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    297 views29 pages

    Intellicare PDF

    Uploaded by

    Ella Arlert

    Copyright:

    © All Rights Reserved
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    GROUP CORPORATE AGREEMENT ‘No: 80-00-08723/6 This agreement is made and entered into by and etree: ASALUS CORPORATION. «carport onic an exsing under Pippin fare sl eMERESL 0 Health Mon eerie toacs Leow aed rescred uber the nl mame INTELLICARE, wi PP Fee ee ning WA. Rafe Swen, Lega Vilage Makati City, berate refed 1 3 SINTELLICARE® and represcnied tn this at by NORMAN P. AMORA, Setlor Viee President and exiting under Philipines, with Corry GOVERNMENT OF VICTORIAS, 2 coporatin sasize nd Se ie .CIS FREDERICK P. PALANCA, rinipal oie a Vicionas Cy, Negros Occidental represen in tis ct by FRAN City Mayor, hescinaer ferred to "Cent WHEREAS. INTELLICARTE isa Heslth Maintenance Organization capsbe an competent in proving andr stranding health are services fr enrolled members Incatthcae an! hath masimenanee WHEREAS, INTELLICARE shall extend, daring the duration of this Agrecment Mids Members of Intlicae upon crices and programs to Client smployesimembers who would qualify as tons ‘arollnent and payment ofthe appropriate Membership Fees hy Tent Panties o this Apresment include INTELLICARE and Client ony [fective date of Agreement is on 17 April 2020, INOW. the parties have area as follows: SECTION ONE - DEFINITION OF TERMS ‘ccationed by a physical or watura eause and oeeurTig, 1. ACCIDENT, A visible, extemal, suen and violent event ath of the Member. rely beyond the Member's consol causing damage to the ACTIVELY AT WORK, Anemployee who: (son elo pat yacaton ave a enti ye Cento 0 t Aer day ti nt abso Form wk Bx 0 sickne nury o tet frm f isi: i was ace at aos tetancrccedang ruta working day port he Fetive Dat of his Agreement +. ANESTHESIOLOGIST. A specaist duly cco and registered to asninter anethtic agents aml coves her heathesia proeeores during media! operation. CARE shall assume for all covered on renewal of th 4. ANNUAL BENEFIT LIMIT (ABL). The main liability that INTI Aaa thd to Member win the one-year ters ofthis Agreement, ABI. i replenished ‘Agreement bu nat during extension. edited Hospital 5. ATTENDING DOCTOR. An Accreditedafiited Doctor win ut af the medical sta of an Ace bss ara an ally caps forthe ear vento Merber while inthe hosp or opi 6 AUTHORIZED REPRESENTATIVE. A person duly authored hy INTELLICARE to arene the provision of ‘nical services or claims eemburscinents 1 a Member my ais hereunder COAINSURANCE, Other insurance or benefits which ac paid or are payable in espeto 1B. 2. 24, 2. COSMETIC SURGERY. Reconstruction surgery or surgery stich is et . DURABLE MEDICAL EQUIPMENT. As determined by the Inelfcure, medically CCONFORME LETTER. INTELLICARE's fer ler seeped by the Cle hy affixing his signa om he AEE labeled as “Conforme”. ae i ai Aue DEVELOPMENTAL, CONGENITAL CONDITION, BIKTH DEFECT. A pysieal or mental abnormally °F Pires eating athe Ue of bh a well as neonatal pel or men] sbi veloping heer Peuse ‘of eausal fctors or conditions present atthe ime of bith. oNrRBUTORYIVOLUNTARY MEMBER. A Meer whose Meinbarship Fee i lly or partially pid for by COORDINATOR. Theft eootet doco for prinary cnslain.Thsnehides Assistant Coordinators medically necesary or which is performed ‘which the pervon coneemed considers oF ‘with the principal objective of improving the appearance of person oF for peychological reasons. adoption and believes will improve his appearance and inchales any surgery NECESSITY ‘personal satisfvetion in repeat of an illness or acident hereunder. CUSTODIAL CARE. Care provided mainly: (0 For pesto neds, amon or conenenee bY sees Wt aoe acting oil) To maiman pertona neds aerhan improve Neves! condition eee ae orl ered f= ysl or mena fncin orf provide = poked errno: DOMICHAARY CARE, Care provided becaute care inte pains home i ot avaiable ois unsuade preseribed items of modical DURA on repcd we, ned Feed, sch abt ot nied to cries nd wheels ‘which are placed in Tine ofa Member to feciiat treatment and/or reabiliation of lines or Injury. DREADED