existing condition.

Coordination of Benefits

 Benefits will not exceed the total medical expenses when combined with other health care or medical coverage in force or organizations or which are provided free of charge in government or private facilities.

 Reimbursement of Claims

In cases where InLife Health Care covered costs were not deducted from the medical bills and a Member is made to pay for the health care cost, a Member may request for reimbursement of such costs which are covered under the Agreement. The request must be made on the prescribed claim form to which shall be attached official receipts, together with supporting charge slips, detailed itemized accounts and other necessary documents. No reimbursement shall be made to the Member unless such original documents are submitted by the Member or if the Member has otherwise been fully indemnified or reimbursed of the medical bills or costs incurred under any other health care coverage or insurance policy or any other similar contracts or Agreements. Requests must be presented within sixty (60) days from date of discharge or date of availment. Failure to submit within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time.

InLife Health Care will process the payment of all claims within thirty (30) days upon receipt of complete documents and in accordance with the terms of the Agreement. All benefits that pertain to a Member will be paid by check to the order of such Member and in instances of a Dependent, to the Principal Member. InLife Health Care, in its discretion, may make the payment in another manner if it considers it more practicable. In case of death of a Member, any benefit due but remaining unpaid shall be paid to the first surviving class of the following classes of successive preference of beneficiaries: the Member’s (a) widow or widower; (b) surviving children; (c) surviving parents; (d) surviving brothers and sisters; and, (e) executors or administrators.

 Request for Reconsideration

 If a claim for reimbursement is denied, or the Member is not satisfied/agreeable to the reimbursement paid by InLife Health Care, a written request for reconsideration must be filed with Head Office not later than ten (10) days from receipt of such denial or questioned reimbursement. Otherwise, the claim shall be deemed satisfied or terminated. The request for reconsideration shall contain all the reasons upon which reconsideration is sought and shall be decided upon by an authorized personnel of InLife Health Care, whose decision shall be final. InLife Health Care reserves the right to deny Claims for Reimbursement if the procedures and requirements have not been strictly complied with.

 Fraudulent Claims

If any claim under this Agreement is in any respect fraudulent, all benefits payable and/or paid in relation to that claim shall be forfeited and if deemed appropriate, recoverable respectively.

Physical Examination and Autopsy

InLife Health Care shall have the right and opportunity to examine the Member when and as often as it may reasonably require during the pendency of claim hereunder, and the right and opportunity to make an autopsy in case of death, where it is not forbidden by law.

 General Limitations to Benefits

10. No Access to Healthway Medical Clinics, Inc. and American Eye Center.

 Permanent Exclusions to Health Care Coverage

xxx..xxx..xxx

4. Sterilization of either sex or reversal of such, artificial insemination, sex transformations, or diagnosis and treatment of infertility, and circumcision (except for treatment of urological conditions).

xxx..xxx..xxx

20. Organ or Blood donor screening and other screening services that are purely diagnostic or for screening purposes including among others, Purified Protein Derivative (PPD), and procedures conducted prior to hormonal replacement therapy.

21. Organ Donor Services for organ transplants and/or open-heart surgery and all services related thereto.

22.   All hospital charges and professional fees after the day and time hospital discharge have been duly authorized.

23.  Professional fees of assistant surgeons.

24. Conditions excluded by medical underwriting.

25. Concealment cases.

VII. ELIGIBILITY and MEMBERSHIP

The following shall be the eligibility requirements for Membership under this Agreement and where applicable the eligibility of Dependents as an optional coverage, as appearing in the Data Page.

1.   Principal Members

a.     All regular employees actively at work, in case where Client is an employer;

b.     Must at least be 18 years of age but not more than 65 old;

c.     Any employee, whose employment status has become regular after the effective date stated in this Agreement, shall be eligible for coverage;

d.     Similarly situated persons although no employer-employee relationship exist.

