ARTICLE |- ACCEPTANCE 1 Maxicare shall extend, during the effectivity ofthis Agreement, healthcare and health maintenance services and programs to Members who would qualify 28 bona fide Members of Maxicare upon payment of appropiate Membership Fees and registration by Member. For minor Member, it is hereby understood thatthe payonilegal guardian has agreed onthe terms and conditions of this Agreement on behalf of the Member. Within fifteen (15) days from receipt of this Agreement, the Member may cause the cancellation or revocation of this Agreement by returning the Maxicare Card or e-voucher and this Agreement to Maxicare. Maxicare shall thereafter cancel or revoke the membership and the Membership Fee paid shall be returned in full. Failure to cancel or revoke this Agreement within the period set shall be understood as an acceptance of all the terms and conditions provided hereunder. Any availment within the 15-day period shall also mean acceptance of this Agreement. Maxicare reserves the right to amend or modify the provisions ofthis Agreement during the effective term, provided that it shall ive the Member notice before the amendment takes effect. Maxicare shall extend and provide the folowing healthcare benefits and coverage forthe Members on the date of coverage (the “Effective Dat’). All other procedures, conditions, and benefits not listed below are covered whenever Medically Necessary in the medical management ofthe Member subject to the exclusions, imitations and conditions specified in this Agreement. HEALTHCARE BENEFITS PLAN PER COVERAGEILIMIT | All outpatient consultations and outpatient procedures (as Covered tong as it Meicaly Necessary) 2 | Eye laser therapy only for retinal tear, retinal hole, renal Covered detachment and glaucoma prescribed by an Afflicted Physicin/Specilit. Eye correction such as Lasik, PRK and te ike are not covered. 3 | Electrocauterization of skin lesions such as plantar warts, Covered flat wars, periungual warts, fiform warts, and mollscum contagiosum, in any part of the body prescribed by an Affliated Physician/Specialist. 4 | Sclerotherapy for varicose veins (except medicines and for Covered cosmetic purposes) as prescribed by an Afiiated Physician, to be availed through affliated vascular surgeons. 5 | Alergy Testing! allergy soreening and other related Covered examinations prescribed by an Affiliated Physician. 6 | Speech therapy for stroke patients only Covered 7 | Tuberculin est Covered 1 | Dreaded Conditions Covered 2 | Non-Dreaded Conditions Covered Page tof 18 Form Template Control: Product Development/anary 16, 2020/FO-PD-0.049Rev 01If a Member is enrolled under an Agreement that covers Pre-existing Conditions from the Effective Dale of the Member's coverage, then the Member shall be covered for any Pre-existing Cor Effective Date of the Member's coverage under that same Agreement. ‘AI diagnostic 7 therapeutic procedures medically necessary for treatment Doctor services, X-Rays, laboratory and diagnostic examinations, and other medical services related to the emergency treatment ofthe patient ion from the Covered, subject to Emergency ABL of 20,000/Memberiyear 2 | in Non-Affiiated Hospitals. Reimbursable up to 80% of hospital bls & Professional Fees based on Maxicare rates incured during the fist ‘24h. of treatment subject to Emergency ABL of 20,000/ /Memberlyear 3 | Outside the Philipines. Reimbursable upto 100% of actual cost subject to Emergency ABL of 20,000! /Memberiyear 4 | Areas without Affiated Hospital Covered, subject to Emergency ABL of P20,000Memberlyear ® | Ambulance Service (Afliated HosptalMedical Cinic to Covered, subject to Emergency ABL of ‘lites HospitalMedicl Cini), 20,000/Member/year © | Ambulance Service (Non-Afiated HosptaiCinic to Reimbursable upto P2,500 per conduction Aiated HositalMedical Cini), "Note: The ambulance service provided herein shall be avallable regardless of the location within the Philippines. Initial Treatment within 24 hours from time of bite of Animal bites Covered for Emergency cases and OP only 2 | Succeeding treatment afer 24 hours from time of bite of ‘Covered (except cost of vaccines) Axial bites 3 | Vaccines for realment of tetanus and animal bles Covered for Administration only. 4 | Scoliosis including necessary procedures, except physical Covered therapy sessions, whether congenital, pre-existing, developmental or acquired 5 | Congenital Conditons except physical therapy sessions Covered ‘and developmental disorders. © | Chronic Dermatoses Covered 7 | Hepatitis 8 ‘Covered (except cost of vaccines) 1 | Provider ‘Al Metro Dental Branches 2 | Procedures Page2ot 19 orm Template Control: Product DevelopmentJamuary 16, 2020/F0-PD-0.049/Rev.01Denial Consultation Covered once a year Covered once a year ’. Emergency reef of Dental Pain through Medication Covered once a year Covered once a year °c. Dental Nuttin and Counseling Covered once a year ‘Covered once a year &. Denial Health Education ‘Covered once a year Covered once a year «Preparation of Dental Certicates ‘Covered once a year Covered once a year { Sleep of Dra Roca eso By LWT BY | Ct esa your anise ‘8 CosmelicfOral Rehab Treatment Planning Covered once a year ‘Covered once a year 1 Oral Prophyfaxis (Cleaning) Mild Covered once a year ‘Covered once a year 7, Panoramic X-Ray (Full Mouth) Covered once a year Covered once a year }. Fluoride Gel (Tray-Type) ‘Covered once a year Not covered Notwithstanding any provisions to the contrary, the folowing shall not be covered: 1 ‘Services oblained for non-emergency conditions from Physicians and Hospitals in any ofthe folowing circumstances: ‘a. Non-Affiated Physicians in non-Afiiated Hospitals; b. _ Non-Afliated Physicians in Afiiated Hospitals; ‘. Affllated Physicians in non-Afiated Hospitals or other non-affiliated healthcare facity. ‘Adaonal hospital charges and physician's Professional Fees resulting fom: ‘2, Room-upgrading beyond Member's allowable time during emergency care; . Extension of hospital stay despite release of discharge order from Members attending physician; ©. Fees ofthe assistant surgeons / resident doctors who assisted the Attending Physician in the process of rendering the services shall not be chargeable tothe Member andior Maxicare except for hospitals that do not have resident physicians to assist during surgeries subject othe prior approval of Maxicare; 4. Use of extra bed, TV, electic fan, DVD/ VCD, and other similar items unless such appliances and items are necessarily and ordinary incuded inthe Member's Room & Board Accommodation; ®. Extra food {Toilet artices lke face towel, soap, toothbrush and the lke; 19. Difference in room and board, the incremental rate differences for Professional Fees, diagnostic and laboratory examinations, and other ancilary medical services brought about by obtaining a room accommodation higher than the Member's Room and Board Accommodation imi; h. Services ofa private ora special nurse: and |. Allotheritems not medically necessary in the medical management ofthe patent. ‘Custodial, domicilary, convalescent and intermediate | Modified: Covered for Outpatient consultations, care, laboratories and procedures, longterm rehabiitaon and psychiatric andlor | Modified: Covered for Ouipatent consultations, psychological ilinesses and conditions including neurotic | laboratories and procedures. ‘and psychotic behavior disorders; anxiety disorders. ‘Treatment for injury and is compicationsresuling from | Modified Covered for Ouipaient consultations, selfinfted injuries including infections as a result of | laboratories and procedures. tatoos, piercing of the ear orn any body part, whether selFinfled or done by atrd party o attempted suicide ‘or set-destucton, whether sane or insane Developmental disorders including functional disorders | Modified: