MediCard Standard Plan Form

MediCard Philippines, Inc.
URG – FO – 001
Head ofﬁce: 8th Floor The World Center Bldg., Rev. 02
330 Sen. Gil Puyat Avenue, Salcedo Village, Makati City 1200
Tel. Nos.: (02) 8884-9999 / 8841-8080 • Toll Free: 1800-1888-9001
1 JANUARY 2020
Fax No.: (02) 8810-3855
Text: Key in REG <NAME> and send to 0917 851-2648 (Globe) or
0908 884-1814 (Smart & Sun Subscribers)
E-mail: [email protected]
Website: www.medicardphils.com
APPLICATION FOR MEMBERSHIP

INSTRUCTIONS:
PLEASE PRINT OR TYPE YOUR ANSWER TO THE QUESTIONS AND CHECK THE APPROPRIATE BOX WHERE APPLICABLE.
USE INK. DO NOT FILL-OUT SHADED BOX, THIS IS FOR EDP USE ONLY.
FAMILY NAME FIRST NAME MI BIRTHDATE PLACE OF BIRTH
YYYY MM DD
SEX CIVIL STATUS HEIGHT WEIGHT NATIONALITY CONTACT No(s). EMAIL ADDRESS
MALE SINGLE WIDOW / WIDOWER FT. IN. LBS.
FEMALE MARRIED SEPARATED
PRESENT ADDRESS: UNIT/BLDG., NUMBER, STREET, SUBDIVISION, BARANGAY CITY PROVINCE TIN NUMBER
PERMANENT ADDRESS: UNIT/BLDG., NUMBER, STREET, SUBDIVISION, BARANGAY CITY PROVINCE SSS NUMBER
TYPE OF PLAN OCCUPATION GROUP/CORPORATE NAME NATURE OF WORK

(I)NDIVIDUAL (G)ROUP
(F)AMILY (C)ORPORATE
PRINCIPAL/PAYOR (FOR APPLICANT UNDER PLAN TYPES F, G, OR C) RELATIONSHIP TO PRINCIPAL/PAYOR
LAST NAME FIRST NAME MI
ROOM PLAN MODE OF PAYMENT SOURCE OF INCOME INSURANCE BENEFICIARY

ANNUAL QUARTERLY EMPLOYED PENSION (NOT MINOR, FOR SME OR CORPORATE ACCOUNTS ONLY)
SEMI-ANNUAL MONTHLY SELF EMPLOYED OTHERS
AGENT: LAST NAME FIRST NAME MI CODE
1. Have you ever been treated for or ever had any known indication of: Yes No DETAILS OF “Yes” ANSWERS, IDENTIFY QUESTION NUMBER,
a. Disorder of eyes, ears, nose, or throat? CIRCLE APPLICABLE ITEMS: (Include diagnosis, results, dates,
b. Dizziness, fainting, convulsions, headache, speech defect, paralysis duration and names and addresses of all attending physicians and
or stroke, mental or nervous disorder? medical facilities)
c. Shortness of breath, persistent hoarseness or cough, blood-spitting
bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic
respiratory disorder?
d. Chest pain, palpitation, high blood pressure, rheumatic fever, heart
murmur, heart attack, or other disorders of the heart or blood vessels?
e. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis
colitis, hemorrhoids, recurrent indigestion, or other disorders of the
stomach, intestines, liver or gallbladder?
f. Sugar, albumin, blood or pus in urine, venereal disease, stone or
other disorders of kidney, bladder, prostate or reproductive organs?
g. Diabetes, thyroid or other endocrine disorders?
h. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the
muscles or bones, such as spine, back or joints?
i. Deformity, lameness or amputation?
j. Disorder of skin, lymph glands, cysts, tumor, or cancer?
k. Allergies, anemia or other disorders of the blood?
l. Excessive use of alcohol, tobacco or any habit-forming drugs?
2. Are you now under observation or taking treatment?
3. Do you smoke cigarette? If so, how many sticks a day?
4. Other than above, have you:

a. Had any physical disorder or any known indication thereof?
b. Had a medical examination, consultation, illness, injury, surgery?
c. Been a patient in a hospital, clinic, sanitarium, or other medical facility?
d. Had electrocardiogram, x-ray, other diagnostic tests?
e. Been advised to have any diagnostic test, hospitalization, or surgery,
which was not completed?
5. Have you ever had military service deferment, rejection or

discharge because of physical or mental condition?
6. Have you ever applied for or received a pension, payment, or

benefit due to injury, sickness or disability?
7. Do you have a parent, brother, sister who died of or had high

blood pressure, tuberculosis, diabetes, cancer, heart or kidney
disease, or mental illness?
8. FOR FEMALES ONLY:
a. Have you ever had any abnormal menstruation, pregnancy, childbirth
or disorder of the female organs or breast?
b. Are you now pregnant? If yes, how many months?
c. Are you taking contraceptive pills?
9. Have you ever been rejected or terminated for medical insurance
including MediCard program, or have been offered insurance at
a higher (rated-up) premium? If Yes, please explain.
This medical questionnaire must be updated to include any condition or disease which occurs after the date of submission of the application and prior to MediCard’s
acceptance. Failure to provide this information to MediCard will constitute a misrepresentation of the presence of a pre-existing condition or disease and may void the
coverage. Receipt of membership fees by MediCard does not constitute acceptance of the application as a MediCard program member. MediCard reserves the right to
reject any applicant and is not obligated to disclose the reason for rejection.
We hereby certify that the foregoing answers are true and complete and to the best of our knowledge. Our health is accurately represented in the above statements. We
understand that MediCard may require us to have a physical examination and we authorize the release of any information from such examination to MediCard for use in
considering our application. We also understand and agree that whenever necessary in the administration of the Service Agreement, MediCard physicians may discuss
with any hospital, health care facility, physician and surgeon, or other health care professionals medical information related in this application. We understand that this
information is collected in connection with the evaluation and processing of any application for coverage or a change of benefits, or to determine eligibility for benefits.
We apply for MediCard program membership and agree that we shall abide by the provisions of the Contract and MediCard regulations. We understand that there is no
coverage unless our application is approved by the MediCard Underwriting Group and that MediCard will not be liable for any medical bills between the time that we sign
this application and the effective date of our coverage if our application is approved. Any money we may have sent will be returned if the application is rejected, except our
processing fee.
Note: In the event the applicant is applying alone or is a minor, the applicant’s name should be entered on the “Signature of Applicant” line, and the applicant’s payor, parent
or guardian or family member should sign where indicated.
CONSENT: In compliance with Republic Act 10173 also known as the Data Privacy Act of 2012, we need your Consent to allow us to collect and process your information.
We will only disclose and share your information with our accredited healthcare providers who may also be responsible in rendering our services to you
Withholding or withdrawal of such Consent shall relieve us from our obligation to deliver the appropriate services to you.
You are afforded with certain rights and protection in accordance with the said Act and you may visit www.medicardphilscom/privacy or email [email protected]
for more information
By signing below, we will consider that you agree to give your Consent to us. If in case, applicant/patient/claimant is unable to sign, his/her authorized representative
may warrant that he/she has full authority to sign on behalf of the applicant/patient/claimant.
SIGNATURE OVER PRINTED NAME / RELATIONSHIP TO APPLICANT DATE
WITNESSED BY:
SIGNATURE OF SOLICITING AGENT AGENT’S CODE NUMBER SIGNATURE OF APPLICANT DATE
NAME OF AGENCY SIGNATURE OF APPLICANT’S DATE

PAYOR, PARENT OR GUARDIAN
OR FAMILY MEMBER
MEDICAL ACTION / DATE

(A)PPROVED
(D)ISAPPROVED
D(E)FERRED YYYY MM DD
MEDICAL DEPARTMENT REMARKS

MediCard Healthcare Program Agreement
For Individual/Family – Standard
MediCard Philippines, Inc., (hereinafter referred to as “MediCard”), a duly organized and registered
corporation, with principal office address at 8th Floor, The World Centre Building, 330 Sen. Gil Puyat
Avenue, Makati City 1200, through the undersigned as its duly authorized representative, hereby
confers this MediCard Healthcare Program Agreement – Standard (the “Agreement”) to the
PRINCIPAL MEMBER who agreed to engage the services of the former under the terms and
conditions stipulated herein.
ATTY. JUAN ANDRES S. MONTOYA

COO - MediCard Philippines, Inc.
Conforme:
_________________________________________
Signature over printed name of Principal Member
_________________________________________
Date signed
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MediCard Healthcare Program For Individual/Family – Standard P a g e | 2 of 28
TERMS AND CONDITIONS
I. DEFINITION OF TERMS
1. 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.
2. ACCREDITED HOSPITAL - A duly licensed hospital included in the list of accredited hospitals
of MediCard with which MediCard has an existing and valid service agreement and where a
MEMBER can avail of medical services pursuant to this Agreement.
3. ACCREDITED MEDICAL CLINIC - A duly licensed medical health care facility included in the
list of accredited medical clinics of MediCard which has an existing and valid accreditation
agreement with MediCard and where a MEMBER can avail of medical services pursuant to
this Agreement.
4. ACCREDITED PHYSICIAN/DOCTOR - A duly licensed physician or specialist accredited by

MediCard and named in the list of MediCard’s accredited physician with whom MediCard
has made arrangements to provide the required services under this Agreement.
5. ANESTHESIOLOGIST - A specialist duly licensed and registered to administer anesthetic

agents and conduct other anesthesia procedures during medical operation.
6. ATTENDING PHYSICIAN - An Accredited Physician who is part of the medical staff of an

