SOP Exhibits

Title:

Benefits Plan Manual - EHCP

SOP Number : HR-PB19

NATIONAL FOOD AUTHORITY NFA EXECUTIVE
BENEFITS PLAN MANUAL HEALTH CARE PROGRAM (EHCP)
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PURPOSE AND TYPE OF PLAN

The NFA Executive Health Care Program under PhilamCare is designed to provide health care services to eligible NFA executives through availment of medical services i.e. out-patient benefits, hospitalization benefits, emergency benefits and dental benefits as a supplemental rider.

ELIGIBILITY

All regular and full-time NFA executives, who are below age 65 and are actively performing their regular and usual duties, as of June 30, 1989 are eligible for membership to the partial contributory plan where the NFA executive will shoulder percentage share of the membership fee or the amount in excess of the allotted budget per executive as applicable.

NFA employees promoted or hired to an executive position after June 30, 1989 are eligible for membership only under a total contributory plan where full payment of the corresponding membership fee will be shouldered solely by the participating executive.

ENROLLMENT/COVERAGE PERIOD

Enrollment of NFA executives to the EHCP shall be on a per policy period as renewable yearly. Coverage shall commence at the beginning of every policy period and shall remain until the end of the term.

Additional coverages within the policy term shall be effected on the date of enrollment.

DATE OF ELIGIBILITY

Your coverage as a member of the Health Care Program shall become effective on the applicable date set forth below:

a. the Effective Date of the Agreement
b. in the case of a benefit added to the Agreement at a date later than the effective date of agreement, the effective date of said benefit, or
c. the date of enrollment,

provided that your enrollment date is not more than one calendar month after the Effective Date of the Agreement. When the date of your enrollment is not within said calendar month, or if you voluntarily terminated your coverage but remained eligible reapplies for such coverage, you may be required to furnish at your own expense evidence of eligibility satisfactory to the insurance company in addition to a properly completed application and your coverage shall not become effective until the date of approval of the insurance company of such application and evidence of eligibility.

EFFECTIVE DATE PROVISO

If you are not actively working full-time on the date your coverage would become effective as provided above, your coverage shall not become effective until the date you return to full-time active work.

CONTRIBUTIONS FROM MEMBERS

1. Partial Contributory Plan; 95% - 5% Employer-Executive Share

2. Total Contributory Plan: 100% Executive Share

COVERAGE TERMINATION

Your coverage as a member shall automatically terminate on the earliest of the following dates:

1. the date the Agreement terminates
2. the date of expiration of the period for which the last Membership Fee payment is made on account of your coverage
3. the date you enter military, naval or air service
4. the date you cease to be eligible for coverage under the agreement
5. If Sub-Group Provisions are made part of the Agreement, the date on which the coverage for the member's Sub-Group terminates, or
6. the date you retire, pensioned, leave voluntarily or is dismissed from employment, or the date you cease active work, except, in the event of disability, temporary layoff or approved leave of absence. Payment of the required Membership Fee will continue the coverage in force for a limited period commencing with the date you cease active work and automatically terminating on the earliest of the following dates:

a) in the event of disability, the end of the period of disability,
b) in the event of temporary layoff or approved leave of absence, the end of one month, or
c) the date the coverage terminates in accordance with 1,2,3,4 or 5 hereof.

HEALTH CARE COVERAGE

Definition of Terms

The following definition of terms shall apply to all standard provisions applicable to health care benefit coverage.

1. "Hospital" shall mean any public or private institution duly recognized and licensed by the Bureau of Hospitals, Department of Health and which renders hospital services which include beds for hospitalized patients, food and general nursing services. "Hospital" does not include any institution or that portion of any institution which is operated as a convalescent or nursing home, rest home, home for the aged, a place for custodial care, or for any similar purpose.

2. "Affiliated Hospital" shall mean only any one of the hospitals stated in the list of approved hospitals attached hereto as Annex "A" and any other hospital as may be recognized by PhilamCare from time to time for purposes of the agreement.

3. "Physician" shall mean any person legally authorized in the geographical area of his practice to render medical and surgical services.

4. "Specialist" shall mean a Physician who has completed the prescribed training in a particular field of medicine.

5. "PHS Physician" shall mean a Physician employed by PhilamCare to provide medical services to enrollees.

6. "Affiliated Physician" shall mean a Physician who has agreed to provide medical services for enrollees of PhilamCare on a case to case basis.

7. "PHS Medical Clinic" shall mean a medical facility set up by PhilamCare for the purpose of providing out-patient services to enrollees.

8. "Affiliated Medical Center" shall mean a medical facility engaged by PhilamCare to provide out-patient services to enrollees on a case to case basis.