2.   Dependents of Principal. (Following Hierarchy Rule)

a.   For Married Principal Member – The legal spouse who is less than sixty five (65) years old as of effective date of Agreement and his natural born or legally-adopted children who have attained the age of fifteen (15) days and less than twenty-one (21) years old as of effective date of Agreement, unmarried and not gainfully employed or earning an income and fully dependent upon the Principal Member for support.

b.   For Single Principal Member– Parent(s) who is/are less than sixty five (65) years old as of effective date of Agreement and not gainfully employed and siblings who have attained the age of fifteen (15) days and less than twenty-one (21) years old as of effective date of Agreement, unmarried and not gainfully employed or earning an income and fully dependent upon the Principal Member for support.

c.   For Single Parent Principal Member – Children who have attained the age of fifteen (15) days and less than twenty-one (21) years old as of effective date of Agreement, unmarried, not gainfully employed or earning an income and fully dependent upon the Principal Member for support.

3.   Hierarchy Rule for Selecting Qualified Dependents. For Married Principal Members, the spouse must be enrolled first followed by children applying their birth rank. For Single Principal Members, the parents must be enrolled first followed by the siblings applying also their birth rank. For Single Parent Principal Member, eldest child down to the youngest.

Dependents should be enrolled simultaneously with Principal members.

If the Dependent is sick or has a present medical condition at the date of enrollment, the coverage becomes effective on the day immediately following recovery from such illness or medical condition.

Accommodation/Benefit Plan of Dependents must follow a uniform category pre-established by the Client at the start of the health care program; and must be equal to or lower than the Principal’s accommodation/benefits plan

Whenever a Principal Member who has voluntarily terminated his/her Dependent’s coverage but has remained eligible, re-apply for such coverage, the coverage of the Dependent shall become effective upon renewal of the Agreement subject to approval by InLife Health Care.

InLife Health Care reserves the right to require at any time the submission of such documents which it may deem appropriate for the purpose of validating the eligibility of Principal Members and their Dependents.

 Addition and Cancellation of Membership

 The procedure on addition and cancellation of Members shall be subject to the following conditions:

a.   Client shall submit all the required information of additional enrollees to InLife Health Care.

b.   The Client’s authorized representative shall duly endorse the list of enrollees to ensure accuracy and security of data.

c.   The Effective Date of Member’s coverage shall be subject to the following conditions:

c.1.    Change of Effective Date within the coverage period shall not be allowed.

c.2.    InLife Health Care reserves the right to accommodate requests for late enrollment.

c.3.    Effective date of an enrollee’s coverage shall be based on the completion and receipt by InLife Health Care of all requirements.

c.4.    Should the effective date of coverage depend on the date of regularization of the employee, Client shall ensure that the endorsement is made prior to the date of regularization or within thirty (30) days thereafter. The Effective Date of coverage shall then follow the date of regularization or the date of endorsement, whichever is later.

d.   All additional enrollees/dependents must be endorsed within thirty (30) days from the Effective Date and they shall follow the original/renewal Effective Date of coverage Additional enrollees beyond this period shall be considered in the next renewal period except for newly regularized employees, newly-wed spouse and newly-born dependents whose coverage is effective from the date of eligibility or the date of endorsement, whichever is later.

e.   ln case of a member’s resignation, termination, separation or retirement, Client shall notify InLife Health Care in writing prior to the cancellation of membership. The cancellation shall be based on the Member’s cancellation date as advised by the Client or the date of receipt of notice by InLife Health Care, whichever is later. Client shall also cause the return and surrender of the membership card to avoid fraudulent claims.

Upgrading/Downgrading of Plan

Upgrading or downgrading a Member’s plan due to change in Member’s classification (rank, position, assignment) shall be subject to the following conditions:

a.   Client notifies InLife Health Care in writing.

b.   The Effective Date of the upgrading/downgrading of the plan shall be the date as endorsed by the Client.

c.   In case of upgrade of plan, Client shall pay the additional Membership Fee corresponding to the effective date of the upgraded plan. ln case of downgrade, InLife Health Care shall refund the excess Membership Fee corresponding to the effective date of the downgraded plan. There shall be no refund of excess Membership Fee if the member has availed any benefits pursuant to this Agreement.