DISEASES, Cenrlly “hone and inevesble" conditions requing eqpent anor prolongs Pritszation, including those requiring continous confinement for fiteen (15) days or more, ERFECTIVE DATE, (2:0 am.on the date this Agreement takes effect ELECTIVE CASE. A nom-megeney ete hat neds no urgent eiment and ma be defer witha enn the member's life ELIGIBLE EXPENSES, Expenses incured inte teament ofa covered Hlnss oF Injury which are Messy Nesoasay andl not exceeding the limits in Schedule A - Benefit Coverage, EMERGENCY CASPY CONDITION. A conan tht mani isl by ae sign or muons of SITS eae yas medial professional cul reesorably expect thatthe members He or heh would is nt a ‘Sevous risk if no immediate attention is provided. EXPIRY DATE, The dat the Agreement is scheduled fo enate which sone (1) ear fom the Tesive Pate At T2200 midnight on the date of termination ofthis Agreement, GRACE PERIOD. A period orth nb fend days fom he dato ex of bling, For meri es So amc ia iy (30) days fr al ther ee, depends on he grcent between les an Incas 1b MEMBERSHIP CARD. The identification card issued by INTELLICARE fo « Menbercontsning i lates tee. account mamer, and other matters pertaining to his Membership. ILLNESSIDISABLITY.Allisjre aking om the same erent rere of continuous eves se costes one MnessDissbitiy. sickness (ocondion oan iment aTcig the general saundnes and bealth ofa men's bo) ‘A sickness (ction of body organs) having a defied and recognizable pater sympsone or teal condition leading 1 the Hngaimmen of nora psig! fncion and sequires medical treatment. {xcept in wn emergency e480 25, IN-PATIENT. Continoous cntinement in hospital for atleast sx (6) hour ( thon theirallowed 26 INCREMENTAL COST. “The umount eharge to menor who volun upgrade a roam Niger 2, INJURY. Physical damage oF externa, and visible nature existing and valid service 238, INTELLICARE ACCREDITED CLINIC. A helteaefoity whic i 2 rere here member may aval of cupalen consalauons whl SoBe Services. duly lensed by the ‘epartnent of Health and offering diagnostic, lborton feat services, dagnons, treatin Depart of eam ts lies ea jury or aermity arin ned of ‘bstetical or other surgical, ‘medizal and nursing care. sar sing whol ond excusvel from an Accent or oir ret of He OF doctor or specialist affliated by INTELLICARE bas TEDIAFFILIATEO DOCTORS. A duly licensed dock INTELL nee ln of INTELLICARES acre ocor wih who race arrangement provid the required services under iis Agreement gp, INTELLICARH ACCREDITED HOSPITAL. A daly eensed heh ear intinion which Itllcare bas an ae ar grenment providing atin eae wihapeilin a ‘equipment, where amber Ft rane knoweigpe ofampia sthgemra Rospial which basen c2Sa=3Y sider Department of Health (DOH) administrative order 47,2008, 29, INTELLICARE ACR 131. OUTPATIENT: Tis raf vo he series offered onan ou-pte bwss eg Shere procedures tht does not eT instep) pent ont xpd wo being wen ine ine tier ambulatory care fealty. sa MATERIAL INFORMATION. A frmtn is ered ines dlr woul SN o MATERAL INFORMATION, oti oft pa (te uct of her Mena? Fe or) dectnaton of rs eemctons nd exsions oh anes fe Member under is AMES. MAXIBIUM BENEFIT LIMIT (MBL). Te msximum lity tht INTELLICARE sh coves 08 SS MAXIMUM RENEETT. LIMIT at ce of is Agee. MBL reed won renew! of he ‘penment by Cet tnt daring anyexesin thereof sé, MEDICALLY NECESSARY. A mate save, as tein’ by INTELLICARE, wich (0) sntney SA aaa ceca uranct oh conten) cara wih ie ands fad igri rd sn comers the war reared dni, ©) PUES fed media ato uy hem conion (cant with the terms an conden of ‘hie Agreement. 