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PERSONAL ACCIDENT & HOSPITALIZATION ASSISTANCE PROGRAM (Reimbursement Type)

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Presentation on theme: "PERSONAL ACCIDENT & HOSPITALIZATION ASSISTANCE PROGRAM (Reimbursement Type)"— Presentation transcript:

1 PERSONAL ACCIDENT & HOSPITALIZATION ASSISTANCE PROGRAM (Reimbursement Type)

2 Hospitalization Assistance Program (HAP) Features -Reimbursement It is an annual reimbursement scheme for hospitalization expenses of teachers, school personnel and their dependents. Out-patient services are not included. Participation is voluntary and contribution shall be by salary deduction.

3 Pre-existing conditions shall apply to new members. Maximum confinement shall be 31 days per year. Successive confinements for the same cause shall be subject to limitations. Confinements must have 90 days gap.

4 Dreaded diseases are permanent exclusions. Members diagnosed for the first time to have any of such may be given a one-time cash assistance. Benign and malignant new growths found in female reproductive systems shall be covered subject to limitations. Spouse, parents and dependents are not included in this benefit.

5 Dengue shall be covered for one confinement per family, per year. Spouse or parents must not be more than 65 years old. Dependents must be 1-21 years old, but only for a maximum of four children, provided further that they are not yet married. For unmarried member, covered family includes parents and four elder unmarried siblings.

6 Reimbursement will cover only excess of PhilHealth benefits. Maximum limit of assistance per confinement will be: Option 1-P 15,000, Option 2-P17,000, Option 3- P18,000, Option 4-P20,000.

7 Family in military service of PNP are covered subject to limitations. Ailments related to female reproductive functions are covered for one (1) confinement per year for members only. Childbirth and infant/pediatric care are not covered.

8 Single member who gets married shall file a new application form indicating the immediate family as new beneficiaries. Official receipts are required but photocopied and authenticated receipts are also acceptable subject to conditions, namely: if they had been marked or stamped paid by another insurance or by a company benefit, HAP shall cover only 40% of the amount reflected in the receipt, subject further to the limitations of the option. Also, HAP may require original receipts to verify items in the photocopied documents.

9 Claims by husband and wife in the same institution will be subject to usual conditions/limitations on double indemnity. A member whose employment is terminated before the end of the covered year may get reimbursed for any claim but only to a maximum equivalent to his/her total contributions.

10 THE INSURANCE PROGRAM Accidental Death & DisablementPLAN IPLAN IIPLAN IIIPLAN IV Principal Insured50,000 Spouse/Parent25,000 Children/Siblings5,000 Unprovoked Murder & Assault Principal Insured25,000 Spouse/Parent12,500 Children/Siblings2,500 Bereavement Assistance Principal Insured2,0003,0004,0005,000 Spouse/Parent1,0001,5002,0002,500 Children/Siblings ,0001,250 Personal Accident Plan

11 ACCIDENTAL DEATH & DISABLEMENT Pays for the Principal Sum in case of accidental bodily injury that resulted to loss of life. In case of disability, this benefit also provides a fixed amount of compensation based on policy schedule

12 UNPROVOKED MURDER & ASSAULT When the Insured is intentionally injured or killed by another, and the injury or death is not a result of misconduct or provocation but is unforeseen insofar as the Insured is concerned, the program pays 50% of the Principal Sum.

13 BEREAVEMENT ASSISTANCE Pays a fixed amount as financial assistance in case of death to due accident and illness

14 THE INSURANCE PROGRAM Benefit TypePLAN IPLAN IIPLAN IIIPLAN IV Room & Board ,000 Hospital Services & Supply1,5006,0008,00010,000 Surgical Fee4,00010,00015,00020,000 Physician's Fee ,000 Maximum Limit Per Confinement15,00017,00018,00020,000 Cash Assistance for Dread Disease2,0004,0006,0008,000 Health Plan (Reimbursement Type)

15 ROOM & BOARD Takes care of your daily accommodation and hospital meal charges up to 31 days per year

16 HOSPITAL SERVICES & SUPPLIES Assures medical care for expenses such as use of operating room, medicines, laboratory examination, anesthesia, oxygen, nursing administration, ambulance service and other eligible miscellaneous expense

17 SURGICAL FEE Reimburses the cost of surgery, as prescribed in the Table of Surgical Schedule

18 PHYSICIAN’S FEE Pays for the fees charged by the attending physician for treatment or visits made to a patient, for whom a full day's room charge is made by the hospital for non- surgical treatment

19 CASH ASSISTANCE FOR DREADED DISEASE Full payment to the Insured upon diagnosis of Dread Disease specified under the policy, up to the maximum limit of coverage

20 CLAIMS SETTLEMENT The plan holder shall be required to submit the following documents for processing of reimbursement: * Duly Accomplished and Signed Claim Form * Medical Certificate * Hospital Statement of Account * Official Receipts * Other documents as may be required in support to the claim, as deemed necessary.

21 GENERAL EXCLUSIONS 1. Confinement of less than six (6) hours; OUTPATIENT Services. 2. Service of a private nurse or other medical professionals 3. Services of unlicensed medical practitioners 4. Pregnancy, childbirth, miscarriage or complication thereof

22 5. Charges not necessary for treatment of injury or sickness e.g. extra meals, laundry, telephone calls, rent of radio or TV set. 6. Dreaded Diseases such as cardio-vascular diseases, rheumatic heart disease, chronic glomerulonephritis, gullain-barre syndrome, cerebrovascular accident (stroke), neurosurgical/neurological conditions, blood dyscrasias, chronic pulmonary and renal diseases, cancer, benign and malignant growth, cataract, cirrhosis of liver, etc.

23 7. Medical Services provided free of charge by government or any civic organization. 8. Treatment and services not related to the diagnosed disease. 9. Epidemic and communicable diseases (cholera, SARS, bird flu, AIDS, AH1N1etc.)

24 10. Annual or periodic Check-Up. 11. Cosmetic surgery, nervous or mental disorders, HIV or STD- related diseases. 12. Rehabilitation for drug use or Psychiatric Care 13. Engagement in Extreme Sports or Dangerous professional sports or training

25 14. Experimental Medical procedures, acupuncture, speech therapy. 15. Self-inflicted injuries, suicide, and accidents due to drunkenness or illegal acts.

26 16. Injuries from military operations or exercises, assault in military personnel, civil disorder, strike, riot. 17. Medicines bought before or after the confinement dates. Maintenance medicines, supplements/vitamins and other medicines not prescribed by the attending physician.


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