Covered for Outpatient _ consultations, of the mind, such as but not limited to Attention-Defct | laboratories and procedures. Pogo soto Form Template Contot: Product DevelopmentJanuary 16,2020/F0-PD.0.049/Rev 01Disorder (ADDYAttenton-Defcit Hyperacivty Disorder (ADHD), Autsm Spectrum Disorders, Bipolar Disorders, Central Auditory Processing Disorder (CAPD). Cerebral Palsy, Down Syndrome, Neural Tube Defects, and Mental Retardation 7 | Treatment of any injury received when there Modified: Covered for Outpatient consultations, laboratories and procedures. Negligence b. Unauthorized use of prohibited drugs or regulated drugs ©. Alcoholic liquor intake 4. Direct or indirect participation in the ‘commission of a crime whether consummated ornat Violation ofa aw or ordinance Unnecessary exposure to imminent danger, knowingly or unknowingly or hazard to healt, bythe member Note: Maxicare shall be given a copy the Police or Doclors report (the Report), if any. To determine whether or not suoh treatment is an exclusion under this paragraph, Maxicare may rely on the Report, as well as on the evaluation of its own Medical Resource Group Provided, however, that if Maxicare has yet to receive the Repor or the evaluation of its Medical Resource Group, the Member shall shoulder the expenses for mecical treatment subject to Maxicare’ reimbursement should it be found, ater submission of pertinent documentary evidence, thatthe treatment is not an ‘exclusion under this paragraph, Reimbursement willbe based on Maxicare standard rales. @ | Aesthetic, cosmetic and reconstructive surgery or any | Modified: Covered for Outpatient consultations, ‘consultation or treatment for any beautification purposes | laboratories and procedures. except if necessary to treat a functional defect due to accidental injury within the inital confinement. 9 | Oral surgery folowing accidental injury to teeth for | Modified: Covered for Oulpalient consultations, Purposes of beautification. Dental examinations, | laboratories and procedures. extractions, filings, other dental treatment and their ‘complications except to the extent that are medically necessary for repair or alleviation of damage to the Member caused solely by an accident. Medical care resulting from any dental elated conditions. 10 | Watery care and all other conditions (except pre and | Modified: Covered for Ouipatient consultations, post natal consuitatons) related to andlor resulting from | laboratories and procedures. Pregnancy andlor delivery which afect the condlons of the Member and the unborn child FT | Greumeision (except for treatment of urological | Modified: Covered for Oulpatent — consutations, conditions), sex transformation, ciagnosis, treatment and | laboratories and procedures procedures related to fertility or infertity, artificial Insemination, sterization or reversal of such and their compications. 2. | Experimental medical procedures and ts complications. | Modified: Covered for Outpatient consultations, laboratories and procedures. 78 | Acupuncture, chirotherapy and other forms ofaltemative | Modified: Covered for Outpatient consultations, medicine and their complications. laboratories and procedures. 4 | All expenses incurred in the process of organ donation | Modified: Covered for Outpatient consultations, ‘and transplantation ifthe Member is the donor of such | laboratories and procedures. donation or transplantation, and its complications. Pope dol 19 Form Template Contot: Product DevelopmentJanuary 16, 2020/F0-PD-0.049/Rev.0115 | Routine physical examinations required for obtaining or | Modified: Covered for Outpatient consultations, continuing employment, requirement in school, | laboratories and procecure. insurancel travel, goverment licensing, health permit ‘and other sila purposes. 16 | Purchase orlease of durable medical equipment, oxygen | Modified: Covered for Outpatient consultations, dispensing equipment, and oxygen, except during | laboratories and procedures, covered in-patient care. 17 | Comectve appiances, prosthetics and onhotics such as | Modified: Covered for Outpatient consultations, but not limited to eye glasses and contact lenses, | jaboratries and procedures. hearing aids, pacemaker, artical limbs, valves, knee-tbal insert for total knee arthroplasty, vascular grafts, titanium thread, myingotomy tube, Intravascular catheters, vascular stents, bone screwsipales, pins, wites, balloons, orthopedic intemal fixtorfixaion systems, orthopedic external fixatorixation systems, intraocular fens, braces, crutches, hemiorthaphy mesh ‘ormesh used for herionthaphy, 8 | Take-home medicines and outpatient medicines except Chemotherapy mecizne (excep for cancer treatment . Medicine administered during an emergency treatment, 18 | Congenital genetic and hereditary diseases and their | Modified: Covered for Ouipatent — consultations, complications (except for hems) affecting functions of | laboratories and procedures. individuals. 20 | Allphysical deformities prior to enrolment. Wodiied: Covered for Outpatient consultations, laboratories and procedures. 2 | Trealment of injuiesfinesses caused rectly or | Modified: Covered for _Oulpaiont consutatons, indirecty by engaging in any professional sport or | laboratories and procedures. hazardous aciviy such as but not limited to scuba diving, suring, water sking, mountain climbing, rack cimbing, mountaineering, parachuting, airsoft, drag racing, paintballing, wakeboarding and bungee jumping, except for actviies under company-sponsored sports actives. 22 | injuries resuing from direct participation in ios, stikes, | Modified: Covered for Ouipaient consultations, and other cal disturbances. laboratories and procedures 2B | Trealment of injures or linesses resuling rom war or | Modified: Covered for Outpatient consulatons, ‘any combalelated activities while in military service. | laboratories and procedures. 2 | Senvally wansmitted diseases, genital wars, AIDS and | Modified: Covered for Ouipaiont —consuatons, ADS related diseases laboratories and procedures. 25 | Pre-existing Conditions: Modified: Refer to Article 14, Healthcare ‘a. Dreaded Rees b. Non-dreaded 26 | Treatment for Chronic Dermatoses (except | Modified: Covered for Outpatient consultations, consultations). laboratories and procedures. 27 | infectious diseases (Le. Avian Flu, Meningococcemia, | Modified: Covered for Oupatient consultations, tc) that are declared epidemic or pandemic by the | laboratories and procedures. Page So Form Template Control: Product DevelopmentJanary 16,2020/FO-PD-0.049/Rev.01Department of Health, World Health Organization or any recognized heath authority. 28 | Vaccines for all ypes of Hepatitis. 29 | Benefits covered by Phileath and al other goverment | Modified: Covered for Oupatient consultations, funded healthcare enfitements as provided for by aw. | laboratories and procedures. 30 | Speech therapy for developmental and congenital | Modified: Covered for Outpatient consultations, diseases. laboratories and procedures, 31 | Weight reduction programs, surgical operation or | Modified: Covered for Ouipalient consultations, procedure for treatment of obesity, incuding gastic } laboratories and procedures. stapling r balloon procedures and liposuction ‘32 | Costof vaccines and immunization, 38 | Cost ofmedico-egal cases. ‘34 | Routine medical examination or check up or medical | Modified: Covered for Outpatient consultations, ‘examination for employment or medical examination for } taboratories and procedures. travel 35 | Intravenous Immunoglobulin (VIG), Modified: Covered for Outpatient consultations, laboratories and procedures. 