3S. MEMRER. A Princiol who ligile hasbeen aceptd for Membership by INTELLICAR! ‘he Elgibiiy provision, and is curently cnvoled under this Agreement 46. MEMMERSITP. Refers to membership in INTELLICARE, pursuant to his Agreement 47, MEDICINES AND DRUGS. Tos for whic ews medial prone at preseribed fr dispensing, whch ae erally rege for he eatment of» covered ness or jury under his Agreement x £ after complying with 438, NON-CONTRIBUTORVIVOLUNTARY MEMBER. A Member whose Membenin Fee filly pak or by ing whois to be enrolled. MBERSHIIP LIST. The iil isting provided by the lien, de OUT-PATIENT MEDICINES. Toke-bome medicines, drugs, and medial spies preserbed fo, administers eee pben asthe sult of oupaiat conations. Examples arcanibioves analgesies, muss, uty liceged orgs to practice al. Foti ofthe Member up tothe third SURGEON, SPECIALIST, OR DOCTOR: A person quid by dares and tne inthe geographies in whic he serves, Thi pesan must ot Bel degre oF consanguinity and fin. 42, PRE-EXISTING CONDITION (FEC). Any illness or condition wh 2 daze tas been obtained; OR ess was evident yon examination, OR Bek eal dvermied to have sted por tan avainet whee ool He meme fsauareofsick. | PRIVATE NURSE. A licensed aurse providing close observation ond performing certified us Medically Necessary by te Attending Doctr. 44, PROFESSIONAL FEES. As dininet (rom Songeon and Anesthesiologists Fees, professionals inclading but nat linited 40 an Occupational Therapist, Physiotherapist, Pathologiss. 45, PREVENTIVE CARE. Nursing or medics ex Includes early diagnosis of disease, discovery and idetification of people a ‘Counseling, and other intervention to aver x health problem. Annual Piysieal Examination programs ere common exarmpes of Preventive Care. {BE (RCS) A form issued by INTELLICARE which facilitates avaiiment of special weatments, which are fees paid to Hiosnsed medical “Aulending Doctors visits or sertion of disease and health maintenance and sk of developing specifi problems, (APE) and heal education xe that focuses onthe pre 46, REFERRAL CONTROL SII services. “42, RELATIVE VALUE SCALE (RVS), Schedules ofcharge as aged between the Association of Health Maintenance ‘Organizations in the Philipines and various recognized Medical Societies. 448. ROOM AND BOARD ACCOMMODATION. The pre-assigned typeof hospital room and bosrd by INTELLICARE tothe Member based onthe benefit and coverage ofthe health eare plan under this Agreement. 49, STATEMENT OF ACCOUNT (SOA). Te statement of account duly ised by INTELLICARE on or before the du ute of poyment reflecting Membership Fess and other monetary obligations, if any, payable by Client tive procedures forth comestion of deformities and 50, SURGERY. The branch of medicine dealing wih manual or opera This inhides surgery performed in an out-patient fects, repair of injuries, diagnosis and cure of certain diseases eting fora covered lines or Injury |. PRINCIPAL MEMBERS. A Principal Member is an employee who actively works fulltime and mects ‘auirament oF he Clients an eligible member. The rames ofthe Member mst be in thelist submited bythe Cli {to INTELLICARE. Minimum and Maximum Enrollment Ages. A person who has attained the age of eighteen (18) years old but not more than eighty (BO) yeors old. Atsined age i defined as the age ns birthday, Enrollment 10 this Agreement is subject farther to the prevailing Underwriting Guidelines of INTELLICARE. submission of sch documents which INTELLICARE may iy of Principal Members Tuy Menensit” REQUIREMENTS 1. INTELLICARE wi ani te Cetnanbar 3) Menbertip apt fms i camped by meer ppt 3) INTELLICARE HeninetouMenosapeant ©) INTELLICARE Ghat Agama 2, The Client undertakes o furnish INTELLICARE: 3) Membership Lis (upon which INTELLICARE wil bse te intl billig 1) Supplementary List of adetional/deleted members au often as recesary INDIVIDUAL EFFECTIVE DATE OF A MEMBER'S COVERAGE. 28) Itmembership is non-conibutory, coverage shall become effective onthe Fifectve Dat of this Agreement o the ‘ale on which the person frst beeames elle, wiihever is later. Client mst enroll 100% af eligible employees inininy 0 dy mete dee esto oes veneer isp five de shal Date nice ‘este 610 20% ofthe month = Pday ofthe fottowing month 20 ofthe mom tothe Set the follwing month = —=—=—*6*ofthe following month 1) _Ifmembership is conmbutry, coverage shall become effective on the Effective Du of this Agreement, the date ‘of emoliment provided that spat mare than oe (1) rnonth rom effective dae ofthis Agresment, or the date on ‘which the peran becomes eligible, whichover i test ADDITION AND CANCELLATION OF MEMBERSHIP. The procedure on ation and cancellation of Members shal bo subjece tothe folowing conditions: 1, Chit shal submit al the ruled information of additional enrlles to INTELLICARE, 2, ‘The Clients authorized representative shall daly endorse thelist of earalees to ensure sceumey and security of data, 3. The Effective Date of Member's coverage shall be subjet to he following conditions: 2) Change of Effective Dat within the coverage period shall nat be allowed. 