Free Look Provision

By giving a written notice within fifteen (15) days from Effective Date of the Agreement, Client may cause the termination of this Agreement provided the membership cards and this Agreement are surrendered to InLife Health Care within the same period. InLife Health Care shall thereafter terminate the Membership and the termination provision of this Agreement shall apply. InLife Health Care shall return any Membership Fee paid. Failure to terminate this Agreement within the period set or any availment of a Member within the 15-day period shall be understood as an acceptance of all terms and conditions provided hereunder.

Invalidation of Agreement

Failure to disclose, or misrepresentation of, any material information by the Client or any applicant for membership in the application or medical examination shall automatically invalidate the Agreement and/or the corresponding coverage from the very beginning. Such invalidation applies whether the non-disclosure or misrepresentation was intentional or unintentional. In case of invalidation, the liability of Insular Health Care shall be limited to a return of all Membership Fees paid less cost of previous services rendered or amount already refunded.

            An undisclosed or misrepresented information is deemed material if its revelation would have resulted in the declination of the applicant by Insular Health Care or the assessment of a higher Membership Fee for the benefits applied for, or the inclusion of additional restrictions to the benefit or benefits applied for.

Termination of Agreement by the Client

The Client may terminate this Agreement for justifiable reasons at any time by giving a written notice to InLife Health Care at least thirty (30) days prior to the intended termination date. However, termination of this Agreement is allowed only if the Client is not in default in the performance of its obligations, or it has not violated any of its warranties and representations. Starting on the termination date, InLife Health Care shall be free from all liabilities to the Client, Members, and/or their Dependents. This shall be without prejudice to the right of InLife Health Care to collect Member’s obligations which have become due and demandable.

Termination of Agreement by InLife Health Care

InLife Health Care shall have the right to immediately terminate this Agreement in the event that it has discovered any material misrepresentation or false warranty made by the Client or Member relative to the procurement of this Agreement. Termination of Coverage of a Member may also be effected by InLife Health Care if Member commits any act with the intent to defraud InLife Health Care.

Moreover, this Agreement may be terminated due to non-payment of Membership Fees and other obligations subject to agreed payment terms. All medical services and coverage under this Agreement shall terminate on the termination date, without prejudice to any claim for covered medical services rendered to a Member prior to the termination date.

Termination under this provision shall be without prejudice to the right of InLife Health Care to collect the Member’s obligations which have become due and demandable.

Termination of Member’s Coverage

The Member’s coverage shall automatically terminate on the earliest of the following dates:

1.   The date the Agreement terminates;

2.   The date a Member ceases to be eligible for coverage under the Agreement; However, when the Member’s age exceeds the maximum permissible age, coverage will continue until Expiry Date.

3.   The expiration date of the period for which Membership Fee payment is made;

4.   The date on which the Member enters military, para-military or police service;

5.   Effective immediately, when the Member has fraudulent availment or material misrepresentation or misstatements for the purpose of availing the benefits;

6.   If the Client is an employer and the Member is an employee of the Client:

6.1      On the date the employee is retired or pensioned;

6.2      On the date the employee resigns, or is dismissed or otherwise ceases to be an employee of the Client;

6.3      On the day the paid leave of absence benefit granted by the Client is exhausted by an employee who is on an extended leave of absence;

7.   For a Dependent Member:

7.1     On the date the covered Dependent ceases to be eligible as Dependent as set forth under the Eligibility provision;

7.2     The date the Principal’s personal coverage under the Agreement terminates.

The termination, however, shall not prejudice any claim for covered health services provided prior to the applicable termination date.

Invalidation of Membership Coverage

The Client must ensure to inform the Member that failure to disclose any material information, including but not limited to gender, date of birth, hierarchy, Dependent Member’s relationship, or medical information, whether intentional or unintentional, shall automatically invalidate the coverage.