36 | Treatment of workvelated injuries of _highvsk | Modified: Covered for Outpatient consultations, ‘cccupations such as but not limited to construction | laboratories and procedures. workers, miners, loggers and drillers. {37 | Cost of the medical senices and Professional Fees in | Modified: Covered for Ouipatient consultations, ‘excess of the Emergency ABL laboratories and procedures. ARTICLE Il ~ DEFINITION 41. ACCIDENT: A visible, extemal, sudden and voient event occasioned by a physical or natural cause and occuring entirely beyond the Member's control causing damage to the heath ofthe Member. 2. AFFILIATED HOSPITAL: A duly licensed hospital included in the lst of affliated hospitals of Maxicare with which Maxicare has ‘an existing and valid sevice agreement where a Member can avail of Medical services pursuant to this Agreement. 3, AFFILIATED MEDICAL CLINIC: A duly licensed medical health care fact inclided in the ist of afilted medical clinics of Maxicare which has an existing and valid affaton agreement with Maxicare where a Member can avail of Metical services pursuant to this Agreement 4. AFFILIATED MEDICAL STAFF: A group of medical practitioners and other alied health professionals who are affliated and authorized by Maxicare to deliver the required Medical services to Members. 5. AFFILIATED PHYSICIAN OR SPECIALIST: A duly licensed physician or specials affiliated by Maxicare and named in the list of Maxicare’s affliated physician with whom Maxicare has made arrangements to provide the required services under this ‘Agreement. 6. AGREEMENT: This Membership Agreement, including Membership Application Form, and Membership Detail, and any other contracts or documents relevant tothe relationship between the Member and Maxicare. 7. ANNUAL BENEFIT LIMIT (ABL): The maximum labilty that Maxicare shall assume for all covered services rendered to @ ‘Member within the term of this Agreement. Page 6 of 18 Form Template Control: Product DevelopmentvJanvry 16, 2020/FO-PD.0.049/Rev018. AUTHORIZED REPRESENTATIVE: A person duly authorized by Maxicare to approve the provision of medical services of claims reimbursements to a Member, 9. BALANCE BILLING: It is the act of an Affiited Physician and other health pracittoners to charge Members forthe difference between their desired higher Professional Fees and the agreed Maxicare standard Professional Fees for services rendered 10. CONFINEMENTIHOSPITALIZATION: The state of being admitted in an Affiiated Hospital or Aflated Medical Clinic. ‘1. CONGENITAL DISEASE: A disease or disorder that may or may not be present or manifest at bith, which may be a result of genetic abnormalities and intrauterine conditions such a but not limited to errors of morphogenesis or chromosomal ‘abnormalities. Congenital Disease includes but not ited tothe folowing: ‘Congenital physical anomaly: an abnormality of the structure of a body part that may or may nat be present or manifest at birth, . Congenital Matformation: a congenital physical anomaly. . Genetic DisorderIChromosomal Aberration: An ilness or condition caused by one or more abnormalities in the genome, which may be present at bth or recognized until ater inf, such abut not ited to Thalassemia and Hemophilia. 12 CONSENT: Any freely given, specifi, informed indication of wil, whereby the Memiber agrees to the collection, processing, sharing of personal information about andlor relating to him or her, includes personal, sensitive and privileged information. Consent shall be evidenced by written, electronic or recorded means. It may aiso be given on behalf of a Member by a lawful representative or an agent specifically authorized by the Member to do so, 18, CONVALESCENT CARE: The recovery of health and strength after an illness or injury. ‘4, CUSTODIAL OR MAINTENANCE CARE: The degree of care furnished primal to provide room and board, which may or may not include nursing care, training, personal hygiene, and other forms of self or supervisory care, to those persons who are Physically or mentally disabled or both AND '@, Who are not under any specific medical, surgical or psychiatric treatment fo reduce the existing disability to the extent medically necessary to enable the patient o lve outside an institution providing such care; or b. When despite such treatment, there is no reasonable possibilty thatthe disability willbe reduced or diminished. 15. DATA PRIVACY LAWS: Republic Act No. 10173, otherwise known as the Data Privacy Act of 2012, as well sits Implementing Rules and Regulations (1RR’). 16. DEVELOPMENTAL DISORDER: Disorders that interrupt normal development ofa child which may affect a single area or several areas of development. These developmental disorders may respond to interventions such as, but no ited to, speech therapy, physical therapy and occupational therapy. Examples: Autism, cerebral palsy, attention deficit hyperactivity disorder (ADHD), ‘mental retardation. 17. DISABILITY: An illness or injury and any symptoms, sequelae, or complication thereof requiring treatment. Al injuries arising ‘rom the same event or series of continuous events are considered as one Disablity, 18. DOMIGILIARY CARE: Degree of care provided in the patient's home when in-patient care is not mecically necessary. 19. DREADED CONDITION: A condition () that is considered to be chronic, progressive, and life-threatening or which may have ‘complications or may ental felong therapy; oi) wherein complete cure cannat be ensured, 20. EFFECTIVE DATE: The effective date ofthis Agreement, wherein allhe benefits and coverage pursuant to this Agreement shall be made available tothe Member, subject tothe terms and conditions hereof 21. EMERGENCY CONDITION: A life threatening or accidental injury ora sudden and unexpected onsat ofa conto or inoss which atthe time ofthe occurence reasonably appears to have the potential of causing immediate dsabili o death, or which requis the immediate action or aleviation of pain or discomfort. These illnesses or injuries require urgent medical or surgical care and attention which the Member secures immediately afte the onset or as soon asthe care may be made available but in any case, not later than twenty-four (24) hours after the onset. Heart atacks, cardiovascular accidents, poisoning, loss of consciousness or respiration and convulsions are some examples of emergency conditions. Page 7 of 18 Form Template Cont: Product Developmenlansry 16, 2020/FO.PD.0.049Rev 0122, EXCESS CHARGES: Avalments which are not covered within the benefits and coverage under tis Agreement, as well as those wich are evaled in volation thereof, including but net ited tothe beneftavailment of Members with cancelled Membership even if approved by Maxicare, hospital bls and Professional Fees that are in excess of Maxicare rates, amount in excess ofthe AABL and other imitations provided inthe Agreement, and avaiiments which are specifically excluded inthis Agreement. Excess Charges shal be forthe account ofthe Member, 23. EXPERIMENTAL MEDICAL PROCEDURE: Experimental or investigational medical service, procedure or supply: A service, procedure or supply including, but not limited to the diagnostic service, treatment, facility, equipment, drug or device is considered experimental or investigational i any ofthe following criteria are met: b. A medical society o reguatory agency deems it experimental or ©. The services, procedures or supolies requling Governmental body approval, such as drugs and devices, do not have ‘unrestricted market approval from the Food and Drug Administration (FDA) of the Philipines or US FDA or Final approval {rom any other governmental regulatory body for use in treatment ofa specified condition. Any approval thats granted as an interim step in the regulatory process isnot a substitute for fnal or unrestricted market approval or 4d, There is insufficient or inconclusive medical and scientiic evidence to evaluate the therapeutic value of the service, procedure or supply fr the given diagnosis or indication. 