The Group Hospitalization Insurance Plan (GHIP) is designed to provide substantial reimbursement of hospital, medical and surgical and/or maternity care expenses which you and or your insured dependents may incur.
Benefits are paid only on actual hospital confinement of at least 6 hours except for surgical cases not requiring confinement. The benefits under the GHP are tabulated under Schedule of Benefits Summary, page ______.
ELIGIBILITY
All regular full-time employees hired as of June 30, 1989 who are between 18 to 64 years old and their qualified dependents are eligible for membership to the non-contributory plan were the agency will pay for the entire cost of the insurance.
All regular full-time employees hired after June 30, 1989 who are between 18 to 64 years and their qualified dependents are eligible for membership to the total contributory plan where the individual will shoulder the entire cost of the insurance.
The employee's qualified dependents are as follows:
For Married Employees
1. Legal spouse - 18 to 64 years old
2. Children who are at least fourteen (14) days old up to 22 years old, unmarried, unemployed, legitimate, legitimated, legal adopted, recognized natural children including natural children by legal fiction and stepchildren.
3. Mentally retarded and physically handicapped children 23 years old and above who must have been incapable of self-support prior to age 23 and remain dependents upon the employee for support and maintenance.
For single Employees
1. Parents, not over 69 years old, who are wholly dependent upon employee for support; or
2. Any two (2) brothers/sisters of the first blood not over 22 years old, unmarried and unemployed (in the absence of qualified parent/s).
For husband and wife employees, qualified children are eligible as dependents of the husband only. (The wife, for purpose of premium classification shall be classified as "single without dependents". (Refer to Schedule of Premium Rates).
Your dependents shall become eligible under the Plan on the date you become eligible for your own insurance provided they are already qualified as dependents.
If you acquire your qualified dependents after your own eligibility date, each of your dependents become eligible as follows:
1. In the case of your spouse, the eligibility date is the date of your marriage; or
2. In the case of your child, the eligibility date is the date your child reaches the age of 14 days.
You should submit the names, relationship and dates of birth of your dependents, report immediately additional and any change/s in designated dependents and submit required documents such as marriage contract and birth certificate to your respective Administrative Unit/Manpower Services, HRMD to ascertain dependents' coverage under the plan.
DATE OF ELIGIBILITY
Effective Date of Insurance
1. Regular full-time employees On the effectivity date of the plan
who are actively at work
on the Date of Effectivity
of the Policy
2. Regular full-time employees The first day of the month coincident with
who are not actively at work or immediately following the date they
on the date of effectivity of returned to active full-time work
the Policy.
EFFECTIVITY OF COVERAGE
Your insurance takes effect on the effectivity date of the Plan if you are eligible for coverage on such date, provided your application is received by the Company within 31 days from such eligibility date, otherwise your insurance shall be subject to the approval by the Insurance Company and you may be required to submit evidence of insurability satisfactory to the company.
For those, who are not actively at work on the date your insurance is supposed to take effect, your insurance shall take effect only on the first day of the month immediately following the date you return to active full-time work.
The insurance of any of your qualified dependents shall take effect on your eligibility date however, any qualified dependents who is sick or confined in a hospital on the date his/her insurance would normally take effect shall not be considered insured on such date. His/her insurance shall take effect only on the first day of the month immediately following his/her full recovery from such sickness or his/her release from the hospital as a fully recovered patient.
STATEMENT OF COVERAGE
The recommendation of a legally qualified physician for confinement of at least 6 hours in a hospital authorized under this plan is necessary.
Periods of disability arising from the same cause or causes, including any and all complications or closely interrelated causes should be separated by an interval of at least 2 weeks in your case or 6 months in the case of your dependents. An interval is counted from the date of discharge in one confinement to the date of admission in the subsequent confinement.
Once the confinements are so separated, they shall be considered as if they were caused by disabilities unrelated to each other, hence, shall be individually and separately compensable.
In the case of pregnancy, all hospital confinements related to the same pregnancy shall be regarded as one disability.
PREMIUM RATES
The annual premium rates under the GHIP is in accordance with the following classification:
Classification Premium
Single without dependent (SO) P212.00
Single with one dependent (S1) 354.00
Single with two dependents (S2) 496.00
Married with dependent (M) 573.00
BENEFITS
The benefits listed under the GHIP are inclusive of the benefits under the Philippine Medical Care Act otherwise known as the MEDICARE.