1b) INTELLICARG reserves te right o accommodate requests fr late enroliment. €) _Effecive date of an enrllee' coverage shall be based on the completion and receipt by INTELLICARE of all requirerscnts. 48) Shoo the effective date of coverage depend on the dat of regulrization ofthe employee, Client shell ensure that the endorsement is made prior to the date of regulstization or within thisty (30) days thereafter. The [Efeative Date of coverage shall then follow the date of regularization or the date of endorsement in ‘accordance wit the schedule ofthe prinlpal member's efecivity in Paragraph B-a, whichever is ater, {ll aditonal dependents mast be endorsed within thine (30) ays ftom the Etfectve Date and they shal follow original/renewal Effective Date of eoverage. Additional dependents boyond this period shall be considered in ‘the nex! renewal period excep for newly.wed spouse and nwly-bom dependens whose coverage effective from the date of eligibility or the dae of endorsement in aeeordance wih the schedule of the principal member's effectivity in Paragraph B-, whichever is ater Jo, sprain ote, Cent sal atl INTELLICARE in seri Tet ‘lation shall be based on the Members cancellation date Ne dere Chen sal ao , UPGRADING OR DOWNGRADING OF PLAN. Upgrading or dwngraing of» Mensa 1 hangs in Res ae eicatnn (ak, postin, asignmeat stall be subject othe folowing conaiions: 1) shal oy INTELLICARE in wating wi he iach ol eaiain Of 8 employee's new ee eee daly signed by the auhorized by te head ofthe Human Resourees Deparment 1) The tev Dae ofthe upgzdnpdowngiag of he plan al the dt as erdotel BY the Cleat in ree erect ith the acheul o the principal meer’ effectivity in Paragraph B85 sc seb aoancnnininrnne ym tein states earenmang ate Inmagine in. nig a ts a se Sk cee ea Le con omen! See ei . INVALIDATION OF MEMBERSHIP, Fale to dito any mati formation bow a Menier nclaing Hot IRVALIDATION Of bleh Merry dpe’ reaansi of meeal famaton, wither ital 8 ‘ot ned ogee dt of moat te coves of the mambo elective fom the date Of SovSras, 2 eo aI eotonue would have resulted in the (0 dcloton of the appeal Oo norman eae er) the mca of Ngher Merberhp Fee or (the inelsion of eddonst MeSttons sod exclostons othe benefit ofthe Member under this Agreement SCTION Fi PROCEDI 1. NON-EMERGENCY CASE. ‘The member shall fs report his condition tothe INTELLICARE coordinator of the Hosplelinte who sal prescribe the neem mis! proses ac i ogpaliation I nested, row te ospital eforasINTELLICARE reserves te ight to direct the member to other doctors for further opinion so of rote he ftereats oF bh the member and INTELLICARE. This may Include referal to INTELLICARE's review Pound. Before decharge fem hospital a member must complete the INTELLICARE chim form and st thet portion ‘ofthe medical bil not covered by this Agreement. 2. BERGENCY CAS. een et ey tonal tr hghati, emee PER CENCY cantive maa ory INTELLICARE. ofthe teem win, wanty-four (8) hour. The Bvsclcadcomatuter w detine tia emergeney ease not INTELLICARE wil vt py fran ‘reatment or hospitalization, rey DENEFIT PAYMENT {All benefits payment stl be in PHILIPPINE PESO. 8) Payment of Benefits fa Member incurs Eligible Expenses during the effectivity ofthis Agreement ses e Itllicare wll pay benefit in accordance with Schedule A — Bevetn Coverage ofthis Agreement, Intlicre will pay the Eligible Expenses afer application of any stipulated co-payment or other deductions that may apply. ¥) Coordination of Benefits. Benefits will esr oF me ccd ie to me exes when conned with rhe arse ennai or hc ends gen grime pve 4 FILING OF CLAIMS. In cases wherein Itlisare covered costs were not deducted from te medical bis nd 3 ‘Mesnber i made o pay forthe health cere cara Menber heal ar cost, a Member may request reimbursement of such ests which are covered ‘nde the Atrecment