24, MAXICARE CARD: The prepaid card issued by Member containing a unique card number which willbe used for registration and ‘activation of Membership. 25, ILLNESS: A poor health or poor physical condition marked by a pathological deviation from normal healthy state caused by disease or sickness, 26, INJURY: Physical damage or trauma arising wholly and exclusively from an Accident or other events of violent or extemal, and visible nature 27. INPATIENT MEDICAL SERVICES: The hospitalization services which include accommodations, medicines and supplies, procedures and/or surgery whenever medically necessary, furnished to a patiant admitted in an Afiiated Hospital. 28. INTERMEDIATE CARE: A level of nursing care service that provides long-term care for the chronically il, disabled or elderly people. 29, LETTER OF AUTHORIZATION (LOA: Letter of authorization duly issued by Maxicare to, and signed by, the Member which shall serve asthe authority of the latter to avail of the Medical services. 30. MAXICARE COORDINATOR: A duly licensed metical practioner designated by Maxicare in an Affilated Hospital or Afitated Medical Clinic to drect and supervise the extension of Medical services to Members, and who may render medical advice, prescribe medication or treatment, issue referrals to Afflated Specialists, and request for laboratory examination and hospitalzation, upon consultation by Members. 31, MEDICALLY NECESSARY: A Medical Service, as determined by Maxicare, which is (a) consistent with the diagnosis and ‘customary medical treatment ofthe condition, (b) in accordance withthe standards of managed care and good medical practice, {6) not for the convenience of the Member or the Affilated Physician or Specialist, (4) performed in the most cost effective ‘manner requited by the medical condition and (e) consistent withthe terms and conditions of this Agreement. 32, MEMBER: Who is eligible, has been accepted for Membership by Maxicare after complying with the Membership Eligibility, and is currently enrolled under this Agreement. 38, MEMBERSHIP: refers fo membership in Maxicare, pursuant to this Agreement, 34, MEMBERSHIP FEES: refer to the fees for the enrolment of Member. 35. OUT-PATIENT MEDICAL SERVICES: The Medical services which include consultations, treatment, laboratory, diagnostic ‘examinations, andlor anciary procedures provided to a Member by an Aflited Physician or Specials, excluding the In-Patient Medical services rendered to such Member, Page Bot 18 Form Template Corto: Product DevelopmentvJaniry 16,2020/F0-PD-0.049/Rev.01136, PARTYIPARTIES: Individually / collectively refer to Maxicare and Member. 37, PERSONAL INFORMATION: Any information, whether recorded in a material form or not, from which the identity ofthe Member is apparent or can be reasonably and directly ascertained by the enfty holding the information, or when put together with other information would directly and certainly identity the Member. 38, PHILHEALTH: Philippine Health Corporation, an entity administering the National Heath Insurance Program of the Philippines. 39. PHYSICIAN, SURGEON, SPECIALIST, OR DOCTOR’ A person qualified by degree and duly licensed or registered to practice medicine in the geographical area in which he serves. This person must not be a relative of the Member up the third degree of ‘consanguinity and aft. 40. PRE-EXISTING CONDITION: An illness, injury or condition shall be considered pre-existing if: (1) any professional advice or treatment has been obtained for such Illness, injury, or condition prior to the Effective Date of Member's coverage, (2) such illness, injury or condition was evident upon medical ‘examination in connection with the Member's application, and (3) the pathogenesis of such illness, injury cr condition can be clinically determined to have started prior to the Effective Dato of the Member's coverage or at the time of processing of the Member's application, whether or not the Member is aware of such illness or injury. 41. PROFESSIONAL FEES: As distinct from Surgeon and Anesthesiolgists Fees, fees paid to licensed medical professionals Including but no ited to an Oocupational Therapist, Physiotherapist, Attending Physician's visits or Pathologists. 42, REHABILITATION CARE: The restoration ofa person's ability to function as normaly as possible after an ness or injury. 48. RELATED CONDITION: An illness, condition, or disease whichis associated with the particular diagnosis in question either as a direct symptom or sign, a risk factor, an underying cause, a part of a syndrome, or a complication including complications of cagnostios and treatment 44, ROOM AND BOARD ACCOMMODATION: The pre-assigned type of hospital room and board by Maxi (on the beneft and coverage ofthe health care plan under this Agreement. ARTICLE Ill~ INTERPRETATION 1. In this Agreement, uniess the context otherwise requires, words importing the singular number shall include the plural and vice ‘versa, and words importing the masculine shal include the feminine and neuter gender and vice versa, 2. Any reference to Artcies is a reference to Articles inthis Agreement, and Application Form shal be deemed integral parts hereto, ‘Any reference to any document, instrument or agreement (i) shall include all exhibits, schedules and other attachments thereto; (i) shall include all documents, instruments or agreements issued or executed in replacement thereof and (i) shall mean such document, instrument or agreement, oF replacement or predecessor thereto, as amended, modified and supplemented from time to time in accordance withthe terms thereof and in effect at any given time. 3. The headings ofthe Articles and paragraphs herein are inserted for ease of reference only and shal not affect the interpretation thereof or ofthis Agreement. Uniess otherwise provided, any reference to “wting” of cognate expressions includes a reference to telex, cable, facsimile transmission, email or comparable means of communications. Al consents and approvats o be obtained hereunder shal be in writing, 4. Any reference toa person includes its permitted successors and assigns. 5. The words ‘include’, “includes” and “inciuding" are not limiting and shall be deemed to be followed by the words “without limitation,” whether or not so folowed. The words “hereo?, “herein” and “hereunder” and words of similar import when used in any document shal refer to such document as a whole and not to any particular provision of such document. 6. Any reference to “days” shall mean calendar days, unless the term "Business Days” is used, and any reference to "month" shall mean a calendar month Page 9019 Form Template Control: Product Development January 16,2020/F0-PD-0.049Rev017. Words denoting persons shall include individuals, corporations, partnerships, joint ventures, truss, unincorporated organizations, Poltical subdivisions, agencies or instrumentaites. ARTICLE IV ~ BENEFITS AND COVERAGE 1. Maxicare shall extend and provide during the effectivity ofthis Agreement all the benefits pertaining to Membership, subject to the terms and conditions stipulated herein, 2, This Agreement and the benefits appurtenant thereto shall apply only within the tettorialjurisicton of the Philippines. 3. Maxicare undertakes to arrange the availment of the Members’ healthcare benefits in Affiliated Hospitals, Afflated Medical Clinics and Staff as specified in the Agreement, subject to the exclusions, imitations and conditions specified in this Agreement. 