Accredited Hospital or Accredited Medical Clinic, and legally responsible for the care given
to a MEMBER while in the hospital or on out-patient basis.
7. AUTHORIZED REPRESENTATIVE - A person duly authorized by MediCard to approve the

provision of medical services or claims reimbursements to a MEMBER.
8. CONVALESCENT CARE OR REHABILITATION CARE - The restoration of a person's ability to

function as normally as possible after a disabling illness or injury.
9. CUSTODIAL OR MAINTENANCE CARE - Care furnished primarily to provide room and board
(which may or may not include nursing care, training in personal hygiene and other forms
of self-care and/or supervisory care by a physician); or care furnished to a person who is
mentally and physically disabled and:
a. who is not under specific medical, surgical or psychiatric treatment so as to reduce the
disability to such extent necessary as to enable them to live outside an institution
providing such care; or
b. when, despite such treatment, there is no reasonable likelihood that the disability will
be so reduced.
10. COMPLEX DIAGNOSTIC EXAMINATIONS - Procedures which may or may not be invasive in
nature involving use of nuclear/radionuclide scans, digital imaging, fiberoptic/video
endoscopy, markers/dyes and specific modalities listed in “Schedule A - Benefit Coverage”.
11. DEVELOPMENTAL, CONGENITAL CONDITION, BIRTH DEFECT - 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.
12. DISABILITY - An illness or injury and any symptoms, sequelae, or complication thereof
requiring treatment. All injuries arising from the same event or series of continuous events
are considered as one Disability.
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13. DISEASE – Any illness, injury or adverse medical condition characterized by the abnormal
functioning of a part, organ or system of the human body hallmarked by identifiable signs
and symptoms, including all Disease Complications thereof.
14. DISEASE COMPLICATION – Any illness, injury or adverse medical condition that is caused by
or is a consequence of an identifiable disease process. A disease complication shares the
same limit as the primary disease which caused it.
15. DOMICILIARY CARE - Care provided because care in the patient's home is not available or
unsuitable.
16. DURABLE MEDICAL EQUIPMENT - As determined by the MediCard, medically prescribed

items of medical equipment for repeated use, owned or rented, such as but not limited to
crutches and wheelchairs which are placed in the home of a MEMBER to facilitate
treatment and/or rehabilitation of illness or injury.
17. EFFECTIVE DATE - The date the Agreement commences as specified in this Agreement.
18. ELIGIBLE EXPENSES - Expenses incurred in the treatment of a covered illness or injury
which are Medically Necessary and not exceeding the limits in “Schedule B – Membership
Fees ”.
19. EMERGENCY CONDITION - A life threatening or accidental injury or a sudden and

unexpected onset of a condition or illness which at the time of the occurrence reasonably
appears to have the potential of causing immediate Disability or death, or which requires
the immediate action or alleviation of pain or discomfort. These illnesses or injuries require
urgent medical or surgical care and attention which the MEMBER secures immediately
after the onset or as soon as the care may be made available.
20. EXPIRY DATE - The date the Agreement is scheduled to terminate.
21. HAZARDOUS JOB-RELATED ILLNESSES/INJURIES ARISING FROM NEGLIGENT ACTS -

illnesses/injuries suffered on the occasion, or as a consequence, of the performance of a
job brought about by negligence or non-use of protective measures in jobs requiring the
handling of biological agents, radioactive substances, toxic chemicals and high voltage
equipment.
22. IN-PATIENT - A person who has been admitted to a hospital as a registered bed patient and
is receiving services under the direction of a MediCard accredited physician.
23. INJURY - Physical damage or trauma arising wholly and exclusively from an Accident or
other events of violent or external, and visible nature.
24. LETTER OF AUTHORIZATION (LOA) - Letter of authorization duly issued by MediCard to,
and signed by, the MEMBER which shall serve as the authority of the latter to avail of the
medical services.
25. 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.
26. MAXIMUM BENEFIT LIMIT (MBL) - The maximum limit that MediCard shall cover and
assume per covered illness or injury (including related illnesses) of a MEMBER within the
term of this Agreement. MBL is replenished upon renewal of the Agreement.
27. MEDICAL BENEFITS - The medical, surgical and dental services available as out-patient or
in-patient benefits generally at no cost to MEMBERS if within the agreed scope of
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coverage, whenever the need for them arises, and when rendered by and in MediCard
accredited doctors, hospitals and clinics.
28. MEDICAL DIRECTOR (in an HMO set-up) - is a physician who is responsible in assuring
healthcare delivery for health plans, products and services by leading, developing, directing
and implementing medical and non-medical activities that impact health care quality, cost
and outcomes in a financially responsible manner.
29. MEDICALLY NECESSARY - A medical service, as determined by MediCard, which is (a)

consistent with the diagnosis and customary medical 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.
30. MEDICAL SERVICE UNITS/TEAMS - A group of MediCard physicians and other allied health
professionals, who will carry out the delivery of MediCard medical and hospital services to
MediCard MEMBERS.
31. MEDICARD HEALTH PROGRAM AGREEMENT - Refers to this Agreement. It contains the
provisions of enrollment eligibility and effective date; benefits and coverages; claims and
member satisfaction provisions; exclusions and limitations of benefits; payment of
membership fee; termination of coverages; etc.
32. MEDICARD IDENTIFICATION CARD - The identification card issued to the MEMBERS for
their identification. It contains the MEMBER’s name, account number and validating
signature.
33. MEDICINE AND DRUGS - Those for which a licensed medical practitioner has prescribed for
dispensing, which are specifically required for the treatment of a covered illness or injury
under this Agreement.
34. MEMBER - A Principal and/or Dependent who is eligible, has been accepted for
Membership by MediCard after complying with the Eligibility provision, and is currently
enrolled under this Agreement.
35. MEMBERSHIP - Refers to membership in MediCard, pursuant to this Agreement.
36. OUT-PATIENT - A person receiving medical services under the direction of a MediCard
physician, but not as an in-patient.
37. PRIMARY ACCREDITED PHYSICIAN - The officer-in-charge physician who acts as the family
physician of the MEMBERS in their MediCard accredited hospital. He directs the MEMBERS'
medical care, examines, treats and/or refers MEMBERS to specialists, orders x-ray and
other laboratory tests, prescribes medicines and arranges for hospitalization, if needed.
This person must not be a relative of the MEMBER up to the third degree of consanguinity
and affinity.
38. PRIVATE NURSE - A licensed nurse providing close observation and performing special
treatments, which are certified as Medically Necessary by the Attending Physician.
39. PROFESSIONAL FEES - Fees paid to licensed medical professionals including but not limited
to Occupational Therapists, Physiotherapists, Attending Physicians, Surgeons,
Anesthesiologists, or Pathologists.
40. ROOM AND BOARD ACCOMMODATION - The pre-assigned type of hospital room and
board by MediCard to the MEMBER based on the benefit and coverage of the health care
plan under this Agreement.
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41. STATEMENT OF ACCOUNT (SOA) - The statement of account duly issued by MediCard on or
before the due date of payment reflecting Membership Fee and other monetary
obligations, if any, payable by the Principal Member.
42. SURGERY - The 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 out-patient setting for a covered lllness or
lnjury.
II. BENEFITS AND COVERAGES
All the benefits provided for in this Agreement are detailed in “Schedule A – Benefit
Coverage”, and subject to the following terms and conditions:
1. In case of Out-Patient, the MEMBER can go directly to the primary physician of any
accredited hospital/clinic for out-patient consultation. The primary physician will request
for laboratory or diagnostic examinations or refer the MEMBER to a specialist. The
MEMBER may avail of services from any accredited hospital/clinic of his/her choice upon
issuance by MediCard of the Out-Patient Consultation Form or Laboratory Request Form.
2. For In-Patient services, all limits are inclusive of room and board, operating room charges,
professional fees and other incidental expenses relative to the procedure. A Letter of
Authorization (LOA) together with other necessary documents shall be issued by
MediCard prior to confinement. The maximum benefit limit and annual benefit limit shall
be inclusive of consultations, diagnostic procedures and hospitalization. Before being
discharged from the Hospital, a Member must fill up the prescribed discharge form and
settle that portion of the medical bill not covered by the Agreement. That portion of the
bill covered by the Agreement shall be settled directly by the HMO with the hospital
and/or Attending Physician(s).
3. All procedures or benefits are subject to the limitations on pre-existing conditions as

stated in this Agreement.
4. Non-emergency confinement or surgery (elective cases) shall be subject to prior review

and approval by the MediCard review board. MediCard reserves the right to direct the
MEMBERS to other physicians or specialists for further opinions as needed so as to
protect the interest of both the MEMBER and MediCard.
5. In all circumstances of Emergency Care Services, MediCard reserves the right to validate
whether treatment received is emergency in nature and/or the illness or condition is
covered under the provisions of this Agreement.
6. In case a MEMBER is simultaneously covered under another health maintenance

agreements with MediCard, the MEMBER shall not use the benefits of his other
MediCard coverage (if any) simultaneously with the benefits of this MediCard Health
Program Agreement, the MEMBER on a per confinement basis, shall only avail of the
benefits accruing from one agreement. The MEMBER must choose which agreement will
apply and his/her confinement will be governed by the terms and conditions and the
limits of the agreement of his/her choice. The provision is without prejudice to the other
benefits availed of by the MEMBER under another agreement which may apply for other
confinements.
7. Hospitalization or in-patient coverage of a MEMBER will depend on his/her final

diagnosis. All diagnostic procedures will only be covered if results are within inclusions of
this Agreement.
8. All MediCard patient-MEMBERS are considered to be patients of the MediCard Medical