9. "Health Care" shall mean out-patient benefits, hospitalization benefits, maternity benefits and other such medical benefits when provided for in the Agreement.

10. "Emergency" shall mean he sudden, unexpected onset of illness or injury which at the time of contract reasonably appeared as 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 infection (heart attack); (d) Hypertensive crisis (e.g. stroke, HPN coma); (e) Fracture/multiple injuries secondary to accidents; (f) Convulsions; (g) Diarrhea associated with moderate to severe dehydration; and (h) Syncope.

11. "PHS Authorized Physician" shall mean a Physician authorized by PhilamCare to issue letters of authorization or letters of referral to physicians or medical facilities for the purpose of providing medical services to its members.

STANDARD PROVISIONS

The following standard provisions shall apply in your health care coverage.

I. Hospitalization Rules and Conditions

The following conditions shall be followed for ailment which requires hospitalization except for emergency illness or injury;

1. The hospitalization must be arranged or approved by a PHS Authorized Physician prior to the confinement.

2. The confinement shall be in an affiliated hospital and the type of hospital and the type of hospital room accommodation shall be in accordance with your benefit classification.

3. Professional services shall be provided only by PHS Physicians or Affiliated Physicians.

4. If discharge from the hospital has been authorized by a Physician and you fail or refuse to do so, PhilamCare shall not be responsible for any charges for Hospital Service rendered after the day for which discharge has been authorized.

II. Medicare/ECC Provision

This agreement is integrated with your benefits under Medicare and/or Employees Compensation Commission (ECC) and as such, benefits to which you are entitled to under Medicare and/or ECC shall be made deductible in the computation of benefits under this Agreement.

III. Motor Vehicle Liability Provision

If the member's bodily injuries are claimed to be caused by any act or omission of a third party through a motor vehicle, health Care benefits under this agreement shall be provided only if you execute an agreement to subrogate to PhilamCare whatever rights you may have by reason of such accident or event that gave rise to such claim.

IV. General Exclusions Applicable to Health Care Coverage

No Health Care Benefit shall be paid for the following services, products or conditions:

1. Care by non-affiliate Physicians or in non-affiliated hospitals or non-affiliated medical centers, except in emergencies wherein the Emergency Provision of the Agreement shall apply;

2. All Pregnancy related conditions requiring medical/surgical care;

3. Sterilization of either sex or reversal of such, artificial insemination, sex transformations or diagnosis and treatment of infertility;

4. Rest cures, custodial, domiciliary or convalescent care;

5. Cosmetic surgery and oral surgery for the purpose of beautification except constructive surgery to treat a functional defect due to disease or accidental injury;

6. Psychiatric conditions, drug addiction or alcoholism;

7. Congenital anomalies and conditions;

8. Medical or Surgical procedures which are experimental in nature or not generally accepted as standard medical treatment by the medical profession;

9. Procurement or use of corrective appliances, artificial aids and durable equipment;

10. Physical examination required for obtaining or continuing employment, insurance or government licensing;

11. Additional hospital charges resulting from taking a Room Accommodation different from that specified in the Schedule, or additional personal comfort rooms; e.g. telephone and television, admission kit, and/or such other items of the same nature;

12. Injuries or illness due to military service or suffered under conditions of war;

13. Executive check-ups and confinements which are for purely diagnostic purposes;

14. Diseases or injuries wherein the care or reimbursement of services is provided by law or a government program, up to the stipulated limits;

15. Injuries or illness which are self-inflicted, caused by attempt at suicide, or incurred as a result of or while participating in the commission or a crime; and

16. Out-patient medicine and take-home medicine in case of hospitalization, except medication administered during an emergency treatment.

V. General Limitations

Your right as a member and the obligations of PhilamCare shall be subject to the following limitations:

1. If a major disaster or epidemic cause unavailability of facilities or personnel, or if circumstances not within the control of PhilamCare such as temporary lack of hospital facilities, complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes, or similar causes occur, then PhilamCare shall not be liable for any delay or failure to provide services to the enrollee. PhilamCare shall, however exert its best efforts to provide services to the enrollee, as the circumstances permit.

2. If a member avails of the latest modalities of treatment and/or diagnostic tests, the liability of PhilamCare shall be limited to the prevailing amount of fees ordinarily charged for traditionally accepted treatment modality and/or diagnostic tests. Notwithstanding this provision, PhilamCare's liability shall be limited to the following amounts in case of Lithotripsy and Magnetic Resonance Imaging (MRI):

Lithotripsy P20,000.00
MRI 3,000.00

3. If the enrollee refuses to follow the recommended treatment or procedure and the PHS Physician believes that no professionally acceptable alternative exists, then PhilamCare shall no longer be responsible to provide care for the condition under treatment.