4. The benefits mentioned in the Agreement, shall be subject othe folowing general conditions: @. OUT-PATIENT CARE: Coverage of Out-patient medical services, sal be subject othe following condlons: |. The service availment shall be in Maxicare Primary Care Centers and Afiated Medical Clinics as indicated on the ‘welcome letter, and in accordance with benefits and coverage set out inthis Agreement. li, Professional services shall be provided only by Affiiated Physicians. ii, Maxicare shall issue approval and necessary documents prior fo the avalment of any Out-patient care, b, EMERGENCY CARE i. InAffifated Hospital I the emergency treatment has been administered in an Affiated Hospital and the Member stil requires confinement, the In-pationt Medical Services shall be paid by the Member direcly tothe hospital ii, InNon- Affiiated Hospital If emergency treatment has been administered in Non-Affiated Hospital and the Member stil requires confinement, the In-patient Medical Services shall be pad by the Member directly tothe hospital. il. In all these circumstances, Maxicare reserves the right to validate whether the treatment received is emergency in nature andor te ilness or condition is covered under the provisions of this Agreement. 5._AREAS WITHOUT AFFILIATED HOSPITALS: In areas without Afiliated Hospitals as identified by Maxicare, Maxicare wil reimburse the folowing: a, 100% on other hospital ils Professional fees based on Maxicare rates for an Afiiated Physician rendering the service in an Afliated Hospital 6, PHILHEALTH COVERAGE: Itis hereby dectared and agreed that this Agreement is integrated with PhilHealh. ‘a. All Members must be a PhlHealth member. in case a Member fails o fle and process his PhilHeath benefits, the PhlHealth portion must be paid by the Member directly to the hospitalcinic. b. The benefits accruing under this Agreement may be utlized only after the exhaustion of PhiHealth benefits For Members who are qualified to receive PhiHealth benefits, the computation oftheir ABL shal not include the amount of PhilHealth benefits which they are ented to receive. However, any Member who fails to qualify to receive any PhiHealth benefits shall have to pay the PhlHealtn portion directly tothe hospital. Maxicare will not pay or advance the costs of such benefits, nor be responsible fr fling eny claims under PhitHeatt, 4, For Non-PhlHealth Members, the PhlHealth portion shall be for the personal account of the Member and shall pay the PhilHealth portion directly to the hospitalltinic. 7. EXCESS CHARGES Page 10118 Form Template Control: Product DevelopmentJanuary 16, 2020/FO-PD-0.089/Rev.0a. Any availment that is not covered but is advanced by Maxicare shall be charged to the Member and the Member shall be lable to pay such advances within thity (30) days from the statement date indicated in SOA or due date, whichever is appicabe, from Maxicare, These shall include but not mite tothe following: i. Beneft avaliment of lapsed or cancelled Members even if approved by Maxicare, i. Hospital bls and Professional Fees that are in excess of Maxicare rates, i. Avaliment that is not intended to be covered by Maxicare, such as exclusions, fraudulent avaiments, uncoverable items, telephone cals, adltonal beds, ee. iv. Beneft availment found to be not covered and deemed excluded by the Agreement, including concealment of relevant ‘medical information, even if unintentional or unrelated to the current avaiment, and those in excess of Benefit Limits set out inthe Agreement, even fcondonaly approved by Maxicare. atthe time of issuance of the LOA, the amount of the Member's previous avaiiment is not reflected yet, Maxicare reserves the right to re-adjudcate the Member's coverage based on the total remaining balance ofthe benefit iit; and V. Other expenses and charges analogous to the foregoing Ifthe Excess Charges are not pad after the due date, Maxicare reserves the right to suspend al services to the Member ntl the excess charges due, including penalty charge, have been paid and seted. Penalty charge is equivalent to one percent (1%) oF a fraction thereof of the unpaid excess charges due, computed from the due date, subject to clearing of checks, whichever is later (Waiting Period’). Suspension shall be lited after three (3) business days fom receipt of payment incisive of the penalty charge. . Claims incurred during the Suspension and Weiting Period shall not be reimbursed. In no case shall the suspension exceed two (2) months. Otherwise, Maxicare has the option to automatically cancel the Membership without prior notice fo Member. ©. REACTIVATION: Upon ling of the suspension, Maxicare shal initiate the reactivation of Membership to the effect that "Members can acoess Maxicare's network of medical providers, 8, BALANCE BILLING: Maxicare shall maintain alist of prefered Affiiated Physicians and Specialists. Upon avalment, the Member shall be directed by Maxicare to the appropiate Affiated Physician/Specialston the lst. the Member inssts on availing the services of an Affiiated Physician’Speciaist not refered by Maxicare and Balance Biling results, the Member shall be responsible forthe additonal charges. in no case shall the Member demand reimbursement from Maxicare forthe Balance Bling charged by the Afliated Physician/Specialis tothe Member. ARTICLE V - PROCEDURE ON AVAILMENT The benefits and services conferred under the tiles: Outpatient and Emergency Care must be claimed in accordance with the Procedure set forth below, 1. OUT-PATIENT NON-EMERGENCY SERVICES a. Any out-patient or non-emergency services are accomodated by the Maxicare primary care physician at any Maxicare Primary Care Center (PCC) or Aated Medical Cini. Please refer tothe list and location of Maxicare PCCs, helpdesk and ‘Affiated Medical Cinics covered inthis plan listed on welcome letter andlor PRIMA kit , Prior to avaiiment, Member shall present his Maxicare Card or e-voucher and, another valid identification card (e.g, ‘company ID, SSS 1D, driver’ license, or other ID cards bearing photo and signature) for verification, For cases when the Maxicare Card isnot available, the Maxicare Certification can be honored, ‘6 The Maxicare Coordinator shall diagnose the Member for any ailment. Appropriate medical treatment wil then be given or confinement may be recommended, i necessary. However, the in-patient medical service shall be onthe personal account ‘of the Member and shal be paid dre tothe hospital/tnic. if medical case requires treatment or consultation with another specialist, the Maxicare primary care physician or Coordinator may refer accordingly. 4d, Necessary laboratory examinations or diagnostic procedures may be requested by the Mexicare primary care physician or Coordinator using the Maxicare Laboratory Request Form. Member then proceeds to laboratory where the tests will be performed, Resut ofthe tests may be folowed up with the Maxicare primary care physician or Coordinator. 