Director handled by his authorized designates. As such, coverage or non-coverage of
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certain illness not listed herein shall be upon his discretion after proper consultation with
the concerned accredited physician.
9. For purposes of determining the amount utilized by the MEMBER of his/her “per disease,
per year limit,” it shall be understood that any Disease Complication shall share the same
limit as the primary disease which caused it, and any amount expended for the treatment
of the Disease Complication shall be included in the total amount expended for the said
primary disease for the year. Similarly, the exclusion of a primary disease from coverage
by MediCard shall cover any Disease Complication that may have been caused by the said
excluded primary disease. This provision shall be applicable to all benefits provided by
MediCard under this Agreement, especially those provided for under this “Schedule A –
Benefit Coverage”. Note that this Section is applicable only for Accounts which limit is
MBL.
III. PRE-EXISTING CONDITIONS PROVISIONS
1. Any illness, injury or any adverse medical condition shall be considered pre-existing if
prior to the effectivity date of membership, the pathogenesis or onset of such illness,
injury or adverse medical condition has started as determined by MediCard's Medical
Director or accredited physicians. The determination of the pre-existing condition shall
not be limited to one (1) year from the effectivity date of membership.
2. Without necessarily limiting the following enumeration, the following are automatically
considered as pre-existing conditions if consultation or treatment is sought within the
first twelve (12) months of coverage:
a. Any dreaded diseases as defined in this Agreement except letters k and l.

b. Hypertension
c. Goiter (Hypo/Hyperthyroidism)
d. Cataracts/Glaucoma
e. ENT conditions requiring surgery
f. Bronchial Asthma/Allergy/Urticaria
g. Tuberculosis
h. Chronic Cholecystitis/Cholelithiasis (gall bladder stones)
i. Acquired Hernias
j. Prostate disorders
k. Hemorrhoids and Anal Fistulae
l. Benign Tumors
m. Uterine Myoma, Ovarian Cyst, Endometriosis
n. Buergher's Disease
o. Varicose Veins
p. Arthritis
q. Migraine Headache
r. Gastritis/Duodenal or Gastric Ulcer
3. Pre-existing condition as defined in Sections 1 and 2 shall only be covered after twelve
months from effectivity date of membership, except as otherwise stated in Schedule “A”
of this Agreement; provided however, that there is no failure to disclose, misrepresent or
conceal, material information in the original Application or Application for reactivation.
Notwithstanding the disclosure by the Member of a pre-existing condition, MediCard
may permanently exclude from coverage a specific medical condition, illness or injury
upon written notice to the MEMBER.
4. It is understood that the foregoing benefits shall likewise be applicable to "dreaded

diseases" as defined under Article XII, Section 2 of this Agreement.
5. If there is a stipulated maximum limit on selected procedures or benefits, the coverage

should be within both the pre-existing conditions coverage and the stated maximum
limit.
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6. 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.
IV. CLAIMS AND REIMBURSEMENTS
1. REIMBURSEMENT PROCEDURE
All claims for reimbursement must be submitted or forwarded to MediCard Head Office
within thirty (30) calendar days after discharge from the hospital. Failure to do so shall
invalidate the claim, except if it can be shown in writing that it was not reasonably
possible to furnish such documents within thirty (30) calendar days.
Required documents in availing reimbursement:
a. Emergency confinement in non-accredited hospital attended by a non-accredited

doctor
▪ Duly filled-up claim form
▪ Clinical Abstract
▪ Medical Certificate to include complete final diagnosis
▪ Surgical/Operative report if an operation was done
▪ Original Official Receipt paid to hospital and doctor
▪ Hospital statement of account and corresponding charge slips
▪ Police report if due to accident or medico-legal case
▪ Incident report why MEMBER was confined in a non-accredited hospital
b. Emergency confinement in an accredited hospital attended to by a non-accredited

doctor
▪ Duly filled-up claim form
▪ Clinical Abstract
▪ Original Official Receipt paid to the hospital and doctor
▪ Hospital statement of account and corresponding charge slips
▪ Incident report or proof that MediCard accredited doctor was not available
during the time of confinement
c. Out-Patient emergency consultation/treatment by a non-accredited doctor in areas

where there are accredited hospitals/clinics.
▪ Original Official Receipt paid to the doctor
▪ Incident report
d. Out-Patient emergency or non-emergency consultation/treatment by a non-

accredited doctor in areas where there is no accredited Hospital/Clinic.
▪ Original Official Receipt
▪ Incident report
2. RECONSIDERATION OF DENIED REQUEST FOR PAYMENT
If a request for payment is denied, the MEMBER or the MEMBER's authorized

representative may appeal the decision by filing a written request with MediCard Head
Office within thirty (30) days after receiving a negative decision. The request must set
forth why the MEMBER believes that the decision was in error. The MEMBER may
examine pertinent documents not subject to "privileged communication" (as discussed in
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Rule 130, Section 24 of the Rules of Court) or disclosure and may submit additional
written statements for consideration of the appeal.
Upon completion of the procedure, the MEMBER will receive a written notice stating the
final MediCard decision and the reason for such decision.
3. 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.
4. PHYSICAL EXAMINATION AND AUTOPSY
MediCard 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.
5. BENEFIT PAYMENT
a. All benefits payment shall be in PHILIPPINE PESO.
b. lf a MEMBER incurs Eligible Expenses during the effectivity of this Agreement,

MediCard will pay benefits in accordance with “Schedule A - Benefit Coverage” of
this Agreement. MediCard will pay the Eligible Expenses after application of any
stipulated co-payment or other deductions that may apply.
c. 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.
d. MediCard reserves the right to deny Claims for Reimbursement if the procedures
and requirements have not been strictly complied with.
6. PAYMENT OF CLAIMS
All benefits that pertain to a MEMBER will be paid by check to the order of Principal
Member, unless the Principal Member requests otherwise, or HMO, in its discretion,
considers it preferable to make the payment 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 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.
V. EXCLUSIONS AND LIMITATIONS
1. HOSPITALIZATION
a. All confinement shall be upon recommendation of the MEMBER’s MediCard

accredited Physician, or the MediCard Medical Director or the Emergency Room
Resident Physician of the MediCard Accredited Hospital who decides to admit
MediCard patient-MEMBER in cases of life threatening emergencies.
b. Hospital bills for the following hospital services shall be charged to the account of
the MediCard patient-MEMBER: services of a private nurse or doctor, use of extra
food and/or bed, T.V., electric fan, video/audio disc player, ID bracelet, thermometer
and all other items not directly related to the medical management of the patient.
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c. Hospitalization and treatment outside the Philippines is not covered except where
there is a coverage for “Emergency Care Services in Foreign Countries”, explicitly
indicated in “Schedule A - Benefit Coverage” of this Agreement.
d. MediCard is not responsible and will not recognize any hospital bills incurred by a
MEMBER in hospitals not accredited by MediCard, except for emergency care
services under the terms provided in this Agreement.
e. Cost of hospitalization, medical services, medicine and other expenses incurred as a

result of a MEMBER's decision to avail of such hospitalization, medical services,
treatment or procedure, not prescribed or contrary to what has been prescribed by
the MediCard attending physician, or without MediCard’s express written report shall
not be shouldered by MediCard.
2. OUT-PATIENT SERVICES
a. Prescribed medicines on an out-patient basis are not provided by MediCard-owned

Clinics or Medical Service Units.
b. The absolutely no charge out-patient medical and health care services are provided
only during clinic hours of Medical Service Units.
c. Second opinions and cost of treatment incurred in non-accredited hospital or clinic

should the MEMBER unilaterally decide to seek such recourse.
3. EXCLUSIONS
Except as otherwise provided in this Agreement, the following shall be excluded in the
coverage given by MediCard:
a. Services which a MEMBER receives from a non-MediCard Physician, non-MediCard

Accredited Hospital or other provider of care, Accredited Physician in non-MediCard
Accredited Hospital or other provider of care, except as described in the emergency
care in non-MediCard hospitals, as provided for in this Agreement;
b. Hereditary and/or congenital defects of whatever form;
c. Sensorineural hearing impairments except those acquired during time of

membership;
d. Plastic and reconstructive surgery for cosmetic purposes and for physical congenital
deformities and abnormalities;
e. Dermatological care for aesthetic purposes such as electrocautery or chemical

treatment for skin tags, xanthelasma, milia, keloids, scars, etc. on any exposed area
of the body;
f. Guillain-Barre syndrome, multiple sclerosis, demyelinating disease, Parkinson’s

disease, Alzheimer’s disease, Myasthenia gravis, epilepsy, seizure disorder and other
autoimmune neurologic diseases;
g. Slipped disc, scoliosis, spinal stenosis and spondylosis;
h. AV malformation and aneurysms which are considered congenital except only those
unequivocably proven to be acquired secondarily;
i. Corrective eye surgery for error of refraction including laser surgery for correction of
myopia and hypermyopia;
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j. Psoriasis, vitiligo;
k. Experimental medical procedures, acupuncture, acupressure, reflexology and

chiropractics;
l. Services to diagnose and/or reverse infertility or fertility and virility/potency (erectile

dysfunction);
m. Open heart surgeries, angioplasties, valvuloplasties, permanent pacemaker insertion,