4. Hospital Service is subject to all rules and regulations of the hospital selected, including the rules and regulations governing admission.

5. In no event shall the cost of Health Care benefits during the one year term of this Agreement exceed the Maximum Sum per Disability stated in the Membership Fee Schedule for the following diseases or conditions: (a) neurological; (b) blood dyscrasisas; (c) collagen/immunologic disorders; (d) liver cirrhosis; (e) chronic pulmonary/renal; (f) cardiovascular; (g) cancer; (h) any condition which will necessitate the use of ICU; (1) AIDS; and (j) accidental injuries Neither shall the total liability of the company during the entire lifetime of the member exceed two times the Maximum Sum per Disability stated in the Schedule for each one of the above-mentioned diseases or conditions.

HEALTH CARE BENEFITS

As an eligible member, you are entitled to the following health care benefits provided for members/enrollees in accordance with the maximum amount payable and the limits applicable as set forth in the provisions of the agreement.

I. OUT-PATIENT BENEFITS

A. Annual Physical Examination

The Physical Examination includes the following services:

1. Taking of Medical History
2. Physical Examination
3. Chest x-ray
4. Urinalysis
5. Stool Examination
6. Complete Blood Count
7. Electrocardiogram (ECG) for members above 40
8. Pap Smear for female members above 40
B. Preventive Health Care

Preventive health care shall mean any of the following services:

1. Immunization (does not include the cost of vaccine and determination of susceptibility);
2. Consultation and advice on diet, exercise and other healthful habits;
3. Periodic monitoring of health problems'
4. Family Planning Counseling

C. Out-Patient Services

The following services are provided for treatment of illness or injury which does not require hospitalization.

1. Consultations, including specialist evaluation;
2. First aid treatment of injury or illness;
3. Necessary x-ray and laboratory examinations;
4. Minor surgery not requiring confinement;
5. Eye, Ear, Nose and Throat Care.

All out-patient benefits shall be provided only at PHS medical clinics and only by PHS Physicians, except for emergency treatment of illness or injury wherein the Emergency Provision of the Agreement shall apply. Out-patient treatment may also be provided in affiliated medical clinics and by affiliated physicians or Authority Physician.

II. HOSPITALIZATION BENEFITS

1. Services of Physician and Surgeon, including surgery;
2. Room and Board, according to type of enrollment and subject to maximum rate of daily benefit as stated in the Membership Fee Schedule;
3. General nursing service;
4. Use of operating room and recovery room;
5. Anesthesia and its administration;
6. Drugs and medications for use in the hospital;
7. Oxygen and its administration;
8. Dressing, plaster casts and other medical supplies;
9. Laboratory tests, x-rays and other necessary diagnostic services, except as otherwise limited in the General Limitations of the Standard Provisions Application to Health Care Coverage.
10. Transfusion of blood and other blood elements;
11. Dialysis up to a maximum of 10 treatments;
12. Confinement in intensive care unit up to a maximum of 14 days.

Hospitalization benefits shall be available only when you have been referred or admitted to a PHS affiliated hospital by a PHS Authorized Physician, except for emergency treatment of illness or injury where the Emergency Provisions of the Agreement shall apply.

In case you avail of hospitalization benefits and get admitted to any of the listed full service hospitals, the applicable Maximum Rate of Daily Room and Board for such confinement shall be P500.00/day.

Membership Fee Schedule
Annual
Classification Enrollment Type Max.Rm & Board Daily Max. Sum Membership Fee
Executive Diamond P400.00 P75,000 P2,086.00

III. EMERGENCY BENEFITS

in the event of an emergency and you receive health care in a hospital or medical center, you or your representative shall notify PhilamCare within 24 hours after the emergency has commenced. You shall be responsible for presenting information as to conditions of the emergency to enable PhilamCare to determine whether the services rendered were for the care of a sickness or injury which is emergency in nature.

1. Emergency Care in Non-Affiliated Hospital or Medical Center

If the emergency health care was administered in a non-affiliated or medical center, whether as in-patient or out-patient, and PhilamCare was notified of such emergency within 24 hours following the commencement of the emergency, PhilamCare shall pay or reimburse up to 80% of the usual, customary and reasonable charges for medical care and services which are incurred as a result of such emergency, but in no case shall this exceed the amount which would have been paid by PhilamCare according to the Benefit Classification of the member had the member been treated in an affiliated hospital or medical center by an affiliated Physician, or P5,000 whichever is lesser. PhilamCare shall not be liable for any charges if it is not notified of such emergency within the required 24 hours after the emergency has commenced.