2, EMERGENCY CARE SERVICES: For Emergency Conditions as defined under Article I21, the Member may proceed to the ‘emergency room of the nearest hospitalidnic whether affliated or non-afiated. Member must present his Maxicare Card or ‘e-oucher together with a valid ID. Once confinement is determined, the in-patient coverage shal be the personal account of the ‘Member and shal be paid directly to the hospitalcnic. Page 1 of 19 Form Template Control: Product Development Jamsary 16, 2020/FO-PD-0.049/Rev.01‘After treatment at the emergency room of a non-Affiiated Hospital, ll necessary receipts and clinical records must be secured by Member for processing of caim for reimbursement, The Maxicare claim for reimbursement form, medical certficate and al pertinent documents must be promptly accomplished and submited to Maxicare Head Office within tity (30) days upon the date ofcischarge. ARTICLE VI CLAIMS PROCEDURE (Applicable to Emergency Cases Only) 4. CLAIMS SUBMISSION ‘2. Cerification, information and Evidence: All certificates, accounts, receipts, information and evidence required by Maxicare shall be fumished in such form as Maxicare may require, b. Sufficiency of Notice: Witten notice of any claim given by ar on behalf of the Member or Beneficiary to Maxicare orto any Authorized Representative of Maxicare, with information suffcient to identify the Member, shall be deemed notice to Maxicare ©, Notice of Claim ‘in cases wherein Maxicare covered costs were not deducted from the medical bls and a Member s made o pay for the health care cost, a Member may request for reimbursement of such costs which are covered under this Agreement The request must be made onthe prescribed claim form to which shall be attached oficial receipts, together supporting charge sips, detailed itemized accounts and other necessary documents. No reimbursement shall be made to the Member unless shall orginal documents are submitted by the Member or if the has otherwise been fuly indemnified or reimbursed ofthe medical bil or costs incured under any other heatth care coverage oF insurance policy or any other similar contracts or Agreements, Such request for benefits must be presented within tity (30) days after the expiration ofthe period of confinement for wrich claim for benefits is being mado. Failure to submit within the time required shall not invalidate nor reduce any caim fit was not reasonably possible to give proof within such time, Payment of Clans: Payment ofthe approved claims shall be made directly tothe Principal unless otherwise agreed upon by the Parties. Maxicare shall pay the approved member reimbursement claims within thity (30) days from receipt of al the supporting documents Any outstanding excess charges shal be offset agains the approved caim, In case of death of the Member, payment shall be made tothe beneficiary or benefiiaries, In case of no beneficiary, payment ofthe approved claims shall be made to the executor or administrator of the estate of the deceased Member in accordance vith the rules on testate or intestate succession under the Civil Code of the Philippines. if there is no executor or administrator, then the payment shall be made to the legal heirs of the Member after thelr elainshio to the Member is satisfactory established. The beneficiary, executor, administrator or the legal hel shall be required to sign ‘oF execute an afiavit of satisfaction of claim, which shall discharge Maxicare from any and all obligations arising out of the same, 4d, Fraudulent Claims: If any claim under this Agreement sin any respect fraudulent, all benefts payable andlor paid in relation to that claim shall be foreted and if deemed appropriate, recoverable respectively, . Physical Examination and Autopsy: Maxicare shall have the rght and opportunity to examine the Member when and as often at is may reasonably require during the pendency of claim hereunder, andthe right and opportunity to make an autopsy in case of death, where itis not forbidden by law. 2, BENEFIT PAYMENT ‘All benefits payment shall in PHILIPPINE PESO. a. Payment of Benefits Ia Member incurs Eligible Expenses during the effectivity of this Agreement, Maxicare will pay benefits in accordance with the Schedule of Benefit Coverage of this Agreement. Maxicare wil pay the Eligible Expenses after application of any stipulated co-payment or other deductions may apply. b. Coordination of Benefits Benefits wil 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 faces 3, REIMBURSEMENT CLAIMS FOR EMERGENCY CASES: Page 120418 Form Template Control: Product DevelopmentJanuary 16,2020/FO-PD0.010/Rev 01‘2. Limitation: The claims for reimbursement shall apply only in emergency treatments, whether out-patient or in-patient, rendered in non-Afiiated Clnice/Hosptas, b. Filing of Claims: All claims for reimbursement must be fied using the Maxicare reimbursement form and submitted to Maxicare Makat, Cebu or Davao Offices within tity (30) days from the date of avalment for out-patient availment or from date of discharge for in-patient avaliment. The claim must be accompanied bythe following |. Completely filed-out Maxicare reimbursement frm; ii Original Bureau of internal Revenue (‘BIR’) registred oficial recep(s) sales invoice; i, Clinical abstract history, iv. Operative reports fr surgical cases; v. _Histopathological result Vi. Medical certficate indicating the diagnostic and procedure(s) done (f any); vii. Charge sips or detailed itemizedPoreakdown of charges (charges per item paid); vil. Police report for cases of assault and vehicular acidents; and i. Certification of non-availability of medicines ftom hospital pharmacy and original prescriptions signed by the Attending Physician (for In-Patient medicines bought outside the Hospital. Failure to submit within the me required shall nt invalidate nor reduce any claim if it was reasonably possible to give proof within such time, ©, Reservation: During the pendency of the claim, Maxicare reserves the right and opportunity to conduct @ comprehensive ‘examination of the Member who is claiming for reimbursement 4. Payment of Claims: Refer to Article VI, Item 1, Letter Ci 4, REQUEST FOR RECONSIDERATION: If 4 claim for reimbursement is denied, or the Member is not satisfied! agreeable to the reimbursement paid by Maxicare, a written request for reconsideration must be filed with the claims department of Maxicare Head Office not later than ten (10) days ftom receipt of such denial or questioned reimbursement, Otherwise, the claim shall be deemed satisfied or terminated. The request for reconsideration shall contain all the reasons upon which reconsideration is sought and shall be decided upon by authorized personnel of Maxicare, whose decision shall be final. Maxicare reserves the right to deny claims for reimbursement if the procedures and requirements have not been striclly complied with, ARTICLE Vil - RENEWAL 1. RENEWAL: Maxicare may, in its discretion, offer renewal of Membership inthe healthcare program under the same, qualified or ‘other terms and conditions deemed relevant, necessary and essential to the maintenance and furtherance ofthe contractual relationship ofthe partes. A Member to whom Membership renewal fs ofered may acceptor reject the same. Acooptance is limited to the terms of the offer; a qualifed acceptance constitutes @ counter offer. In case of acceptance of the offer, Membership shall be deemed uninterrupted. Members with unpaid excess charges billed by Maxicare shall be endorsed for renewal only upon receipt of fll payment. 2, PROCEDURES: A Member who desires to renew his or her Membership must settle the renewal Membership Fees prior to the ‘expiration of his current Membership. ARTICLE VIll- LIMITATIONS IN SERVICES ‘The rights ofthe Member and obligations of Maxicare are subject tothe folowing limitation: 1. Ifa major disaster or epidemic causes unavaiablty of facities or personel, or if circumstances not within the control of Maxicare such as complete or partial destruction of feces, war, ro, civil insuection, labor disputes, or similar causes occur, Maxicare shall not be held lable for any delay or failure to provide services tothe Member. Maxicare shall, however, exertits best effort to provide services to the Member, as the circumstances permit, 2. Maxicare's aggregate lability for Emergency Care Benefits for any one-year period with respect to any particular diseaselcondion and thei complications shall be limited to the Member's ABL. 3. Maxicare's obligation with respect tothe Professional Fees of Afflated Physician/Specialist for specific Medical services shall be limited tothe agreed Maxicare standard Professional Fees. Page 130119 Form Template Control: Product DevelopmentJantary 16, 2020/FO-PD-0.049/Rev.014. If the Member refuses to follow the recommended treatment or procedures nd the Afiiated Physician believes that no professionally acceptable alternative exists, then Maxicare shall no longer be responsible to provide care forthe condition under ‘treatment while such refusal exsts. Further, if the earl refusal resulted inthe aggravation of the medical condition, Maxicare shall no longer be responsible fo the treatment thereof 5. Ifa Member refuses to comply with established rules, regulations and procedures of the chosen hospitals or clinics and by reason of hich services are denied, Maxicare shall not be lable for any claims, charges or damages caused to the Member. 