intracoronary thrombolysis, balloon valvuloplasties, transvenous endocardial biopsy,
percutaneous intraaortic balloon pump insertion, balloon atrial septostomy, previous
craniotomy sequelae, organ transplantation and complication and other surgeries
related to the heart;
n. Diagnostics for hypersensitivity and desensitization treatment;
o. Purchase or lease of durable medical equipment, oxygen dispensing equipment and

oxygen except during hospital confinement under the Hospital Confinement Benefit;
p. Corrective appliances and artificial aids and prosthetic devices;
q. Human blood products like platelets, packed RBC, plasma, gamma globulin, etc. and
its processing;
r. Psychiatric and psychological illnesses including neurotic and psychotic behavior

disorders;
s. Treatment for alcoholic intoxication and drug addiction or overdose reaction to use
of prohibited drugs including illnesses directly related to it and other injuries
attributed as a result of it;
t. Rehabilitation treatment, physical, speech, occupational and hormonal therapies;
u. Developmental disorders, metabolic diseases, sleep and eating disorders;
v. Sexually transmitted diseases such as Hepatitis B, condyloma, gonorrhea, syphilis,

herpes, etc. and their attendant complications;
w. Pelvic inflammatory disease, tubo-ovarian abscess, pyosalpingitis, etc.;
x. HIV/AIDS;
y. Hazardous job-related illnesses and/or injuries;
z. Physical examinations required for obtaining or continuing employment, insurance or

government licensing, health permit, requirement in school and other similar
purposes;
aa. Injuries or illnesses resulting from participation in war-like or combat operations,

riots, insurrection, rebellion, strikes and other civil disturbances;
ab. Treatment of self-inflicted injuries or injuries attributable to the MEMBER'S own

misconduct, gross negligence, use of alcohol and/or drugs, vicious or immoral habits,
participation in act of crime, violation of a law or ordinance, unnecessary exposure to
imminent danger or hazard to health and hazardous sports related injuries;
ac. Maternity care and other conditions as a result of pregnancy unless specifically
provided;
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ad. Custodial, domiciliary care, convalescent and intermediate care;
ae. Oral surgery for purposes of beautification, temporomandibular joint disease (TMJ)
surgery done by dental practitioner;
af. Circumcision, except for correction of Phimosis;
ag. Treatment of injuries sustained in a motor vehicle accident if the MEMBER or his
guardian fails or refuses to execute the Deed of Subrogation specified in Article XII,
Section 16 of this Agreement;
ah. Professional fees of medico-legal officers;
ai. Diagnosis of unknown etiology or the absence of any organic dysfunction;
aj. Cost of vaccines for active and passive immunization except as otherwise provided
for in this Agreement;
ak. Laboratory examinations for screening sexually related illnesses and injuries; and
al. Any condition or illness waived upon membership except as otherwise provided for in
this Agreement.
4. LIMITATION IN SERVICES: MediCard is not responsible for the following:
a. Delay or failure to render services due to major disasters, brownouts or epidemics

affecting facilities or personnel.
b. Unusual circumstances such as complete or partial destruction of facilities, war, riots,

disability of a significant number of MediCard personnel or similar events which result
in delay to provide services.
c. Conditions for which a MEMBER has refused recommended treatment for personal
reasons, for which MediCard physicians believe no professionally acceptable
alternative treatment exists.
d. Sudden change of hospital policies.
VI. MEMBERSHIP ELIGIBILITY
1. The following are eligible for Membership under this Agreement:
a. Principal Member:
Any person at least 18 years old up to 60 years of age.
b. Qualified Dependent Member:
For Married Principal Member
b.1 Legal spouse up to 60 years of age.

b.2 Legitimate and/or legally adopted children 30 days old and up to 21 years of age
who are not gainfully employed and unmarried.
For Single Principal Member
b.1 Parents up to 60 years of age.

b.2 Brothers and sisters 30 days old and up to 21 years of age.
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For Single Parent Principal Member
Children 30 days old and up to 21 years of age.
2. HIERARCHY RULE FOR DEPENDENTS. The choice of enrolling dependents must follow a
hierarchy. This means that for married principal member, the spouse must be enrolled
first followed by the eldest child, second child and so on. For single principal member, the
parents must be enrolled first followed by eldest brother/sister and so on.
If the Principal Member is married, his/her parents, brothers or sisters are no longer
eligible as Qualified Dependents unless expressly provided for in this Agreement.
VII. PHILHEALTH/ECC PROVISION
It is hereby declared and agreed that hospitalization benefits due under the PHILHEALTH
and/or Employee Compensation Commission (ECC) program are assigned to and integrated
with the MediCard program such that any of the MediCard benefits due under this
Agreement shall be net of the MEMBER's PHILHEALTH and/or Employee Compensation
Commission (ECC) benefits. MediCard will not pay or advance the costs of such benefits, nor
be responsible for filing any claims under PHILHEALTH and/or ECC.
VIII. EFFECTIVITY AND DURATION OF THIS AGREEMENT
1. This Agreement shall take effect on the date specified in Schedule B – Standard
Membership Fee upon signing by the parties thereof and upon receipt by MediCard of
the full membership fee, and will be in force and effect for a period of one (1) year.
2. This Agreement terminates upon expiration of the one-year period unless the same is
renewed under such terms as may be agreed upon by both parties. Such agreements to
be signified in writing as an amendment to this Agreement, or a new Agreement may be
issued to replace the expired agreement.
3. Any aggrieved party may pre-terminate this Agreement for cause (i.e. any act of bad
faith, breach of agreement, etc.), save in cases cited below, upon service of thirty (30)
days notice to the other. MediCard shall have the right to immediately terminate this
Agreement in the event that: (a) any material misrepresentation; or warranty made by
the MEMBER is false or untrue; or if the MEMBER commits any act with the intent to
defraud MediCard; or (b) the MEMBER’s non-payment of appropriate fees and other
obligations subject to agreed payment terms.
4. Free Look Provision. The MEMBER may terminate this Agreement by giving a written
notice within fifteen (15) days from his/her receipt of the contract. The MEMBER may
cause the termination of this Agreement provided the membership lD Cards and this
Agreement are surrendered to MediCard within the same period. If payment was made
by the MEMBER, the amount shall be returned in full to the MEMBER. MediCard shall
thereafter terminate the membership and the termination provision of this Agreement
shall apply. Failure to terminate this Agreement within the period set shall be understood
as an acceptance of all terms and conditions provided hereunder. Any availment of a
MEMBER within the fifteen (15) - day period shall also mean acceptance by the MEMBER
of all the terms and conditions of this Agreement.
5. The MEMBER may terminate this Agreement for justifiable reasons at any time by giving
a written notice to MediCard at least thirty (30) days prior to the intended termination
date. The MEMBER may only terminate this Agreement if it 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, MediCard shall be free from all
liabilities to the MEMBER. This shall be without prejudice to the right of MediCard to
collect Client's obligations which have become due and demandable.
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6. Membership coverage shall automatically terminate when: (a) the MEMBER has
fraudulent availment or material misrepresentation or misstatements for the purpose of
availing the benefits; or (b) when the MEMBER fails to observe the terms and conditions
of this Agreement with utmost good faith.
7. In all cases, termination shall be without prejudice to the right of MediCard to collect
MEMBERS obligations which have become due and demandable. All medical expenses
incurred after the date of termination of the MEMBER’s coverage shall be charged to the
MEMBER.
8. The termination of this Agreement will not hold MediCard responsible to provide the
medical and health care services described herein to such enrolled MEMBER, who are still
confined in any of the MediCard Accredited Hospitals or undergoing emergency
treatment in non-accredited hospitals at the time of the termination of this Agreement.
However, only the hospital charges applicable up to the time of termination of the
Agreement will be paid by MediCard.
9. In case of pre-termination under Article VIII, Section 3 hereof, where the MEMBER is the
aggrieved party entitled to a refund, maximum benefit limits as well as other benefits
with limits will be pro-rated according to the number of months where applicable
premiums were made. All benefits availed beyond determined limits will be deducted
from refundable fees, or will be billed to the MEMBER, as the case may be. The provision
of Article IX, Section 8 shall apply.
10. In case of renewal, the MEMBER cannot avail the benefits under this Agreement unless
the Membership Fee is fully paid and the MEMBER has no outstanding obligations with
MediCard.
IX. PAYMENT TERMS AND CONDITIONS
1. MEMBERSHIP FEE. The Principal Member with respect to this Agreement, agrees to pay
MediCard the full membership fee as specified in “Schedule B – Membership Fees”.
2. PAYMENT OF MEMBERSHIP FEE. The Membership Fee are considered due on the
effective date of this Agreement. Upon renewal, the MEMBER is however, given a grace
period of thirty (30) days from the due date, which is the date the effectivity of this
Agreement lapses, to pay the full membership fee.
Should there be any dispute, contest or conflict regarding the SOA on any substantial
matter pertaining thereto, the MEMBER shall pay the undisputed portion of the
Statement of Account (SOA) on or before the due date stated therein, notwithstanding
such dispute, contest or conflict, unless the MEMBER 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 that dispute,
contest or conflict was settled by the MEMBER and MediCard. In this regard, a full
payment of such adjusted SOA shall be made within fifteen (15) days from the time of
receipt of such adjusted SOA.
The absence of any written notice to MediCard regarding dispute, contest or conflict in
the details contained in the SOA within seven (7) days from receipt thereof shall
constitute MEMBER’s absolute agreement thereto.
3. DELINQUENCY, GRACE PERIOD AND LAPSATION PROVISIONS.
a. This Agreement shall automatically lapse and be void, without need of any notice,
if the membership fee remains unpaid after thirty (30) days from the due date,
which is the grace period for payment of membership fee.
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b. During the thirty (30) days period, all the benefits and privileges of membership
under this Agreement shall be suspended until such time that the membership fee
are settled.
c. All claims incurred during the grace period shall be reimbursed to the MEMBER, after
the membership fee due is paid, which reimbursable amount should be based on
MediCard relative rates.
4. APPLICATION OF PAYMENT. All payments received by MediCard from the MEMBER shall
be applied to the SOAs, in the order of respective due dates, starting from the earliest.
Payment will be applied to the interest or penalty first before applying it to the principal
amount.
5. EFFECTS OF NON-PAYMENT OF MEMBERSHIP FEES. Non-payment of the Membership