There shall be no refund of paid Membership Fees if invalidation is due to fraud.

Civil Code, Article 1250 (Waiver)

The provisions of Article 1250 of the Civil Code (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.

New Taxes and Government Laws

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 InLife Health Care, any additional amount due shall be charged to the Client in addition to the Fees stated herein. 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.

XII. GENERAL PROVISIONS

Maximum Benefit Limit Provision

The Maximum Benefit Limit (MBL) per person per illness or injury per year is the cost of health care benefits a member is entitled to under his health care program as indicated in the Data Page of this Agreement. The MBL applies to both dread and non-dread diseases.

Annual Benefit Limit Provision

The Annual Benefit Limit (ABL) per person per year is the cost of health care benefits a Member is entitled to under his health care program as indicated in the Data Page of this Agreement. The ABL applies to both dread and non-dread diseases.

Downgrading of Room Accommodation

Availment of a room accommodation lower than the Member’s Room and Board Accommodation can be done at the option of the Member but there shall be no refund or offsetting for the cost difference in room accommodation and other related medical benefits.

Room Upgrading and Incremental Rate Differences

If A Member is confined in a hospital room of higher category than his Room and Board Accommodation within InLife Health Care accredited network for whatever reasons except during Emergency Care referred to under Benefit provisions, incremental rate difference and excess charges due to voluntary or involuntary room upgrading shall be charged to the Member, in accordance with the following:

1.     For covered hospital charges or ancillaries, the Member shall pay the amount equivalent to twenty percent (20%) of such charges.

2.     For Professional Fees, the Member shall pay the difference between the allowable professional Fees (PF) of the occupied or upgraded room and allowable PF of Member’s room entitlement based on InLife Health Care’s Schedule of Professional Fees.

3.     For Room and Board charges, the Member shall pay the difference between the actual rate of the room occupied and the allowable room rate.

4.     Room upgrade shall not be allowed for Suite Accommodation.

 Excess Charges

 Any availment that is not covered but is advanced by InLife Health Care shall be charged to the Member and the Member shall be liable to pay such advances. These shall include but not limited to the following:

1.     Benefit availment of lapsed or cancelled Members even if approved by InLife Health Care

2.     Hospital bills and professional fees that are in excess of InLife Health Care rates.

3.     Amount in excess of the MBL/ABL and other inner limitations.

4.     Availment that is not intended to be covered by InLife Health Care, such as exclusions, fraudulent availments, non-coverable items, telephone calls, additional beds, etc.

If the excess charges are not paid after the due date, InLife Health Care reserves the right to suspend all services to the Member until the excess charges due, including penalty charge, have been paid and settled.

 Non-transferability

All benefits in this Agreement are not transferable or assignable. A Client may not assign any of its rights or delegate any of its obligations under this Agreement without the prior written consent of InLife Health Care. InLife Health Care may assign any of its rights or delegate any of its obligations upon written notice to Client. Any purported assignment or delegation in violation of this Agreement is null and void.

 Authority to Examine Medical Records

Client hereby represents and warrants that, at the time of the effectivity of this Agreement and effectivity of coverage of each Member and his/her Dependents, it has obtained from such Member and his/her dependents the required consents authorizing InLife Health Care and any of its authorized representatives to: (a) obtain, examine and process the Member’s personal information, including the medical records of their hospitalization, consultation, treatment or any other medical advice in connection with the benefit claim availed under this Agreement; and (b) disclose such information to the Client and its representatives.

It is hereby agreed that it is the sole responsibility of the Client to obtain from the Members the consent herein specified and that InLife Health Care shall have all the right to rely on the representation by the Client that this consent shall have been duly and timely obtained. The Client shall hold InLife Health Care free and harmless from and against any and all suits or claims, actions, or proceedings, damages, costs and expenses, including attorney’s fees, which may be filed, charged or adjudged against InLife Health Care or any of its directors, stockholders, officers, employees, agents, or representatives in connection with or arising from the use by InLife Health Care of the Member’s medical records and other personal information pursuant to this Agreement and disclosure of such information to the Client and its representatives pursuant to InLife Health Care’s reliance on the Client’s representation and warranty that InLife Health Care has the authority to examine, use or disclose, as the case may be, said medical records or personal information.

