For Independent, Healthy Individuals
and Their Families
Self-employed professionals need a professional range of health coverage options.
The Health Journey Starts Here
It’s time to start planning for your family’s future, one filled with the reassurance of affordable medical coverage anytime you need it.
Affordable medical coverage for you and your family.
If you work for yourself, you probably work longer and harder than you ever expected. Set aside some funds for a work benefit you or your family should not live without – affordable medical coverage.
Emergency Care Benefits
Summary of Plan Benefits for Individual Comprehensive
Plan A (Open Access to Accredited Hospitals Program)
- Under this plan, a member may use any Insular Health Care accredited hospital and clinic nationwide.
Plan B (Preferred Hospital Program)
- Under this plan, a member will have to select and strictly use his preferred hospital except during genuine emergencies (as defined in the “Agreement”) whereby he may use any hospital nearest him. If a member uses an accredited hospital, we afford him full coverage according to his benefits classification. If a member uses a non-accredited hospital, reimbursement of expenses will be governed by the Emergency Benefits provision of the Agreement.
Plan features applicable to both Plan A & Plan B
- For primary care (non-emergency cases), entry point to accredited/preferred hospitals SHOULD BE THE COORDINATOR’S OFFICE. During off-clinic hours, and only for genuine emergency cases (as defined in the Agreement), a member may go to the Emergency Room for treatment. Unless stipulated in the Agreement, accredited clinics are not used for health care service availments.
- During genuine emergencies (as defined in the Agreement), a member may use any hospital nearest him. If a member uses an accredited hospital, we afford him full coverage according to his benefits classification. If a member uses a non-accredited hospital, reimbursement of expenses will be governed by the Emergency Benefits provision of the Agreement.
- Some accredited Metro Manila and provincial hospitals no longer have ward and semi-private rooms or no longer admit HMO patients to ward or semi-private rooms. For members who select the ward or semi-private room accommodation plan and/or use hospitals without ward or semi-private rooms for in-patient benefits, please be advised that these hospitals will automatically admit the member to the next higher room accommodation on a step-ladder basis.
- For genuine emergency cases (as defined in the Agreement), Insular Health Care takes care of the difference in upgraded costs for the first 24 hours. After the first 24 hours, the member pays for the difference in upgraded costs prior to his discharge from the hospital.
- For elective cases, the member pays for the difference in upgraded costs from day one of his confinement prior to his discharge from the hospital. Please see provision “b” under Room and Board of In-Patient Benefits.
Maximum Benefit Limit (MBL)
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:
|Suite||Php 125,000.00||Plan 1,000||Php 125,000.00|
|Private||Php 100,000.00||Plan 800||Php 100,000.00|
|Semi-Private||Php 75,000.00||Plan 600||Php 75,000.00|
|Ward||Php 50,000.00||Plan 400||Php 50,000.00|
1. Dental Benefits
To avail of this outpatient benefit at the member’s preferred dental clinic (for those who select strict preferred dental facilities) or at any dental clinic (for those who select open-door dental facilities) under the Filipino Doctors Preventive Healthcare Management, Inc., 100% participation of all qualified enrollees (by category, i.e., Officer / Supervisory / Rank & File, with or without their dependents) is required.
- Any number of consultations on dental problems including but not limited to lesions, wounds, burns, and gum problems (during clinic hours and by appointment)
- Annual Oral Prophylaxis (mild to moderate cases)
- Unlimited simple tooth extractions, except surgery for impaction or extraction of impacted tooth or complicated extractions involving the use of other dental instruments aside from pliers and/or the re-administration of anaesthesia
- Unlimited temporary fillings
- Unlimited re-cementation of fixed bridges, jacket crowns, inlays and onlays (limited to 4 abutments)
- Dental education and counseling during consultations
- Simple adjustments of denture clasps
- Two (2) surfaces of amalgam fillings
2. For “open-door” dental plan, add:
- Any number of consultations/dental examinations including treatment of lesions, wounds, burns, gum and other dental problems except diagnostics, prescribed medicines, surgeries and “root canal” procedures
- No limit as to the number of abutments covered (on item 5 above)
- Orthodontic consultations
- Aesthetic dental consultations
- Emergency desensitization of hypersensitive teeth
- Option to choose between two (2) surfaces of amalgam fillings or one (1) surface of “light cure” filling
3. Life (Group Term) Insurance With Insular Life
This is applicable only to Employee-Principal members.