Fees due after the grace period shall entitle MediCard to:
a. Suspend all services under this Agreement or services to MEMBERS whose

Membership Fees have not yet been received, until full payment of all Membership
Fees due, including penalty charges equivalent to five percent (5%) a month or a
fraction thereof on the unpaid Membership Fees due, computed from due date; and
b. Terminate this Agreement without prejudice to collecting the amount due and the
corresponding penalty charges that have accrued thereon.
6. REACTIVATION OF AGREEMENT. A Member whose coverage has lapsed may apply to

reactivate his or her coverage within fifteen (15) calendar days from the end of the grace
period by (a) submitting a written request for reactivation; (b) paying the Membership
Fee due with arrears, including the penalty charge per Member; (c) for modes of
payment other than annual, paying in advance the Membership fee due for the next
period.
Suspension of benefits under this Agreement shall be in force until such time the
Member shall have paid in full all fees required in reinstatement of his or her coverage.
If, after fifteen (15) days from the end of the grace period, all fees required in reactivation
of coverage have not yet been paid and settled, MediCard shall have the right to
disapprove reactivation. However, Member may re-apply subject to approval of
MediCard. Claims incurred during the suspension shall not be reimbursed even after the
lifting of suspension.
7. REFUND/CREDIT OF MEMBERSHIP FEE. If a member’s coverage is terminated or

cancelled, the unused pro rata Membership Fee paid shall be refunded to the MEMBER,
only if no availment has been made by the MEMBER prior to the termination or
cancellation. The schedule of refund is provided below:
If the Agreement/Membership has Percent of refund from the paid

been in force for Annual Membership Fees
Not more than one (1) month 80%
More than one (1) month but less than
70%
three (3) months
At least three (3) months but less than
40%
six (6) months
Six (6) months or more No refund
Note: A processing fee of P50.00 shall be deducted from the refundable amount.
Furthermore, there shall be no refund of membership fees in the event that the MEMBER
has availed of any benefit under this Agreement.
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If the Membership Fees are unpaid prior to cancellation or termination of membership,

MEMBER shall settle the pro rata membership fee, inclusive of penalty charges if
applicable.
X. MEMBERSHIP
1. DEADLINE FOR ENROLLMENT OF DEPENDENTS:
a. For dependents who meet the eligibility requirements within the Agreement
period - 30 days from the date dependent becomes eligible for membership (copy of
birth certificate or marriage agreement must be submitted).
b. Any additional dependents other than the above can be enrolled upon the renewal of
AGREEMENT.
c. After the lapse of the periods specified above, MediCard shall no longer receive,
evaluate and accept any designation or application to be a Qualified Dependent of a
Principal Member.
2. UNDERWRITING CUT-OFF DATES IN ASSIGNING EFFECTIVITY DATE:
Date of Receipt of Application/Endorsement Effectivity Date

11th to 25th of the month 1st of the following month
26th to 10th of the month 16th of the same month
3. New enrollees who are approaching age of ineligibility must be enrolled at least six (6)
months counting from the date of effectivity up to the date that the enrollees become
ineligible for them to be accepted as MEMBERS (i.e. If age of eligibility is up to 60 years
old, only applicants who are 60 years and 6 months old and younger will be accepted for
membership). All pre-existing conditions/maximum benefit limits will be computed on a
prorated basis.
4. Renewing MEMBERS who will become age ineligible within the next renewal agreement
year will be allowed to renew regardless of the remaining months that the MEMBER will
remain eligible. However, pre-existing conditions/maximum benefit limits will be
computed on a prorated basis (i.e. If age of eligibility is up to 60 years old, a renewing
MEMBER who is 60 years and 9 months old will still be renewed). All Pre-existing
conditions/maximum benefit limits will be computed based on the following formula:
Total months that MEMBER remains eligible X PEC/MB limit = Pro-rated limit
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5. Enrolled MEMBER who will reach the age of ineligibility can still be accommodated until
the end of the contract period, provided that, within thirty (30) days prior to reaching the
age of ineligibility, the MEMBER will pay the membership fees for the remaining months
that he is considered ineligible.
6. In relation to his/her dependents, the MEMBER shall be known as the Principal and
he/she shall be deemed to have undertaken to comply with all the requirements and
obligations of individual regular membership under the Agreement on behalf of said
dependent/s, particularly the payment of the required fees, dues and charges.
7. MEMBERSHIP REQUIREMENT
a. The MEMBER undertakes to submit to MediCard the following:
Valid Identification Card

b. MediCard undertakes to furnish the MEMBER the following:
b.1 Membership application forms to be filled by the MEMBERS;
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b.2 MediCard Identification Card
b.3 this Agreement
C. The Identification Cards merely provide information about the MEMBER and do not
constitute this Agreement and neither do they guarantee the delivery of the benefits
herein contained.
8. UPGRADING/DOWNGRADING OF PLAN. Upgrading or downgrading of MEMBER's plan

shall not be allowed during the contract period. Changes in plan, including upgrading or
downgrading of plan is allowable only during the renewal of this Agreement subject to
the approval of MediCard.
XI. MATERIAL MISREPRESENTATION OR NON-DISCLOSURE
Failure to disclose or misrepresentation of any material information by the MEMBER or any

applicant for membership under this Agreement, whether intentional or not, shall entitle
MediCard to terminate this Agreement, and/or terminate the membership of the MEMBER
concerned, respectively, at the option of MediCard, effective immediately upon receipt of
the MEMBER of a notice of termination for this case. Information is deemed material if:
a. it is among those required to be answered or supplied in the corporate and/or individual

application and/or medical examination forms of MediCard at the time of application;
b. it would have revealed the existence of a pre-existing condition under Article III or of a
"dreaded disease" as defined under Article XII, Section 2;
c. it would be determinative of an "exclusion" as defined under Article V; or
d. it would have resulted in the disapproval of the application of the PRINCIPAL MEMBER
and/or the MEMBER for membership, or the assessment of a higher membership fee for
the benefit/s applied for with MediCard in accordance with the prevailing practice of
MediCard at the time the misrepresentation or non-disclosure was discovered.
In case of invalidation of the agreement due to fraudulent non-disclosure or

misrepresentation of any material information by the MEMBER, he/she shall not be entitled
to a return of membership fees which may have been paid already to MediCard, as well as
any and all benefits which may be provided under this Agreement. Furthermore, MediCard
may also demand for reimbursement of the cost of services rendered or amount already
refunded to the member plus administration fee; however, in the event that there is no
fraud, MediCard shall return the membership fees paid less cost of previous services
rendered by MediCard and all amounts already refunded to the MEMBER including
administration fee.
XII. GENERAL PROVISIONS
1. ENTIRE AGREEMENT. This Agreement together with its Annexes and the Applications
for Membership altogether constitute the entire agreement between MediCard and the
MEMBER, and no statement, promise or inducement made by or through any other
party not contained herein shall be binding or valid. All statements and information
contained in the MEMBER’s Application Form shall be deemed representations and
warranties made by the MEMBER himself for purposes of applying the provisions of this
Agreement. The Conforme Letter, Renewal Agreement or any agreement between the
Parties shall constitute as execution of this Agreement by the Parties. This Agreement
supersedes all prior undertakings, arrangements, representations, agreements, whether
valid or verbal between the Parties. All services and benefits arising out of this
Agreement are valid only in the Philippines. Any amendment to this Agreement must be
approved by MediCard and shall form part of this Agreement. Unless agreed by the
Parties in writing, no such alteration or endorsement shall affect any agreement issued
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prior thereto. This Agreement shall be governed by and construed in accordance with
the laws of the Republic of the Philippines. It is hereby agreed that the venue for actions
arising out of this Agreement shall be in Makati City, Philippines.
2. DREADED DISEASES. Potentially or actually life threatening conditions. They may also be
illnesses that may require unusually or uncustomary prolonged or repeated
hospitalization and may likewise require intensive care management. These are
enumerated but not limited to the following illnesses/conditions which are considered as
dreaded disease:
a. Cerebrovascular Accident (stroke)