PhilamCare reserves the right to transfer the member to an affiliated hospital or PHS Authorized Physician, it is medically safe to do so. If such transfer has been recommended by a PHS Authorized Physician and the member shall fail or refuse to do so, PhilamCare shall not be responsible for any charges for hospital services rendered after the day for which transfer has been recommended. If, however, it is determined by the PHS Authorized Physician that it is not medically safe to transfer the member to an affiliated hospital, the P5,000.00 amount limit in the computation of benefits as stated in the preceding paragraph shall no longer apply.

2. Emergency Care in Affiliated Hospital or Medical

If the emergency health care was administered in an affiliated hospital or medical center whether as in-patient or out-patient, the member shall be entitled to full coverage under the Hospitalization Benefits Provision or Out-patient Benefits Provision of this Agreement provided that PhilamCare has been notified of such emergency and a prescribed referral letter was issued by a PHS Authorized Physician and provided further that the illness or condition is covered under this Agreement. However, if no such prescribed referral letter was issued or if the professional service was provided by a non-affilliated Physician, PhilamCare shall pay or reimburse up to 80& of the amount which would have been paid by PhilamCare according to the benefit classification of the member had the member been entitled to full benefit under the Agreement, or P5,000 whichever is lesser.

3. Emergency Care in Foreign Territories

If the emergency health care is administered in a medical facility outside the territorial limits of the Republic of the Philippines, PhilamCare shall pay or reimburse up to 80% of reasonable charges for medical care and services which are incurred as a result of such emergency, but not to exceed 80% of the amount which would have been paid by PhilamCare according to the benefit classification of the member had the member been treated in the Philippines in an affiliated hospital or medical center by an affiliated Physician or P5,000.00 whichever is lesser. PhilamCare also reserves the right to determine whether treatment received in the foreign territory is emergency in nature and is covered under the provisions of this Agreement.

IV. DENTAL BENEFITS

A. As a member you shall be entitled to the following dental services listed below as a supplemental rider to the ECP.

1. Annual dental examinations;
2. Annual oral sealing and polishing;
3. Simple tooth extraction
4. Treatment of pain, lesions, wounds and burns;
5. Cum treatment, except alveolectomy and gingivectomy
6. Recementation of fixed bridges, crowns, jackets, inlays and onlays;
7. Temporary fillings ; and
8. Consultations

B. In case you would require dental services other than those in the above list, you may avail of these services at a cost not higher than the rates indicated in the attached Schedule of Dental Fees (Annex B) provided these services are given at the accredited dental clinic listed below:

Dental Clinic: Dr. Deanna Samaniego
2nd Floor, Buenaventura Plaza Bldg.
Ortigas, San Juan, Metro Manila

IV. CLAIMS PROCEDURE

1. Unless the illness is emergency in nature, you shall first report your condition to a PHS Physician before proceeding to any clinic or hospital for treatment. The PHS Physician shall, upon examining you, prescribe the necessary medical procedure and, if hospitalization is needed, provide the required hospital referral in the prescribed form. Before being discharged from the hospital, you must fill up the prescribed PhilamCare claim form and settle that portion of medical bill not covered by the Agreement. That portion of the bill covered by the Agreement shall be settled directly by PhilamCare with the hospital and/or attending physician(s). See Exhibit 1.

2. In case of emergency, you may proceed directly to a medical facility for treatment or hospitalization, after which PhilamCare shall be informed of the treatment within 24 hours. The prescribed referral letter and/or claim forms shall be furnished by the PHS Physician after he has determined that the treatment or hospital confinement is emergency in nature as defined in the Agreement. See Exhibit 2.

3. In cases wherein PhilamCare covered costs were not deducted from the medical bills and you are made to pay for the total health care cost, you may request the 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 the original official receipts to confirm that at least a sum equal to that being requested as benefits has been paid. Such request for benefits must be presented within six (6) month after the expiration of the period of the treatment for which claim for benefits is being made.

4. PhilamCare will process the payment of all claims for benefits in accordance wiht the terms of the Agreement. All benefits that pertain to you as a member will be paid by check to the order of said member, unless you requests otherwise, or PhilamCare, in its discretion, considers it preferable to make th epayment in another manner. 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 beneficiaries. The member's (a) widow or widower; (b) surviving children; (c) surviving parents; (d) surviving brothers and sisters; (e) executors or administrators.

5. PhilamCare shall have the right and opportunity to examine the covered person when and as often as it may reasonable require during pendency of a claim.

a.