The request mist be made onthe reseal ia rm o wh shal beatae oe roeips, together with saperting charge slp, dalled lemized aeeounis ond other necessary documents, No ‘simbursement shall be made othe Maer ines such original docurins ure submited by the Member ori the “Mamiber hat otherwise been fll ademnlfied or reimbused of the medial bills or casts inured under any ober heath ear coverage or insurance policy or any oer slr cont or Aremienis, Such request for Benefits mast te preseried within sixty (60) days alr the expragn ofthe pared of conrinernent for whieh claim for bene being mde, Upon recip ofthe complet documents fom the mensber, nile sal process the reimbutsenet lames within hity (30) ays. Filet submit within th Une required shall pet invalidate nar redoce any cai if was not reasonably posible to give proof within such tins 5, SUFFICIENCY OF NOTICE. Writen notice of any claim given by or on betalf ofthe Member or Deneicay Tnteliure orto any authorized rpresontative of Incr, wat information wuicint to Kenify the Member, sll bbe deeme notice t tela, 6. PAYMENT OF CLAIMS. All benefits that pein wo Mester wil be pid by ces tothe order of Principat ‘Member, unless the Pinepal Member requests beri or Ilene its discretion, consider it prefras to make ‘he payment in another manner, fn cae of death af « Meer, any bent due but seraiing unpaid sal be pl to ‘he fie surviving close ofthe following lasses of sucesive preference of beneicaries the Member’ (a) widow or ‘dower ) suing ble: (svi pret: (svn bas end ste an (2) esos 7. REQUEST FOR RECONSIDERATION. If 9 clio. for reimbursement is denied, or the. Member i not Fiedigrecabe tothe eanbursement paid by INTELLICARE, a writen roquest fr reconsideration mt be fied Wwith the INTELLICARE Head Office not Iter than tea (10) days fiom receipt of such denial or ‘questioned ‘immbursemen. Otherwise the claim shall be deemed susie oF leinated. Tae request for consideration shall ‘oniain llth easons upon which reconsideration (s sought and shall be decided ypen by an muthrized personnel of INTELLICARE. whove cecsion shal be nel. INTELLICARE reserves the ight 10 deny Claims for Reimbursement if the procedure and requirements have not been stity complied with. 8. CERTIFICATION, INFORMATION AND EVIDENCE. All cenifistes, eccouns, receips, information and ‘videas quired by INTELLICARE shal be fornished in such form as INTELLICARE mney require. FRAUDULENT CLAIMS. If any claim under thi Agreomeat sin any respcet fraudulent, al benefits payebe andor ‘aid in relation ta hat lim shall be forfeited and if deemed appropiate, resoverabe respectively. 10, PHYSICAL EXAMINATION AND AUTOPSY. INTELLICARE stall have the right end opporenity to examine the Member whan and as often at ay retznably require during the pendency of claim hereunder, and the right and ‘opportunity to make an sutopsy in case of death, where itis not obidden by aw. 11. COANSURANCE. INTELLICARE will py benefits after dosucing te value of wy co-insurace in respect of hase ‘benef The member shall provide proof of hi eo-insurance cover fr purposes of verfcalin Provision on mulkiple covers: Ifa otember has two oF more covers with INTELLICARE, the maximum ability of INTELLICARE foreach ilnesfccidont hal be the aroun provided in the cover withthe highest maximum bene Umit, Portier, any experscs incurred by the member and paid by INTELLICARE under one cover cannot be claimed under other covers. 12, EXTRA BILLINGS. }) For medica, surgical hospital and professional services expenses NOT EXPLICITLY COVERED under this ‘Agreement ember must sel al bilings upon discharge fom the hosp. I TISTELLICARE wil advance th armors, ClendMemiber shell poy PNTELLICARE within oven (7) days of receiving statement of account wih se rninisratin fee offen percent (15%), TF not sted within seven (7) days a penalty of two pect (2%) ertmonthof tc smount owing nil the db is sailed. INTELLICARE hes the option to suspend the LD. car Of the member(s) invalved nil selemen. 2 ny eve reemp nisi Se arena anon cotiree Sib eeederoedncr areas ©) SERVICES OF NON-INTELLICARE AFFILIATED DOCTOR. The meer will ny forthe services ofa non- Insta esrodteahtned acer nce reed yc ona nn my orenressoran ni INCREMENTAL (ADDITIONAL) CHARGES. “THAN ALLOWABLE. 