b. Central Nervous System lesions (Poliomyelitis/Meningitis/Encephalitis/
neurosurgical conditions)
c. Cardiovascular Disease (Coronary/Valvular/Hypertensive Heart Disease/
Cardiomyopathy)
d. Chronic Obstructive Pulmonary Disease (Chronic Bronchitis/Emphysema),
Restrictive Lung Disease
e. Liver Parenchymal Disease (Cirrhosis, Hepatitis (except Type A), New Growth)
f. Chronic Kidney/Urological disease (Urolithiasis, Obstructive uropathies, etc.)
g. Chronic Gastrointestinal Tract Disease requiring bowel resection and/or
anastomosis
h. Collagen diseases (Rheumatoid Arthritis, Systemic Lupus Erythematosus)
i. Diabetes Mellitus and its complications
j. Malignancies and Blood dyscrasias (Cancer, Leukemias, Idiopathic
Thrombocytopenic Purpura)
k. Injuries from accidents or assaults, frustrated homicide or frustrated murder;
subject to police report
l. Complications of an apparent ordinary illness including MODS and SIRS (e.g. sepsis
due to pneumonia, typhoid ileitis, Kawasaki disease, cerebral malaria, etc.)
m. Single or multiple organ dysfunction and failure (MODS and MOF)
n. Conditions that may require dialysis
o. Chronic pain syndrome (greater than six weeks)
p. Any illness other than the above which would require Intensive Care Unit
confinement
MediCard shall pay for the consultation and hospitalization services, as herein defined,
of a MEMBER for "dreaded disease" up to the stated maximum amount or limit as
specified in “Schedule B – Membership Fees”, “per illness per year” or “per member/per
family unit per year”, whichever is applicable.
"Dreaded diseases" which are pre-existing in accordance with this Agreement are to be
governed by the provisions of Article III.
3. 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.
4. GENERAL PROVISIONS FOR ROOM ACCOMMODATION
If a MEMBER occupies a room higher than what he/she is entitled to, during confinement
except during emergency care, he/she shall share in the medical expenses according to
the following formula:
a. If a MEMBER occupies a higher priced room of the same category, the MEMBER shall
pay for the excess on room & board:
Computation:
(Rate of room occupied minus maximum room and board benefit) multiplied by
(No. of days confined)
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b. If a MEMBER occupies a room one category higher than what he/she is entitled to,
the MEMBER shall pay for the incremental cost on hospital expenses and professional
fees and the excess on room & board.
▪ Incremental cost for hospital expenses:

(Total hospital bills minus total room and board charges minus disapproved
charges) multiplied by 30%
▪ Incremental cost for professional fees:

Medical case: MRV* Actual Room – MRV* Assigned Room
Surgical case:
Ward to Private Room: MRV* Private – MRV* Ward
Private Room to Suite: MRV* Suite – MRV* Private
Note: *MRV – MediCard Relative Value
c. If at the time of the confinement the Accredited Hospital has no available room in
accordance with the MEMBER’s Room and Board Accommodation and the MEMBER
is entitled under this Agreement to avail of the next higher room available, he/she
may avail the said benefit in accordance with “Schedule A - Benefit Coverage”, Article
VI.
5. EXCESS CHARGE. Services availed by a MEMBER in excess of the coverage or allowable

limit shall be settled by the MEMBER directly with the hospital. Failure of the MEMBER
to settle the excess charges shall necessitate MediCard to bill the MEMBER, all excess
charges with corresponding twenty percent (20%) service fee, payable within fifteen (15)
calendar days from receipt of billing. Otherwise, a corresponding penalty of one percent
(1%) per month will be incurred. If the bills remain unpaid after thirty (30) calendar days,
the concerned MEMBER shall cease to be entitled for coverage until after bills have been
settled in full.
6. NON-TRANSFERABILITY PROVISIONS. This Agreement or any of the benefits hereunder

can neither be transferred nor assigned by the MEMBER to any other person. Any
purported assignment or delegation of this Agreement is null and void and can be
considered as breach of this Agreement.
7. AUTHORITY TO EXAMINE MEDICAL RECORDS. The MEMBER hereby represents and

warrants that, at the time of the effectivity of this Agreement and effectivity of
coverage, it has authorized MediCard and any of its authorized representatives to
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;
The MEMBER shall hold MediCard 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 MediCard or any of its directors,
stockholders, officers, employees, agents, or representatives in connection with or
arising from the use by MediCard of the MEMBER's medical records and other personal
information pursuant to this Agreement.
8. MISCELLANEOUS PROVISION. It is hereby understood that, to be entitled to the

benefits under this Agreement, the MEMBER hereby waives his/her consent to the
disclosure and processing of his/her medical/health information which is determinative
for the assessment of his/her coverage and necessary for the treatment of his/her illness.
MediCard, its Medical Service Units/Teams and its Accredited Hospitals/Clinics are hereby
released from any liability by reason of such disclosure.
9. CONFIDENTIALITY. The MEMBER shall not use or reproduce, directly or indirectly any
Confidential lnformation for the benefit of any person, or disclose to anyone such
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Confidential lnformation without the written authorization of MediCard, whether during

or after the term of this Agreement, for as long as such information retains the
characteristics of Confidential lnformation.
"Confidential lnformation" means any data or information, that is proprietary to

MediCard 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 MediCard; (iv) any
vendor, names, customer, 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
MediCard; (vi) all intellectual or other proprietary or material information of MediCard;
(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 MediCard. All information which the MEMBER acquires or becomes
acquainted with during the period of this Agreement, whether developed by MediCard
or by others, which the MEMBER has a reasonable basis to believe to be Confidential
lnformation, or which is treated, designated and/or identified by MediCard as being
Confidential lnformation, shall be presumed to be Confidential lnformation. Confidential
lnformation need not be novel, unique, patentable, copyrightable or constitute a trade
secret in order to be designated as Confidential lnformation.
10. FUTURE TAXES, LEVIES AND GOVERNMENT IMPOSITION. lf during the effectivity of this
Agreement, the fees and benefits are made subject to new taxes, levies or fees, or such
law, regulation or its equivalent resulted to changes in the formula or manner of
computing taxes thereby resulting in additional obligations on the part of MediCard, any
additional amount due shall automatically be charged to the MEMBER in addition to the
fees stated therein. Future taxes, levies or fees referred herein are only those that affect
the quoting of Membership Fee (Ex. 12% VAT), other future taxes, levies or government
impositions that do not affect the quoting of Membership Fee are therefore excluded.
11. ARBITRATION. Any difference arising between the MEMBER and MediCard shall be
referred to an arbitrator to be appointed by the parties to the dispute. lf the parties are
unable to agree on a single arbitrator, two (2) arbitrators shall be appointed (one by
each party). ln 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
MediCard, may be registered medical practitioners 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 MediCard.
12. AUTHORIZED SIGNATORY. The Parties hereby represent that their respective
representatives had been duly authorized by the Board of Directors to sign, execute and
deliver this Agreement.
13. SEPARABILITY. lf any term or provision of this Agreement is declared invalid, illegal or
unenforceable under Philippine laws, such invalidity, illegality or unenforceability shall
not affect or render unenforceable any other term or provision of this Agreement.
14. NOTICES. All notices, demands and other communications required or permitted
hereunder shall be made in writing and sent to the Parties addresses indicated herein.
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15. MEMBERS SATISFACTION SERVICE
a. All questions or concerns of MEMBERS about the medical services and benefits shall
be directed to the MediCard Head Office. MEMBERS must provide complete and
necessary information so that the Customer Management Assistant, Customer care
Officers and/or other appropriate staff or Administrative Personnel can work with the
MEMBER to resolve the MEMBER's concern in a timely manner.
b. An Emergency Assistance Response Service (E.A.R.S.) that operates on a 24 hour/day

365 day/year basis to respond to inquiries shall be available at the following
telephone numbers:
Tel. No. : 8841-8080

Toll Free Nos. : 1800-1888-9001
Text MediCard : Key in specific information or request on your mobile phones
and send to: (0917) 8512648 for Globe subscribers; (0908)
8841814 for Smart subscribers and (0922) 3822943 for Customer
Management Group.
c. Open door policy. Direct access to a network of one thousand fifty-two (1,052)
accredited hospitals/clinics nationwide, three (3) mall-based clinics, nine (9) hospital-
based clinics, fifteen (15) referral desks and sixteen (16) free-standing clinics including
a Head Office Clinic.
16. RIGHT OF SUBROGATION. MediCard medical and hospital services are extended to a
MEMBER if the MEMBER's bodily injuries and fractures are claimed to have been caused
by any act or omission of a third party through a motor vehicle. Provided, however, that
the MEMBER executes an agreement to subrogate to MediCard whatever rights the
MEMBER may have by reason of such accident or event that gave rise to such claim to
the extent of the value of the services so rendered and that the MEMBER will undertake
to assist MediCard in the successful recovery of the losses. The agreement to subrogate
form is available at MediCard Head Office.
17. CIVIL CODE ARTICLE 1250 WAIVER. The provisions of Article 1250 of the Civil Code of the
Republic of the Philippines (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.
18. IMPORTANT NOTICE. The lnsurance 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. lt is ready at all times
to assist the general public in matters pertaining to HMO. For any inquiries or complaints,
please contact the Public Assistance and Mediation Division (PAMD) of the lnsurance
Commission at 1071 United Nations Avenue, Manila with telephone numbers 632-
85238461 to 70 and email address [email protected]. The official
website of the lnsurance Commission is www.insurance.gov.ph.
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Schedule A – Standard Benefit Coverage

I. PREVENTIVE HEALTH CARE SERVICES. The Preventive Health Care Services will be provided to
MEMBERS by designated MediCard Medical Service Units.
HEALTH CARE BENEFITS COVERAGE/LIMIT

1. Annual Physical Examination (APE) shall be conducted once a year at designated MediCard
Clinics. APE shall include the following:
a. Complete Blood Count
b. Urinalysis (urine examination)
c. Fecalysis (stool examination)
d. Chest X-ray up to the maximum benefit limit
e. Electrocardiogram (for members 40 years old per member per year
and above, or if prescribed)
f. Pap smear (for women 40 years old and above,
or if prescribed)
2. Management of Health Problems up to the maximum benefit limit
per member per year
3. Routine Immunization (except cost of vaccines) up to the maximum benefit limit
per member per year
4. Counselling on health habits, diets and Family up to the maximum benefit limit
Planning per member per year
5. Record Keeping of Medical History up to the maximum benefit limit
per member per year
II. OUT-PATIENT CARE SERVICES. Out-Patient Services will be provided to MEMBERS in any
MediCard accredited hospitals/clinics.