- Minimum of P 10,000 in coverage
- Maximum of P 50,000 in coverage
(To avail of this benefit, 100% participation of qualified employee-principals is required. Coverages over the above limits will need special approval. )
In accordance with Insular Life Group Term Policy No. G-014175 dated 15 January 1999 and all of its succeeding endorsements, any individual with adverse medical findings shall automatically be covered for one-half (1/2) of coverage of a standard risk for deaths due to natural causes and one hundred percent (100%) of coverage for deaths due to accident.
(All regular female employees must enroll but in no case less than 25)
- Pre-natal and Post-natal diagnostic procedures at Insular Health Care Clinic or accredited/preferred hospitals.
- Hospital care during pregnancy and delivery. Limits will depend on the needs of the corporate client.
- Ordinary nursing care for newborn baby while mother is confined or for three days, whichever comes earlier.
Maternity Benefits shall be available only after the enrollee (principal or dependent member) has been continuously covered under the “Agreement” for a period of 280 days from date of initial enrollment except that in the event of pre-termination of pregnancy within the said period of 280 days, maternity benefit shall be available provided such pregnancy commences after the coverage of the enrollee becomes effective.
Latest Modalities of Treatment (examples of)
Procedures covered up to MBL or up to certain limits:
- 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).
- Hysteroscopic Myomectomy
- Hysteroscopic D&C and Polypectomy
- Gamma Knife
- Arthroscopic Surgery
- Magnetic Resonance Imaging (MRI) / Magnetic Resonance Angiogram (MRA) / Computerized Tomography (CT Scan)
- Functional Endoscopic Sinus Surgery (FESS)
- 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
- 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.
- 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
- Electro Shock Wave Lithotripsy (ESWL) (limited to one session per year)
- 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.
- Endoscopic Procedures is covered up to MBL for diagnostic purposes; and Php 5,000 per session for therapeutic purposes.
- Percutaneous Ultrasonic Nephrolithotomy (PUN) is covered up to Php 40,000 (one session per year).
- Stereotactic Brain Biopsy is covered up to Php 20,000 per session.
- Transurethral Microwave Therapy of Prostate is covered up to Php 30,000 per session.
- Speech Therapy (inclusive of out-patient speech therapy)
- Positron Emission Tomography Scan (PET Scan) is covered up to Php 5,000 per session.
- Sleep Studies is covered up to Php 5,000 per year.
- Pain Management is covered up to Php 3,000 per year.
- Post-operative Analgesia is covered up to Php 3,000 per operation.
Dreaded Diseases (Examples of)
- Neurological disorder
- Blood dyscracia
- Collagen/Immunological disorder
- Liver Cirrhosis
- Chronic Pulmonary/Renal disorder
- Cardiovascular disorder
- Any condition which necessitates the use of Intensive Care
- Unit subject to other limitations
- Accidental injuries
- Other conditions causing partial or total organ damage or failure
Pre-Existing Conditions (PECs)
A. An illness or condition shall be considered pre-existing if before the Effective Date of the Agreement:
- Any professional advice or treatment was given for such illness or condition
- Such illness or condition was in any way evident to the member
- 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:
- PECs are covered provided that the 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;
- such PECs are unknown to the member (without established medical history);
- Undeclared PECs with established medical history are excluded from coverage. However, said PECs may be evaluated for possible future consideration.
- 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)
- All tumors and malignancies involving any body organ or system
- Endometriosis, Dysfunctional Uterine Bleeding
- Diseased tonsils requiring surgery
- Pathological abnormalities of the nasal septum and turbinates
- Thyroid Dysfunction/Goiter
- Sinus condition requiring surgery
- Asthma / Chronic Obstructive Pulmonary Disease
- Cirrhosis of the liver
- Anal Fistula
- Cholelithiasis / Cholecystitis
- Calculi of the urinary system
- Gastric or Duodenal Ulcer
- Hallux Valgus
- Diabetes Mellitus
- Collagen Disease / Auto Immune Disease
- Cardiovascular Disease
- Hormonal Dysfunction
- 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:
- Organ transplants and/or open-heart surgery / angioplasty and all services (e.g., coronary angiogram) related thereto (except organ donor services)
- AIDS and AIDS-related diseases except when sexually transmitted
- Congenital abnormalities and conditions are covered up to Php 25,000.