1. ROOM ACCOMMODATION, NOT INCLUDED IN THE AGREEMENT OR 111 ‘Voluntary Upgrading - Ifa principal member choose nl occupies a room onc atgory higher than what he isenitled {o.theineresonal coat fr hospital expenscs such ax professional Fes, room and board difference and other hospital, bills (aboratory, medicines and hospital supplies) is as flows 3095 (8 Xe hospital bill = roonvboard as charge] + [Rooivboad charged ~ allowable cst ofthe room) 2, Involuntary Upgrading — Ifa principal member haste occupy a room one ctegory higher than what hss elle ‘because of non-avlibilty oft category oom fereep! suite room), he wl shoulder the ference in east berween the non-category room and the eatsgory roo while Inslicare pays for the professional fees and other hospital ills ‘Laborsory msdicnes and hospital supplies). loweever, should a room become availabe, the Member is obligate o transfer to 9 calogary wom, otherwise incremental charges (suchas professional fecs, room and board diference end hospital bills (aboratory, medieines and other hospital suppies) shall be billed to the Member (NOTE: Refer to Schedule “A” [Addltional Benefis/Endersensets, tem 3. Foc whatever reasons except during Emergency Care referred ro under ene provision, incremental rte difference and excess charges dv to voluntary oF involuntary room upgrading shal be charges tothe Member, 3. Principal members ented to parculor category of accommodation will pay the atonal cass i confined ia any hospital that dacs not provide that category. oF allow confinement for members under that category. Categories sale ‘down fom: Suter Small Suite: Large Private: Regular Private; Small Private; Semi-Private; Ward. The hospital Afinition thereof applies. PROFFSSYONAL FEES. Pinepal members stall pay the difference between acto charges and RVS. [au Medical and hospitalization bencis covered andor this agreement are specified in Schedule A subject othe following ems and conditions: IN-PATIENT CARE. Covcioge of in-patient benefits, except for Emergeney Conditions, wherein the Emergency Care provision ofthis Agreement wl apply, shal be subject ote folowing conditions: recommended by an Accreiici/afiiated Doctor and approved bythe duly Accredited Hospital prior to confinement. ind im accordance withthe Member's Room sed Board 8) The hospitel confinement must be authorized represeniative of INTELLICARE in 'b) The eonfinersent shall be in an Acereited Nospil eons oN ssa be pv ny by Acie Dat 6) Prion! eres le NTELICARE sl et est Rei Ce SS) Mites eosin (OUT-PATIENT CARE. The Outpatient benefits canbe avail tn an be aeild bythe Member irnediatly from the effentive date (of Member's coverage, and every renewal date Wereafer provided tha the Memberilp Fees shall have been paid ring the ira billing. The Benefits can be avaled on ating te Sin billing, The Bees ean be evel eny trough the Aesedied HsptVCines end Decor of EMERGENCY CAR. inal these emorgoncy circumstances, INTELLICARG reserves the right fo validate whether Ie rtimen reine i emerscy in re oh et enone caer ude he revlon of 8) van Accredited Hospital, Ifthe emeryeney tresiment bas been adninstred in an Accredited Hogpital and 2 Manel eure ones NTELLICAKE al provide ete! ena uj te provisos ofthis Agreement athe time ofthe confinement, the Accredited Hospital hes no availble room in accordance withthe Members Room and Beard Accommodation, the Member may opto aval of room accommodation which is higher dh ‘his Room and Doard Accommnodelion and INTELLICARE wil cover ihe incremental rat diferences forthe room ‘upgrade, professionel fees, diagnostic aad laboratory examinations, end other ancillary medical services of confinement. The oid charges and expenses shall be abject to the Meares MBL, All incremental costs ineured ‘fer the frat tweney-four (24) hours sal be forthe personal account ofthe Member exoxpt wien the AYTited Hospital ssues.ucerficatio of non-availability of tre Members Room end Board Accommodation. b) EMERGENCY CARE IN NONANTELLICARE ACCREDITED HOSPITALS. 