The insurance company shall reimburse the actual, necessary, reasonable and customary expenses which an insured employee may have incurred up to the maximum amount specified in the Schedule of Benefits listed hereunder.
The GHIP medical benefits are composed of the Basic Medical Benefits, Major Medical Benefits and Maternity - Obstetrical Benefits.
The Basic Medical Benefits and the major Medical Benefits shall apply for confinement resulting from covered sickness or injury. In computing, for the allowable amount of benefits, the basic Medical Benefits shall be applied first prior to application of major Medical Benefits.
Maternity/Obstetrical Benefit is a part from the other two benefits and shall cover hospital expenses incurred as a result of childbirth.
SCHEDULE OF BENEFITS
The amount of benefit to be granted shall cover the actual expenses incurred by the insured employee but not to exceed the following limits per item benefits.
I. BASIC MEDICAL PLAN MAXIMUM AMOUNT OF BENEFIT
A. Hospital expense Benefit
Room and Board per day P 80.00
(up to 31 days)
Special Hospital Services,
(100% of actual expenses
including anesthesiologist's
fee not exceeding 30% of
the allowable surgical fee)
up to a maximum of 1,000.00
B. Surgical Expense Benefit,
according to the Schedule
of Operations (Annex A)
up to a maximum of 3,000.00
C. In-Hospital Physician's
Visit per day, up to 31 days 80.00
Co-Insurance (For dependent) 80/20%
II. MAJOR MEDICAL BENEFITS MAXIMUM AMOUNT OF BENEFIT
Maximum Benefit P10,000.00
Corridor Deductible 100.00
Con-Insurance 90%/10% (for employee)
80%/20% (for dependent)
Inner Limit (In addition to Basic Medical Benefits)
Surgical Expense Benefit
according to the Schedule of
Operations (Annex B) up to a
maximum of 5,000.00
Anesthesiologist's Fee
30% of eligible Surgeon's Fee,
up to a maximum of 1,500.00
Operating Room Fee, 25% of
eligible Surgeon's Fee,
up to a maximum of 1,250.00
Room & Board per day 60.00
In-Hospital Physician's Visit Per Day 50.00
Ambulance Service Fee 300.00
Registered Nurses' Fee Per Day 50.00
Special Hospital Services Actual
III. MATERNITY BENEFITS
Room & Board per day maximum of 10 days 100.00/day
Special Hospital Services 1,000.00
Anesthesiologist's Fee 750.00
Obstetrical Fee
Normal delivery 1,000.00
Caesarian Section 3,000.00
Miscarriage or Abortion 1,000.00
Home Delivery 500.00
DESCRIPTION OF BENEFITS
I. BASIC MEDICAL BENEFITS
A. Hospital Expense Benefits
i. Room and Board
This covers the daily charges incurred for room and board up to the daily limit stated. This includes room accommodations, food, services and routine nursing care.
The total amount payable is determined by multiplying the rate of daily benefit by the number of days of confinement.
Under this benefit, charges such as extra bed, transfer fee and similar extra charges are not reimbursable.
ii. Special Hospital Services
This benefit includes the actual cost charges by the hospital for the following up to the limit stated.
a. Use of operating room and treatment room;
b. Anesthesia and oxygen and the cost of administration thereof;
c. Medical supplies as expendable curative materials as drugs and medicines, dressing, ordinary splints, plaster casts, administration of bold and blood plasma, intravenous, injections and solutions;
d. Laboratory services, clinical and pathological;
e. Films and x-rays and their interpretations (cost of x-ray therapy, radium, cobalt and isotopes are excluded) and physician therapy;
f. Ambulance services to and/or from the hospital for any one injury or sickness, but not in excess of P20 during any one period of confinement when such charges are made by an organization which normally provides such services.
EXCLUSIONS
In order to keep the costs of the benefits within the reach of everyone, certain services, products or conditions are excluded from the coverage, namely.
