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

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

Optional Benefits

The limits of the following procedures shall apply inclusive of professional fees and related incidental expenses:

Procedures covered up to MBL or up to certain limits:

1. Laparoscopic Cholecystectomy (LapChole), Adrenalectomy, Hernioplasty / Herniorrhaphy / Herniotomy, Oophorectomy / Oophorectocystectomy are covered up to MBL. All other laparoscopic procedures (except LapChole) for therapeutic purposes are covered up to Php 20,000 per year. All laparoscopic procedures for diagnostic purposes are covered up to Maximum Benefit Limit (MBL).
2. Cryosurgery
3. Hysteroscopic Myomectomy
4. Hysteroscopic D&C and Polypectomy
5. Gamma Knife
6. Arthroscopic Surgery
7. Magnetic Resonance Imaging (MRI) / Magnetic Resonance Angiogram (MRA) / Computerized Tomography (CT Scan)
8. Functional Endoscopic Sinus Surgery (FESS)
9. Nuclear medicine procedures
   • Thyroid Scan
   • Thallium Scintigraphy / Thallium Stress Test
   • Sestamibi Stress Test / Hexamibi
   • Radioactive Isotope Scan
   • HIDA Scan
   • Radionuclide Renography
   • Body Metastatic Survey
   • Bone Scan / Imaging / Densitometry
   • Dacryoscintigraphy
   • Gastric Scintigraphy
   • Glomerular Filtration Rate
   • Liver or Spleen Imaging
   • [Tetro Rest and Stress
   • Thyroid Imaging / Scintigraphy
   • Other nuclear medicine procedures are covered up to Php 5,000 per session.
10. Laser eye procedures (one session per eye per year): Laser lridotomy / Iridectomy, Yag Laser, and Argon Laser are covered up to MBL. All other Laser Procedures (one session per year) are covered up to Php 5,000 except Photorefractive Keratectomy
11. Electro Shock Wave Lithotripsy (ESWL) (limited to one session per year)
12. Electrocautery (ECT), paring and curettage, and other related procedures in the treatment of warts, molluscum contagiosum, and milia shall be covered up to Php 1,000 per year.
13. Endoscopic Procedures is covered up to MBL for diagnostic purposes; and Php 5,000 per session for therapeutic purposes.
14. Percutaneous Ultrasonic Nephrolithotomy (PUN) is covered up to Php 40,000 (one session per year).
15. Stereotactic Brain Biopsy is covered up to Php 20,000 per session.
16. Transurethral Microwave Therapy of Prostate is covered up to Php 30,000 per session.
17. Speech Therapy (inclusive of out-patient speech therapy)
18. Positron Emission Tomography Scan (PET Scan) is covered up to Php 5,000 per session.
19. Sleep Studies is covered up to Php 5,000 per year.
20. Pain Management is covered up to Php 3,000 per year.
21. Post-operative Analgesia is covered up to Php 3,000 per operation.

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 25,000.
4. Chronic glomerulonephritis, gullain-barre syndrome
5. Scoliosis, Spinal Stenosis and Kyphosis are covered up to Php 25,000. For all other physical deformities, only consultations are covered.
6. For Vitiligo and Psoriasis, only consultations are covered.
7. Confirmatory Tests are covered up to the MBL provided the tests are done for valid diagnoses. Coverage shall be extended only up to the time the condition in question has been ruled in/out. Confirmatory tests are not applicable to health conditions listed under Permanent Exclusions.

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. Sterilization of either sex or reversal of such, artificial insemination, sex transformations or diagnosis and treatment of infertility, and circumcision
4. Rest cures, custodial, domiciliary or convalescent care
5. 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
6. Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, adjustment disorders, alcoholism and its complications or conditions related to substance or drug abuse, addiction and intoxication
7. Sexually transmitted diseases
8. Medical and surgical procedures which are not generally accepted as standard treatment by the medical profession
9. Procurement or use of corrective appliances, artificial aids, durable equipment, and orthopedic prosthesis and implants
10. Surcharges resulting from additional personal (luxuries/accommodation) request or service including special nursing services
11. Physical examination required for obtaining employment, medical certification, insurance or a government license
12. Injuries or illnesses due to military, paramilitary, police service, high risk activities, or suffered under conditions of war
13. Reimbursement of procedures obtained through government programs
14. 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 or ordinances
15. Out-patient/take-home medicines
16. Valvular Heart Disease and Rheumatic Heart Disease
17. Medico-legal consultations
18. When a member is discharged against medical advice, and all 19. subsequent benefits/services related thereto.
19. Blood / Organ Donor screening / other screening procedures that are purely diagnostic or for screening purposes including among others, Purified Protein Derivative (PPD), and procedures conducted prior to hormonal replacement therapy
20. All hospital charges and professional fees after the day and time hospital discharge has been duly authorized and professional fees of Assistant Surgeons
21. All conditions and complications requiring dental care
22. Hypersensitivity/allergy tests
23. Diseases declared by the Department of Health (DOH) as Epidemic
24. Use of Emergency Room Facilities on non-emergency cases or by reason of condition/injuries not falling under the term “Emergency” as defined in the Agreement (“Emergency” shall mean the sudden, unexpected onset of illnes or injury having the potential of causing immediate disability or death, or requiring the immediate alleviation of severe pain or discomfort.) For the purpose of implementation, the final diagnosis shall be the basis for a member’s eligibility to emergency care benefits under the plan

Membership Eligibility

Participation and Enrollment:

• If Dependents’ Coverage is Employer-paid, we require 100% participation of employee-principals enrolling at least two (2) immediate dependents each following our hierarchy guidelines.
• If Dependents’ Coverage is Employer-Employee-shared or Employee-paid, we require at least 75% participation of employee-principals enrolling at least two (2) immediate dependents each following our hierarchy guidelines.
• In both instances above, if the minimum participation requirement is not met (because of employees who may have only one or no eligible dependent/s), we may still offer Dependents’ Coverage. Applications will be individually underwritten subject to acceptance or denial as the case may be. It is understood that a re-quote of dependents’ rates based on the actual number of enrollee-dependents may be done, if necessary.
• Dependents should be enrolled simultaneously with principal members.
• Newly married spouse, newly born child / sibling should be enrolled within 31 days from date of qualification as a dependent.
• Accommodation / Benefits Plan of Dependents must follow a uniform category pre-established by the client at the start of the program; and must be equal to or lower than the Principal’s accommodation /benefits plan.

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

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

• Membership fee is due and payable on Effective Date of the Agreement. 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 will be any day preferred by the corporate client after receipt (and evaluation) of the Corporate Application; receipt of the initial deposit for membership fees; and / or after underwriting requirements, if any, have been complied with by the corporate client.