1. When a principal member i in lifothreatering ease or fs that lisse i in immediate danger of tosing 3 Timb, eye or othe part of the body, ori 4vere pai that rquires immediate rele INTELLICARE agrees toreimburse eighty ereent (20%) of th otal hospital bil inlading professional fees based on eative valve scale (RVS) for INTELLICARE aczreited hospitals, but ot to exceed the amount of Thirty Thousand ‘Pesos (PHP30,000,0) ‘Member should notify INTELLICARE within twenty-four (24 hours from time of emergency care In ease the member due t his medical condifon is unable to commnieate diretly or though » guardien or ‘tepresentative, the twenty-four (24) hours notification shal be extended. INTELLICARE shall pay the sod amount when it is verified that INTELLICARE facilites were not used because to have done so woald ental a delay resulting in death, serious disability or significant jeopardy to the mare's eondtion or the ehoie of hospital was beyond the ennrolof the member or the member's family, Other expenses such follow-up cate wre not covered in using Non-INTELLICARE Accredited spit for emergency cases. @) EMERGENCY CONFINEMENT IN A FOREIGN TERRITORV/COUNTRY. If 9 principal member arr 5) All confinements Sod outptint serves must havea write referal fro a coordinator (Prescribed referal eter AOS Gente 12 or 3), INTELLICARE resores the right to determine whether any illness or eonition is covered Titra dng Ifthere is 0 sbsequcn conrdictory diagno, INTELLICARE retaing he ight 0 redeeming saoaver Sue tines or condiion is covered, IF not covered, INTELLICARE, will mot pay forthe cost of the exe oF vweatment, by Successive periods of opt! content fr Drended ssazes sal be consaed a uc yf ngpPSviy ‘and subjeet to the maxima benefit imi, ee Seana ee da ae eo ee og ad artes me pe eg tl yt ered yy le rece ud cena teeter ct et same reset ay aa gs sors Sa ahem TEENA <0 Mens expel agre wave mye ase dass herby aor INTELLICARE to dite ‘qualified doctors and reputable hospitals and clinics to render services. = conpt ‘A. EXCLUSIONS INTELLICARE will not pay for any costs or loses erixing rectly or indvety from: 1. Services rendered by Now-INTELLICARE doctor, except ith the prior writen authorization of en INTELLICARE. in addition tothe fees stated therein, Futre taxes, levies or fees refered herein are only those that afect the quoting of “Membership Foss (Ex. 12% VAT), other future taxes, levies or goverment impositions that do not affect the quoting ‘of Membership fes ae therefore excised, GOVERNING LAW. This Agretment shall be governed by and construed in aovordance with the las ofthe Republic of the Philippines. ARBITRATION ‘Any differnec rising between the Clien orany Member and ltellicare shal be refered town abitrstoro be appointed by the parties to the dispute. Ifthe parties are unable to agree ona ingle arbitrator, t¥0 (2) abirtors shal be appointed {one by each party). In the event of further disagreement, the arbitrators shall select an umpire. If the difference between the partes requires medical knowledge (ineluding any question regarding the appropriate maximum indemnity for any ‘medical service or an operation not listed inthe schedule of surgiea!fes) the arbitrators at the discretion of Intllicare, fay be o registred medical procitiners andthe umpire in such an instance, shall bea consultant Specials, Surgeon, oe Doctor, Determination of an award shall be 2 Condition Precedent to Any Liability or right of ection against “ellicare. LITIGATION. Any scton arising from this Agreement shall be brought ander he jurisdiction of the courts of Maka City tote exclsion ofa other venucs, No action sal be brought to recover payment unl sixty (60) days after proof ‘of claim has been filed AUTHORIZED SIGNATORY. The Patties hereby represent that teirrespective representatives been duly authorized ‘y the Boord of Directors to sign, execute and deliver this Agreement [SEPARABILITY. If any term or provision ofthis Agreement is declared invalid, logal or unenforeesble under Philippine laws, such vali, Megat or unenforceability all notte o render unenfercsble any ole em or ‘provision of this Agreement NOTICES. Al aotics, demands