AFFIDAVIT OF COMPLAINT

KNOW ALL MEN BY THESE PRESENTS:

That I, Camilo N, Villanos, of legal age, Filipino, separated and resident of 72 E Maginhawa St.,
UP Village, Quezon City, after having sworn to in accordance with the laws of the Republic of the
Philippines, hereby state the following;

1. That I am a legitimate card MAXICARE Prima Gold No. 11580110 8353

0603 fully paid under Maxicare OR no. 300087937;
2. That as early as the year 2010 or later, more or less, I have been in
consultation with Dr. Neil T. Gomez, MD,FPCP, FPCC of Phil. Heart
Center and MAXICARE accredited medical practitioner regarding my
health condition;
3. That affiant first used the said Maxicare Prima Gold Card to Premiere
Medical & Cardio Lab for Blood Chem/Test on March 12, 2020. But
Maxicare denied payment for the said basic Blood Chem/Test. Thus, I paid
cash for the said procedures, complete results of which were given &
delivered at Dr. Neil T. Gome’s PHC clinic;
4. Again, for the second time Maxicare denied payment for my Doctor’s
consultation fee at PHC on March 14, 2020 (reason not covered);
5. That on June 8, 2020 , I presented the same Maxicard at MyHeath Clinic
SM North franchise for Blood Chem/Test, ECG, X-ray. 2D Echo w/
Doppler and Doctor’s Consultation. This time Blood test & ECG were only
processed. I was advised to proceed to MyHealth Clinic, Shangria franchise
for X-ray and Consultation. 2D Echo procedure w/ Doppler is again was not
covered by the Prima |Gold Card Likewise, Doctor’s fee was denied
payment for the 3rd time.
6. That on the same date, June 8, 2020 I suffered a lot of stress and almost got
a 2nd heart attack for the insuficiency and unreliability of BOTH Maxicare
and MyHealth Clinic. I started at 8am and ended at around 3pm without
having a clinic for 2D echo with Doppler.
7. That, this affidavit is being executed to attest to the truth of the foregoing
statements of facts in order to secure redress on the Maxicare procedures
and to get CASH refund on affiant expenses on Medical procedures denied
by Maxicare Inc. amounting to more or less P25,000.00 including
Attorney’s fees and other incidental expenses to this regard.

Further, Affiant, say no more.

IN WITNESS WHEREOF, I have hereunto set and affix my signature this ___th day of June,
2020 at Quezon City, Philippines.

CAMILO N. VILLANOS
Affiant

A CK N O W L E D G E M E N T

REPUBLIC OF THE PHILIPPINES )

QUEZON CITY . . . . . . . . . . . . . . . ) S.S.

BEFORE ME, a Notary public for and in the City of Quezon City this ___th day of June, 2020
personally appeared Camilo N. Villanos with CTC No. 00104451 issued in Quezon City, on January 02,
2020 known to be the same person who attested to the foregoing statements.

WITNESS MY HAND AND SEAL this ___th day of June, 2020, Quezon City, Philippines.

NOTARY PUBLIC
Until December 31, 2020

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020.