1. Referral to specialists up to the maximum benefit limit
per member per year
2. Regular Consultations and treatment (except up to the maximum benefit limit
prescribed medicines) per member per year
3. Eye, Ear, Nose and Throat treatment up to the maximum benefit limit
per member per year
4. Treatment of minor injuries and surgery not up to the maximum benefit limit
requiring confinement per member per year
5. X-ray and laboratory examinations prescribed by up to the maximum benefit limit
MediCard physician per member per year
6. Physical and speech therapy up to ten (10) sessions within the
maximum benefit limit
per member per year
7. Laser treatment for glaucoma and retinal up to P20,000.00 per member
detachment per year
8. Cataract extraction (including phacoemulsification) up to the maximum benefit limit
excluding the cost of lens per member per year
9. Cauterization of warts including facial warts up to P1,000.00 per member
per year
10. First dose of anti-tetanus up to P1,000.00 per member
per year
11. Tuberculin test (excluding screening) up to P800.00 per member
per year
12. Consultations for Chronic Dermatoses (except up to the maximum benefit limit
Psoriasis) per member per year
13. Consultations for Scabies up to the maximum benefit limit
per member per year
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III. DENTAL CARE SERVICES. MEMBERS may avail of the following dental care services from any of
the accredited dental clinics:

1. Once a year oral prophylaxis up to the maximum benefit limit
per member per year
2. Consultations and oral examinations up to the maximum benefit limit
per member per year
3. Simple tooth extractions, except surgery for up to the maximum benefit limit
impacted or ankylosed tooth, etc. per member per year
4. Temporary fillings up to the maximum benefit limit
per member per year
5. Gum treatments for cases like inflammation or up to the maximum benefit limit
bleeding per member per year
6. Recementation of loose jackets, crowns, in-lays and up to the maximum benefit limit
on-lays per member per year
7. Treatment of mouth lesions, wounds and burns up to the maximum benefit limit
per member per year
8. Adjustment of dentures up to the maximum benefit limit
per member per year
9. Emergency out-patient dental treatment up to the maximum benefit limit
per member per year
10. Temporomandibular Joint (TMJ) consultations up to the maximum benefit limit
per member per year
11. Restorative and Prosthodontic consultations up to the maximum benefit limit
per member per year
12. Dental nutrition and dietary counselling through up to the maximum benefit limit
chairside instruction per member per year
13. Dental Health Education up to the maximum benefit limit
per member per year
14. Pre and post natal dental consultations up to the maximum benefit limit
per member per year
IV. IN-PATIENT CARE SERVICES. The following hospitalization (In-Patient) services shall apply when
MediCard physicians prescribe the hospitalization of MEMBERS in any MediCard Accredited
Hospitals:

1. No deposit upon admission up to the maximum benefit limit
per member per year
2. Room & Board according to type of enrollment up to the maximum benefit limit
per member per year
3. Use of operating theatre and Recovery Room up to the maximum benefit limit
per member per year
4. Services of MediCard specialist like anesthesiologists, up to the maximum benefit limit
internists, surgeons, etc. per member per year
5. Services and medications for general/spinal
anesthesia or other forms of anesthesia deemed up to the maximum benefit limit
necessary for a surgical procedure per member per year
6. Fresh whole blood transfusions and its up to the maximum benefit limit
processing/screening and intravenous fluids per member per year
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up to the maximum benefit limit

7. X-ray and laboratory examinations
per member per year
8. Administered medicines
per member per year
9. Dressings, plaster casts, sutures and other items
directly related to the medical management of the
per member per year
patient-MEMBER
10. ICU confinements
per member per year
11. Human blood products (e.g. platelets, packed RBC) up to the maximum benefit limit
and its processing/screening except gamma globulin per member per year
12. Admission kit including wee bag
per member per year
up to ten (10) sessions within the
13. Chemotherapy maximum benefit limit per member
per year
14. Radiotherapy:
a. Intensified Modulated Radiotherapy
up to ten (10) sessions within the
b. Three-Dimensional Conformal Radiotherapy
maximum benefit limit per member
(3DCRT)
per year
c. Tomotherapy
d. Brachytherapy
15. Dialysis: up to ten (10) sessions within the
maximum benefit limit per member
a. Continuous Renal Replacement Therapy (CRRT) per year
16. Laparoscopic procedures (once a year): up to P20,000.00 per member
a. Single Incision Laparoscopy Surgery (SILS) per year
up to P20,000.00 per member
17. Lithotripsy/ESWL (once a year)
per year
18. Hysteroscopic procedures (once a year)
per year
19. Stereotactic brain biopsy/ Stereotactic breast biopsy up to P20,000.00 per member
(once a year) per year
20. Gamma knife surgery (once a year)
per year
21. Percutaneous ultrasonic nephrolithotomy (once a up to P20,000.00 per member
year) per year
22. Transurethral Microwave Therapy (TUMT) of the up to P20,000.00 per member
prostate (once a year) per year
23. Arthroscopically-guided procedures
per year
24. CT Scan, MRI and ultrasound guided excisions:
a. CT Guided Percutaneous Discectomy per year
25. Endoscopically-guided excisions/ treatments/ up to P20,000.00 per member
procedures per year
26. Intradiscal Electrothermal Therapy (IDET)
per year
27. Laser/ Coblation Tonsillectomy
per year
28. Endovenous Laser Therapy/Endovenous Laser
Ablation/ Radiofrequency Ablation (except for
per year
cosmetic purposes)
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29. Coblation Procedures
per year
30. Ductoscopy (Breast) guided excisions/ treatment/ up to P20,000.00 per member
procedures per year
31. Endoscopic Ultrasound guided excisions/ up to P20,000.00 per member
treatments/ procedures per year
32. Infrared Coagulation Hemorrhoidectomy
per year
33. Mammotome/ Vacuum Assisted Breast Biopsy
per year
34. Stereotactic Radiation Therapy/ Stereotactic up to P20,000.00 per member
Radiosurgery per year
35. Thyroplasty (implant not covered)
per year
36. Transarterial Hemorrhoidal Dearterialization (THD)
per year
37. Ultroid Hemorrhoid Management
per year
38. Any other modern therapeutic procedure not up to P20,000.00 per member
mentioned above per year
39. Magnetic Resonance Imaging (MRI)/ Magnetic
Resonance Angiography (MRA):
a. Tractography/Diffusion Tensor Imaging up to P5,000.00 per member
per year
b. Superparamagnetic Iron Oxide (SPIO) enhanced
MRI
40. CT Scan:
a. Multislice/ multidetector/ spiral/ multirow CT up to P5,000.00 per member
per year
b. Ultrafast Electron Beam Computed Tomography
41. Ultrasound:
a. Intravenous Ultrasound/ Intravascular up to P5,000.00 per member
Ultrasound per year
b. Contrast Enhanced Ultrasound

42. Robotic Surgery/ Robotically-assisted Surgery
per year
43. Photodynamic Therapy
per year
44. Acoustic Radiation Force
per year
45. Capsule Endoscopy
per year
46. New modalities and/or diagnostic and treatment
procedures for conditions with established etiologies up to P5,000.00 per member
and its use is only an alternative to the conventional per year
methods
47. Laboratory/ancillary services for conditions whose
pathogenesis or subsequent clinical improvement is up to P5,000.00 per member
not yet fully established in Medical Science per year
48. Other medically necessary modalities not mentioned
above and those for which there are no comparable, up to P5,000.00 per member
conventional or traditional counterparts per year
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49. Positron Emission Tomography (PET) Scan
per year
50. Stapled Hemorrhoidectomy
per year
51. Cryosurgery
per year
52. The following complex diagnostic examinations:
a. Angiography (e.g. coronary, cerebral, retinal,
fluorescein, pulmonary, GI, etc.)
b. Serum chemistry panels (e.g. Chem 23, Spec M,
etc.)
c. Pulmonary perfusion scan
d. Tests involving use of Nuclear Technologies (e.g.