- Chronic glomerulonephritis, gullain-barre syndrome
- Scoliosis, Spinal Stenosis and Kyphosis are covered up to Php 25,000. For all other physical deformities, only consultations are covered.
- For Vitiligo and Psoriasis, only consultations are covered.
- 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.
Permanent Exclusions (examples of)
- 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
- All pregnancy related conditions requiring medical/surgical care and screen tests related thereto.
- Sterilization of either sex or reversal of such, artificial insemination, sex transformations or diagnosis and treatment of infertility, and circumcision
- Rest cures, custodial, domiciliary or convalescent care
- 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
- Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, adjustment disorders, alcoholism and its complications or conditions related to substance or drug abuse, addiction and intoxication
- Sexually transmitted diseases
- Medical and surgical procedures which are not generally accepted as standard treatment by the medical profession
- Procurement or use of corrective appliances, artificial aids, durable equipment, and orthopedic prosthesis and implants
- Surcharges resulting from additional personal (luxuries/accommodation) request or service including special nursing services
- Physical examination required for obtaining employment, medical certification, insurance or a government license
- Injuries or illnesses due to military, paramilitary, police service, high risk activities, or suffered under conditions of war
- Reimbursement of procedures obtained through government programs
- 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
- Out-patient/take-home medicines
- Valvular Heart Disease and Rheumatic Heart Disease
- Medico-legal consultations
- When a member is discharged against medical advice, and all 19. subsequent benefits/services related thereto.
- 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
- All hospital charges and professional fees after the day and time hospital discharge has been duly authorized and professional fees of Assistant Surgeons
- All conditions and complications requiring dental care
- Hypersensitivity/allergy tests
- Diseases declared by the Department of Health (DOH) as Epidemic
- 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 fees are based on a specific number of principal-enrollees that were culled from the client’s employee census.
- If membership fee is employer-employee shared or employee-paid, we require at least 75% participation of employee principals.
- Accommodation / Benefits Plan of Principal Members must follow a uniform category (e.g., officers at Private room, rank-and-file employees at Semi-Private room, etc.) pre-established by the client at the start of the program.
A. Principal members: Regular employees at least 18 years old to less than 65 years old.
B. Dependents: (Following Hierarchy Guidelines)
- For single employees: Parent(s) first who is/are less than 65 years old and not gainfully employed; followed by the eldest sibling down to the youngest who is/are 15 days to less than 21 years old, unmarried and not gainfully employed.
- For single parent employees: Eldest child down to the youngest, 15 days to less than 21 years old, unmarried and not gainfully employed.
- For married employees: Spouse first who is less than 65 years old; followed by the eldest child down to the youngest, 15 days to less than 21 years old, unmarried and not gainfully employed.
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.
Philhealth / ECC
- 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.
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 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 / Billing Statement
- 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
Maximum Benefit Limit (MBL)
The Maximum Benefit Limit per person per illness or injury per year will depend on the member’s Room Accommodation.
Philhealth Provision with Additional and Optional Benefits
Our program is not integrated with benefits under the PhilHealth.
Additional Benefits include Prescription Medicine Benefit and Life (Group Term) Insurance with Insular Life. Optional Benefits include Dental Benefits.
Latest Modalities of Treatment and Dreaded Diseases
The limits of the procedures shall apply inclusive of professional fees and related incidental expenses (covered up to MBL or up to certain limits).
Coverage is subject to the Maximum Benefit Limit per person per illness or injury per year.
Pre-Existing Conditions (PECs)
An illness or condition shall be considered pre-existing if before the Effective Date of the Agreement and are not covered in the first year of coverage.
Such as all pregnancy related conditions requiring medical/surgical care, psychiatric disorders, sexually transmitted diseases, and cosmetic/dental/oral surgery.
Membership Eligibility and Coverage
Includes info on Individual and Principal members, also coverage of dependents of Principal members, membership fees, enrollment and approval of application, and effective date of coverage.
You and Your Family Come First
Together, let’s map out a future-proof family health plan.
Insular Head Office
2/F Insular Health Care Building, 167 Dela Rosa corner Legazpi Street, Legazpi Village, Makati City 1229, Metro Manila, Philippines
(632) 813-0131 to 0136
24/7 support through Insular Health Care’s Call Center (Toll Free Number 1-800-10-8177857)