 Confidentiality

 Client, Members and/or Dependents, agents or representatives, shall not use or reproduce, directly or indirectly any Confidential Information for the benefit of any person, or disclose to anyone such Confidential Information without the written authorization of InLife Health Care, whether during or after the term of this Agreement, for as long as such information retains the characteristics of Confidential Information.

“Confidential Information” means any data or information, that is proprietary to InLife Health Care and not generally known to the public, whether in tangible or intangible form, whenever and however disclosed, including, without limitation, (i) personal information, treatments or operations undergone by its Members, (ii) trade secrets, confidential or secret formulae, special medical equipment and procedures, (iii) medical utilization reports, directly or indirectly useful in any aspect of the business of InLife Health Care, (iv) any vendor names, Member and supplier lists, (v) marketing strategies, plans, financial information, or projections, operations, sales estimates, business plans and performance results relating to the past, present or future business activities of InLife Health Care, (vi) all intellectual or other proprietary information or material of InLife Health Care; (vii) all forms of Confidential Information including, but not limited to, loose notes, diaries, memoranda, drawings, photographs, electronic storage and computer print outs; (viii) any other information that should reasonably be recognized as Confidential Information of InLife Health Care. All information which the Client or Member acquires or becomes acquainted with during the period of this Agreement, whether developed by InLife Health Care or by others, which such Client or Member has a reasonable basis to believe to be Confidential Information, or which is treated, designated and/or identified by InLife Health Care as being Confidential Information, shall be presumed to be Confidential Information. Confidential Information need not be novel, unique, patentable, copyrightable or constitute a trade secret in order to be designated Confidential Information.

 Access to Master Agreement

 InLife Health Care and the herein named legal juridical entity are the nominal parties in this Agreement. Hence, the originally issued Agreement shall pertain to the latter. Members may be allowed to access the Agreement for perusal. Digital copies thereof may be requested from InLife Health Care and hard copies may also be provided, subject to a reasonable charge for cost of production. 

Arbitration

Any difference arising between the Client or any Member, and InLife Health Care shall be referred to an arbitrator to be appointed by the parties to the dispute. If the parties are unable to agree on a single arbitrator, two (2) arbitrators shall be appointed (one by each party). In the event of further disagreement, the arbitrators shall select an umpire. If the difference between the parties requires medical knowledge (including any question regarding the appropriate maximum indemnity for any medical service or an operation not listed in the schedule of surgical fees) the arbitrators at the discretion of InLife Health Care may be a registered medical practitioner and the umpire in such an instance, shall be a consultant Specialist, Surgeon, or Physician. Determination of an award shall be a Condition Precedent to Any Liability or right of action against InLife Health Care.

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 InLife 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 InLife Health Care and will undertake to assist the latter in the successful recovery of the losses.

Settlement of Disputes

In case of dispute or disagreement arising out of or related to this Agreement which cannot be settled mutually by Parties through available manner of resolutions (e.g. mediation), the Parties hereby agree that any suit, action or proceeding shall be strictly and most exclusively filed at and resolved in the proper Courts of Makati City, to the exclusion of all other courts in accordance with the laws of the Republic of the Philippines.

Important Notice

The Insurance Commission, with offices in Manila, Cebu and Davao, is the government office in charge of the enforcement of all laws related to Health Maintenance Organization (HMO), and has supervision over HMOs. It is ready at all times to assist the general 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 +632-5238461 to 70 and email address publicassistance@insurance.gov.ph. The official website of the Insurance Commission is www.insurance.gov.ph.

TABULAR SCHEDULE OF BENEFITS

(See table in the Contract)