6. Maxicare is not liable for any aims, charges or damages, legal fees or litigation cost incurred by or caused to the Member by the ‘acts of the doctors or physicians in the course of the delivery ofthe Medial services, whether in-Patient or Emergency. itis hereby understood that the lability of Maxicare is imited to the payment of hospital bils, Professional Fees and al medical ‘expenses directly related tothe medical management ofthe Meme. ARTICLE IX - MEMBERSHIP FEES 1, AMOUNT OF MEMBERSHIP FEES: For the services covered in this Agreement, Member shall pay Maxicare a Membership Fee Per Member. 2. MEMBERSHIP DUE: Every Member is required to pay the Membership Fees. The Membership Fee shall be payable in advance. 3. PAYMENT: Membership dues may be paid at Maxicare Head Office or af such other places as may be designated by Maxicare. 4, GRACE PERIOD FOR PAYMENT OF MEMBERSHIP FEES: No grace period applicable since payment is required prior effectivity of coverage. 5, REFUNDICREDIT OF MEMBERSHIP FEE: There shall be no refund of Membership Fee after the fiteen (15) day period as specified on Article| item 2, ARTICLE X - MEMBERSHIP 1. MEMBERSHIP ELIGIBILITY: The person described below is eligible to enroll under this Agreement. The age shall refer to the ‘age of the Member upon Effective Date of this Agreement. The Member may therefore maintain his Membership until the expiration ofthis Agreement ‘Silver: zero (0) to fiy-nine (58) years old Gold: sixty (60) years old and above 2, INVALIDATION OF MEMBERSHIP: Failure to disclose any material information about a Member, including but not limited to gender, date of bit, or medical information, whether intentional or unintentional, shall automatically invalidate the coverage of the Member effective from the date of coverage. An infomation is deemed material fits disclosure would have resuted inthe (a) decination of the application for Membership of the Applicant, (b) the assessment of a higher Membership Fee or (c) the inclusion of atonal restitions and exclusions to the benefits of the Member under this Agreement. Member shal reimburse Maxicare the difference between the costs of previous Medical services rendered to such Member and the Membership Fe. 3. TERMINATION OF MEMBERSHIP: The rights of Member shall be extinguished at any of the folowing dates: a. Expy date of tis Agreement: b. When Maxicare obligations are not paid within the Grace Period; ¢. Effective immediately, when the Member has fraudulent availment or material mistepresentatios or misstatements for the purpose of availing Maxicare benefits; <4. Effective immediately, when the Member enters military, naval or ir service of any country or intemational authority; . Effective immediately, when the Member fails to observe the terms and conditions ofthis Agreement or fails fo act with utmost good faith. 4. PROCESSING FEE: For lost ID Cards, filed-out Maxicare statement of loss ID card form, photocopy of front and back portion of 2 valid ID with picture or notarized afdavit of loss and a valid proof of payment of processing fee of P200 per card shall be ‘submitted fo Maxicare within tity (30) days from the date of oss. Page 14f19 Form Template Corto: Product Development January 16, 2020(F0-PD-0.049/Rev 01ARTICLE XI TERM AND TERMINATION 1. EFFECTIVE DATE: Unless otherwise provided herein, this Agreement shall commence on the date specified as part of this ‘Agreement and shallbeefectv fr aterm of one (1) year. 2, TERMINATION OF AGREEMENT. ‘2, Maxicare shall have the right to immediately terminate this Agreement inthe event that i. Any material representation or waranty made bythe Member isflse or untrue when made; orf Member commits any act with the intent to defraud Maxicare; ji Nor-payment of Maxicare obligations subject to agreed payment terms; and if Member isin material breach ofthe Agreement and has fled to cure such breach within tity (30) days after its receipt of written notice from Maxicare, b. All Medical services and coverage under this Agreement shall terminate on the termination date, without prejudice to any ‘aim for covered Medical services rendered to a Member prior tothe termination date. ARTICLE Xil - GENERAL PROVISIONS 4. ENTIRE CONTRACT: This Agreement, Maxicare PRIMA ki, welcome letter, confirmation through email andor any stipulation or endorsement attached to this Agreement, and the membership terms and conditions shal conttute the entre contract between Maxicare and the Member, Al statements and information shall be deemed representations and warranties made by the Member himself for purposes of applying the provisions ofthis Agreement. The execution of tis Agreement or any other agreement between the Parties shall consttute as execution of this Agreement by the Parties. This Agreement supersedes all prior Undertakings, arangements, representations, agreements, whether verbal or written between the Parties. Furthermore, by avaling the services of Maxicare and the Member acknowledge and agree to abide by all the membership terms and conditions contained in the Agreement and publshed via Maxicare website at htps:/imavicare,phimerber-terms 2. NON-TRANSFERABILITY: All benefits in this Agreement are not transferable or assignable. Member may not assign any ofits Tights or delegate any of is obligations under this Agreement without the prior written consent of Maxicare. Maxicare may assign any of its rights oF delegate any of its oblgations upon written notice fo Member. Any purported assignment or delagation in violation ofthis Agreement is null and void. 3. AUTHORITY TO PROCESS AND DATA PRIVACY: ‘a. Member hereby agrees and understands that inthe course of providing services to the Member, Maxicare shall engage the services of, andor interact with, other third parties, such as, but not limited to its parent company, affiiated companies, subsidiaries, nancial advisors, affilated third parties or independentinon-affiated third parties and service providers, whether local or foreign (collectively referred to as "Representatives. b. The Member hereby represent and warrant that at the time of the effectivity ofthis Agreement and of their coverage, they are granting the required Consents pursuant to the Data Privacy Laws authorizing Maxicare and any of its Authorized Representatives to: Obiain, collect, examine, process, and store the Member's personal information, including sensitive personal information and privieged information, medical records, or any other information relative to the Member hospitalization, consultation, and treatment or any medical advice in connection wih the beneftclaim availed under the Agreement, as may be deemed necessary by Maxicare. Except as otherwise stated hereon, any information ‘obtained relative to the authority herein given shall be strictly confidential, The extent ofthe collection and processing shall be necessary and incidental to the performance of the services contemplated in the Agreement ii. Disclose the aforementioned information to agents and brokers, Maxicare and its Representatives, incuding the service providers which will perform the services contemplated in the Agreement, for any legitimate business purpose as Maxicare may deem appropriate, including but not limited to outsoureed processing of Maxicare transactions, profling or historical statistical analysis, providing advice or information which Maxicare and its Representatives belive may be of interest to the Member, to effectively administer or manage their accounts, enhance customer services, orto communicate with the Member for any purpose. Processing is hereby understood to include any operation or any set of operations performed upon personal information including, but not liited to, the collection, recording, organization, storage, updating or modification, retrieval, consultation, ‘use, consoldation, blocking, erasure or destruction of data, Processing would include both manual and automated handling Page Bo 18 Form Template Control: Product Development! January 16, 2020/FO-PD.