and oer communications requiced or pemited hereunder shall be made ie wring are sent to Clicnt or is authorized ropreonttive ot the adress indicated in the Conforms Letter. RIGHT OF SUBROGATION. The coverage under his Agrsment ia extended cover injure ofthe Ment cased Pith paryCs) whether Tibi sdeterminele or nat in exsex of weil asienisand others eee Ears dainelvsig but not ited ol th clin, loses, damages which may b recovered bythe MOVES or eae ey have been paid Co of em asa reat of he Tess or Disb which have Deen ps ot ey ua toe Tens snd Contos the Agreement and tha the Meer wil sbropt shy TELL any thr ary to the sven f te vale of he serves so rendered wo INTELLIGARE 299 Wi oe derake to agsist INTELLICARE in the succesful recovery ofthe losses. 20, CIVIL, CODE ARTICLE 125 WAIVER. The provisions of Anil 1250of he Civil Ca of he Republi ihe Sree etre net he eae on cue nono in fe en scl mcrae hs of ceo oben of caine hein nl btm sal et opin cng cient abity ce ie provi fi gsm 21, IMPORTANT NOTICE. The Insurance Com ges in Mala, Cebu and Dawa, is the ance Comission with offices in Mani is tho government ‘office in charge of te enforcement ofall laws elated to Health Msintenance Organization (HMO), and hes supervision ‘over HMOs. For inquires or complaints, please cantar the Public Assistance and Mediation Division (PAMD) ofthe Insurance Coniston a 1071 United Nations Avenue, Metro Manila, with ‘elephone rumbers +632-5238461 10 70 tel seat ice pblmemneremnegneh Th el “website of the Tngurasee. Commission is ov insurance gy SECTION EL IVE DATE AND DURA’ A. BFFECTIVE DATE OF THE AGREEMENT “This Agreement taker effect on of Apel 17,2020 until Apri 16, 2021 fhe conirat period excess twelve (12) months, an excaation claus lth end ofthe 12% month is implernented, 1D. TERMINATION OF AGREEMENT BY CLIENT 42) ‘The Client nay terminate this Agreement for justifiable reasons at any time by giving a writen notice 19 The INTELLICARE at Tes [thy (0) ays) prior tote intended termination dats, Clint way only terminate 1 Agreement is notin detout the performance ofits obligations ort has not violated any ff warrant ‘Stcsonations.Slrting on the lerminaion date, INTELLICARE shall be free from al abiliis to Cen, Ninbers and their dependants. This shall be without peejdiee to te right of INTELLICARE 10 collect Cents ‘Obligations which have Become due and demandable. 1b) Clic shall be entitled to refund in accordance with Refunded of Membership Fee provs C. TERMINATION OF AGREEMENT BY HMO, INTELLICARE shall have the right 0 immediatly terminate this Agreement in the event that a) Any atrial representation or warranty made by Clients alte or wtrue when made; ri Client commits any act ‘yah the intent to deiaud INTELLICARE: by Non-payment of Membership Fees and other obligations subject to agreed payment lems, [All medical services ond coverage under this Agreement shall terminate onthe termination dtc, without prejudice iy inn covered mediel services rendered toa Member prior tthe termination, “Termination ander this provision shall be without pre obi to the sight of INTELLICARE to collect the Client's "hich have Become due and cemandable. No refunds wil be made for LD. card fs D. FREEALOOK PERIOD (COOLING-OFF PERIOD) By giving writen noice within Mee (15) dys om recip ofthe contact fhe tet, Cent ay cass the ein o9 By Bing erat provided the 1D Gard and his Agreement are surendeed to TNTELLICARE within the same Peri ae AESARE shall ihereaflertensiate the Membersip and the teminaton provision of thi Agreement shall apy. Farr vine ini Agreement within the peiod ae shall be undersood as an acplance of all teas and condions vied hcounder, ny avalon of « Meer within he i= (13) oid sal alo mean gpptance i Cen oF Bi the tems and conditions ofthis Agreement, B._ RENEWAL OF AGREEMENT. This Agreement may be renewed for nother year subject to negotiation, TERMINATION OF MEMBER'S COVERAGE. Cover shall matically terminate on the earies of the following, 1. Bsply dates 7% The dle member esses to be eligible for coverage. Upon exceeding the maximum ponnissible age cover will

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