1. If the insured individual is confined less than six (6) consecutive hours;
2. Services of special nurse, physicians, surgeons, assistant surgeons, or interns;
3. Services in connection with pregnancy, including childbirth, miscarriage or any complications thereof;
4. Services or supplies in connection with the care of a new born child, or in respect with the dependent; services or supplies in connection with the care of a child less than two (2) weeks of age;
5. Charges for personal services such as registration fee, laundry, newspaper, extra meals, telephone calls, rent of radio, television, electric fan, copies of hospital records and other similar charges not covered;
6. Charges for services not necessary for the treatment of injury or sickness.
B. Surgical Expense Benefit
This covers professional fee made by the physician for performing an operation up to the limit stated based on the Schedule of Benefits;
1. If two or more operations are performed in different parts of the body through different incision at one time or during any one continuous period of disability, the total amount payable shall not exceed the maximum Surgical Benefits stipulated in the Schedule of Benefits;
2. When an insured individual is attended by two or more surgeons in a surgical procedure, the benefit shall be the same as if only one surgeon had attended the operations.
3. If two or more operative procedures are performed through a single incision, payment shall be made only for that one operation for which the largest amount of benefit is payable.
4. If a single operation is performed in two or more steps, such operations shall be considered as one only.
Only one surgeon's fee is payable, any other charges made by assistant surgeon's are not payable.
If the surgical operation is not shown in the Schedule of Operation, the Company reserves the right to determine the maximum benefit therefor. A surgical operation of equivalent gravity and severity shall be used as basis for the Company's settlement thereof.
C. In-Hospital Physician's Visit
This covers professional fees for doctor's visit up to the daily limit stated for treatment made in connection with hospital confinement not involving surgery.
The total amount payable is determined by multiplying the rate of daily benefit by the number of days of confinement subject to limits as stated in the Schedule.
Limitations
When surgical procedure is done by another physician for which benefits are payable, payment hereunder is limited not to exceed:
1. The preoperative period which includes all days of confinement up to, but not including the date of surgical procedure, multiplied by the number
2. For any treatment received for pregnancy or any medical check-up by x-ray examination or any other means which are purely for diagnostic purposes; or
3. For any treatment received on the day of any surgical operation and during convalescence therefrom if the individual is entitled to receive benefit from such surgical operation, regardless of whether or not the benefit for doctor visits or calls is greater than the surgical benefit; or
4. For any medical treatment involving dental care, eye examination for fitting of glasses, (including contact lenses), x-ray examinations, or supplies such as drugs, dressings or medicines.
A. Maximum Major Medical Benefit
Maximum amount payable to or on behalf of an insured employee in respect to any one disablement.
B. Corridor Deductible
Corridor deductible is the aggregate of eligible medical expense incurred on account of each disability in a continuous period not exceeding three months which shall be personally borne by the insured before any Major Expense benefits becomes payable. The deductible amount shall be the fixed deductible stated in the SCHEDULE OF BENEFITS.
A new corridor deductible shall apply if a separate disability is established whenever injury or disease;
1. is due to a cause unrelated to a prior or concurrent disability;
2. commenced after complete recovery from a previous disability;
3. exist or recurs after any period of three months.
C. Co-Insurance
The employee shall be deemed co-insurer of the total eligible hospitalization expenses to be incurred.
This refers to the amount, which is generally expressed in terms of percentage, to be shouldered by the employee upon computation of the allowable amount for any or all of the benefit-items.
D. Inner Limits
Surgical Expense Limit
Maximum amount of surgical benefit above any amount paid unde Basic Medical Plan and Medicare based on the Schedule of Surgical Benefits for Major Medical Plan (Annex 2).
Anesthesiologist's Fee
Maximum additional amount payable for the services of an anesthesiologist.
Operating Room
The maximum amount payable for the use of the operating room.
Room and Board per Day
Maximum additional room and board accommodation above room and board benefit paid under the Basic Medical Plan and Medicare.
In-Hospital Physician's Visit
Maximum additional physician's visit above any Physician's visit paid under the Basic Medical Plan and Medicare.
Registered Nurse's Fee per Day
Maximum amount for a registered nurse performing private nursing duty other than a private member.
Ambulance Service Fee
Maximum amount for the use of an emergency transportation from place of disability to the nearest hospital.
Special Hospital Services and Supply as charged
- Drugs or medicines, if lawfully obtained only upon prescription of a physician and dispensed by a licensed pharmacist or physician.
- Blood or blood plasma
- Artificial limbs or eyes; casts, splints trusses, braces, crutches, hearing aids or other similar prosthetic devices made necessary by the loss or impairment of a body member except replacement necessary during the growth to maturity of an insured dependent.
- Oxygen and the rental of equipment for the administration thereof.
- Rental of wheelchair, hospital-type bed, iron lung and other mechanical devices used solely for medical treatment.