Radionuclide Scan/Ventriculography, Thallium up to P5,000.00 per member
stress testing, Pyrophosphate Scintigraphy, per year
Myocardial Perfusion Scanning, etc.)
e. Electromyography, Nerve Conduction Velocity
Studies
f. 24-Hour Holter Monitoring, 2-D Echo and
Doppler
g. Treadmill Stress Test
h. Myelogram
i. Diagnostic Endoscopy including one of video: up to P5,000.00 per member
i.1 Multiphoton endoscopy per year
j. Diagnostic Arthroscopy
k. Diagnostic Hysteroscopy
l. Adrenocortical Function, Plasma/Urinary up to P5,000.00 per member
Cortisol, Plasma Aldosterone, etc. per year
m. Mammogram and Sonomammogram
n. Bone densitometry scan (Dexascan)

o. Immunologic Studies:
o.1 Anti-nuclear antibody (ANA)
o.2 C-Reactive Protein
o.3 Lupus cell exam
o.4 Enhanced Luciferase Complementation / up to P5,000.00 per member
Luciferase Immunoprecipitation Assay per year
o.5 Enzyme-linked Immunosorbent Spot
(ELISPOT) Assay
o.6 ESAT-6 and CFP-10 Antigens
o.7 QuantiFERON Tuberculosis (QFTB)
p. Genetic Studies:
p.1 Alpha Globin/Globulin Genotyping
p.2 Beta Globin/Globulin Genotyping up to P5,000.00 per member

p.3 BCR-ABL by Quantitative Real-time per year
Polymerase Chain Reaction (QRT-PCR, RT-
PCR
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p.4 Duolink In-Situ Fluorescence Hybridization

(DISH)/Array Comparative Genomic
Hybridization (aCGH)
p.5 Epidermal Growth Factor Receptor (EGFR)
Mutation Assay/Test
p.6 Fluorescence In-Situ Hybridization (FISH)
p.7 JAK-2 Mutation
p.8 Karyotyping
p.9 KRAS Testing
p.10 Philadelphia chromosome per year
p.11 Polymerase Chain Reaction (PCR) for katG
and rpoB
p.12 Polymerase Chain Reaction Single Strand
Conformation Polymorphism (PCR-SSCP)
p.13 Reverse Transcription Polymerase Chain
Reaction (RT-PCR)
q. Magnetic Resonance Spectroscopy
r. Platelet Aggregation Test
s. 3D/4D ultrasound (except for maternity cases)
t. Ductoscopy (Breast)
u. Endoscopic Ultrasound up to P5,000.00 per member
v. Peritoneal Dialysis Adequacy Test per year
w. Peritoneal Equilibration Test
x. Spinal Angiogram
y. Any other complex diagnostic procedure not
mentioned above
53. Professional fee of the assisting physician in surgical up to the maximum benefit limit
procedures per member per year
54. Assistance in administrative requirements through up to the maximum benefit limit
the liaison officer per member per year
55. All other items related to the management of the up to the maximum benefit limit
case per member per year
V. EMERGENCY CARE SERVICES.

1. EMERGENCY CARE IN MEDICARD ACCREDITED
HOSPITALS/CLINICS
In cases of emergency where the MEMBER avails of

the services of MediCard Accredited Hospitals/
Clinics, the following will be provided:
a. Doctor's services up to the maximum benefit limit

b. Medicines used during treatment or for per member per year
immediate relief
c. Oxygen and intravenous fluids
d. Dressings, plaster casts, and sutures
e. Laboratory, x-ray and other diagnostic
examinations directly related to the emergency
management of the patient-MEMBER
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2. EMERGENCY CARE IN NON-MEDICARD ACCREDITED

HOSPITALS
a. When a MEMBER is in immediate danger of

losing a limb, eye or other parts of the body or is in
severe pain that requires immediate relief and enters MediCard agrees to reimburse
a non-MediCard accredited hospital for treatment.
eighty percent (80%) of the
approved total hospital bills and of
b. MediCard shall pay the said amount when it is professional fees, based on
verified that MediCard facilities were not used MediCard relative value for
because to have done so would entail a delay
accredited hospitals, up to the
resulting in death, serious disability or significant
amount of P30,000.00.
jeopardy to the MEMBER's condition or the choice of
hospital was beyond the control of the MEMBER or
the MEMBER's family. Other expenses not covered
in using non-MediCard Accredited Hospitals for
emergency care is follow up care.
3. EMERGENCY CARE IN FOREIGN COUNTRIES

MediCard shall reimburse one
In cases of emergency where a MEMBER avails of hundred percent (100%) of the
services in a foreign territory. approved total hospital bills and of
professional fees, based on the
MediCard relative value and in
Philippine currency, up to
P30,000.00.
4. Ambulance services (land transport) are covered on a reimbursement basis up to

P2,500.00 per member per year.
5. In cases of non-availability of room according to plan during emergency case, MEMBER
may avail of the next higher room available except suite room within the first twenty-four
(24) hours of confinement upon admission. All incremental costs incurred after the first
twenty-four (24) hours shall be for the personal account of the MEMBER, except when the
Accredited Hospital issues a certification of non-availability of the MEMBER’s room and
board accommodation.
VI. PRE-EXISTING CONDITIONS COVERAGE. This shall be based on the year of membership as
follows:
Year of membership Amount of Coverage

1st year No coverage
Up to P5,000.00 per illness per member per year
provided that the pathogenesis or onset of such
illness, injury or adverse medical condition started
2nd year of continuous
prior to membership or during the first twelve (12)
membership onwards
months from the effectivity date of membership;
otherwise, up to the maximum benefit limit per illness
per member per year
V. We do not offer MEMBERS' FINANCIAL ASSISTANCE in our package; we just endorse it to a third
party namely: Prudential Guarantee and Assurance, Inc. and First Life Guarantee Life Assurance
Company, Inc.; MEMBER will contract with them directly.
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Schedule B – Standard Membership Fee
(A separate page will be issued.)
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MediCard Philippines, Inc.

APPLICATION FOR MEMBERSHIP

FAMILY NAME FIRST NAME MI BIRTHDATE PLACE OF BIRTH

TYPE OF PLAN OCCUPATION GROUP/CORPORATE NAME NATURE OF WORK

ROOM PLAN MODE OF PAYMENT SOURCE OF INCOME INSURANCE BENEFICIARY

SEMI-ANNUAL MONTHLY SELF EMPLOYED OTHERS

AGENT: LAST NAME FIRST NAME MI CODE

2. Are you now under observation or taking treatment?

3. Do you smoke cigarette? If so, how many sticks a day?

4. Other than above, have you:

5. Have you ever had military service deferment, rejection or

6. Have you ever applied for or received a pension, payment, or

7. Do you have a parent, brother, sister who died of or had high

SIGNATURE OVER PRINTED NAME / RELATIONSHIP TO APPLICANT DATE

SIGNATURE OF SOLICITING AGENT AGENT’S CODE NUMBER SIGNATURE OF APPLICANT DATE

NAME OF AGENCY SIGNATURE OF APPLICANT’S DATE

MEDICAL ACTION / DATE

MEDICAL DEPARTMENT REMARKS

ATTY. JUAN ANDRES S. MONTOYA

TERMS AND CONDITIONS

1. ACCIDENT – A visible, external, sudden and violent event occasioned by a physical or

4. ACCREDITED PHYSICIAN/DOCTOR - A duly licensed physician or specialist accredited by

5. ANESTHESIOLOGIST - A specialist duly licensed and registered to administer anesthetic

6. ATTENDING PHYSICIAN - An Accredited Physician who is part of the medical staff of an

7. AUTHORIZED REPRESENTATIVE - A person duly authorized by MediCard to approve the

8. CONVALESCENT CARE OR REHABILITATION CARE - The restoration of a person's ability to

11. DEVELOPMENTAL, CONGENITAL CONDITION, BIRTH DEFECT - A medical abnormality

16. DURABLE MEDICAL EQUIPMENT - As determined by the MediCard, medically prescribed

19. EMERGENCY CONDITION - A life threatening or accidental injury or a sudden and

20. EXPIRY DATE - The date the Agreement is scheduled to terminate.

21. HAZARDOUS JOB-RELATED ILLNESSES/INJURIES ARISING FROM NEGLIGENT ACTS -

29. MEDICALLY NECESSARY - A medical service, as determined by MediCard, which is (a)

35. MEMBERSHIP - Refers to membership in MediCard, pursuant to this Agreement.

II. BENEFITS AND COVERAGES

3. All procedures or benefits are subject to the limitations on pre-existing conditions as

4. Non-emergency confinement or surgery (elective cases) shall be subject to prior review

6. In case a MEMBER is simultaneously covered under another health maintenance

7. Hospitalization or in-patient coverage of a MEMBER will depend on his/her final

8. All MediCard patient-MEMBERS are considered to be patients of the MediCard Medical

III. PRE-EXISTING CONDITIONS PROVISIONS

a. Any dreaded diseases as defined in this Agreement except letters k and l.

4. It is understood that the foregoing benefits shall likewise be applicable to "dreaded

5. If there is a stipulated maximum limit on selected procedures or benefits, the coverage

6. Diagnostic procedures undertaken to determine the existence of a Pre-existing Condition

IV. CLAIMS AND REIMBURSEMENTS

Required documents in availing reimbursement:

a. Emergency confinement in non-accredited hospital attended by a non-accredited

b. Emergency confinement in an accredited hospital attended to by a non-accredited

c. Out-Patient emergency consultation/treatment by a non-accredited doctor in areas

d. Out-Patient emergency or non-emergency consultation/treatment by a non-

2. RECONSIDERATION OF DENIED REQUEST FOR PAYMENT

If a request for payment is denied, the MEMBER or the MEMBER's authorized

4. PHYSICAL EXAMINATION AND AUTOPSY

a. All benefits payment shall be in PHILIPPINE PESO.

b. lf a MEMBER incurs Eligible Expenses during the effectivity of this Agreement,

V. EXCLUSIONS AND LIMITATIONS

a. All confinement shall be upon recommendation of the MEMBER’s MediCard

e. Cost of hospitalization, medical services, medicine and other expenses incurred as a

a. Prescribed medicines on an out-patient basis are not provided by MediCard-owned

c. Second opinions and cost of treatment incurred in non-accredited hospital or clinic

a. Services which a MEMBER receives from a non-MediCard Physician, non-MediCard

b. Hereditary and/or congenital defects of whatever form;