-0.049/Rev.01‘of personal information and storage and data ransfrs using various means including but no itd to physical methods as well as electronic via information and communications systems employed by Maxicare and its Representatives, The Members hereby warrant that they understand their rights and obligations pursuant tothe Data Privacy Laws. They understand that they retain the rght tobe informed, to object, access, complain, and rect, to request for fitering of certain information, and to the corresponding damages in case of violation of thei rights within the corresponding limitations as set forth in the pertinent ws. 4d, The Members hereby represent tht, in order to provide the services contemplated in the Agreement, the authors herein provided shall be valid and existing during the term ofthe Agreement, including any extensions thereof, and until necessary for the estabishment, exercise or defense of any claims arising from the said Agreement ©. Members shall hold Maxicare free and harmless from and against any and all suits or caims, actons, or proceedings, damages, costs and expenses, including attomey' fees, which may be fled, charged or adudged against Maxicare or any Of its directors, stockholders, officers, employees, agents, or representatives in connection with or arising ffom the use, processing, and disclosure by Maxicare or is representatives of the Members’ and their Dependents’ medical records and ‘ther personal information pursuant to this Agreement and disclosure of such information to Maxicare's representatives pursuant to its reliance on Members’ representation and warranty that Maxicare has the authoty to examine, use, process, or disclose, as the case may be, said medical records or personal information forthe purpose of performing services contemplated in his agreament. 4. CONFIDENTIALITY: a. A Party ("Receiving Party), including its employees, agents or representatives, shall not use or reproduce, directly or indirectly any Confidential Information for the beneft of any person, or disclose to anyone such Confidential Information Without the written authorization ofthe other Party (Disclosing Party’), whether durin or ater the term of tis Agreement, for as long as such information retains the characteristics of Confidential Information. “Confidential Information’ means any data or information, that is proprietary to the Parties and not generally known tothe publi, whether in tangible or intangible form, whenever and however disclosed, including, without limitation, () personal information, treatments or operations undergone by its Members, (i) rade secrets, confidential or secret formulae, special ‘medical equipment and procedures, (i) medical uiization reports, directly or indirect useful in any aspect ofthe business of Maxicere, (v) any vendor names, Member and supplier ists, (v) marketing strategies, plans, financial information, or projections, operations, sales estimates, business plans and performance results relating to the past, present or future business activites ofthe Parties, (vi al intelectual or other proprietary information or material of Maxicare; (vi) ll forms of Confidential Information including, but not fmited to, loose notes, dares, memoranda, drawings, photographs, electronic storage and computer printouts; (vii) anyother information that should reasonably be recognized as confident iformation of Manicare. ‘Al information which the Receiving Party acquires or becomes acquainted with during the period of his Agreement, whether developed by the Disclosing Party or by others, which the Recelving Party has a reasonable basis to believe to be Confidential Information, or which is treated, designated andlor identified by the Disclosing Party as being Confidential Information, shall be presumed to be Confidential Information. Confidential Information need not be novel, unique, patentable, copyrightable or constitute a trade secretin order to be designated Confidential information ‘Anything herein tothe contrary, notwithstanding, Confidential Information shall not include information which: i. was known by the Receiving Party prio to receiving the Confidential Information from the Disclosing Paty; ji, becomes rightfully known to the Receiving Party from a third-party source not known, after diligent inquiry by such Party to be under an obligation to the Disclosing Party o maintain confidentiaty; i, iscor becomes publicly available through no fault of or failure to act by a Party in breach of this Agreement; iv. is requied to be disclosed by law of regulon or in any judicial or administrative proceeding provided, however, that: ivi, the Receiving Party tas provided the Disclosing Party with prompt writen noice thereof so thatthe Disclosing Party may seek appropriate remedy andlor injunctive relief prior to such disclosure by the Receiving Party, ivi the Receiving Party has taken all reasonable actions andlor steps to narrow down the information to be disclosed; ivi Should partial disclosure be required, the Receiving Party furnishes only that portion thats legaly required to be disclosed; and Page 160119 Form Template Control: Product Development anuary 16, 2020/FO-PD-0.049/Rev.01iviv the Receiving Party shall not oppose and shall cooperate with the Disclosing Party with respect o any such request for any protective order or other reli; \. 18 oF has been independently developed by employees, consltans or agents ofthe Receiving Party without violation ofthe terms of tis Agreement or reference or access to any Confidential information; and Vis disclosed with the Disclosing Party's prior writen consent. b. The Receiving Party agrees not to use the Confidential information belonging to the Disclosing Party for any purpose other than those contemplated by the Parties and in furtherance of this Agreement. Any other use of such Confidential Information ‘shall be made only upon prior written consent ofthe Disclosing Party. ‘For purposes ofthis Agreement, the Parties agree that their obligations herein shall be binding upon ther rectors, officers, ‘employees, agents, representatives, and al other natural and juridical persons acting for and on ther behalf, including, but ‘ot limited to their subsidiaries, afates, subcontractors and partners 4d, The obligations provided under this Agreement shal include taking steps to: i, restrict disclosure of Confidential Information solely to either Party's directors, officers, employees, agents, and representatives, on a need to know basis, ii. advise either Party's directors, officers, employees, agents, and representatives with access to the Confidential Information ofthe obligation to protect Confidential Information; and li. _use the Confidential Information only for purposes directly related to this Agreement. ‘The obligations imposed herein shall survive even ater the termination ofthe Agreement ‘8. The Receiving Party agrees that all Confidential Information shall remain the exclusive property of the Disclosing Party and its successors, {. Notwitistanding any right granted hereunder, his Agreement shall not grant the Recelving Party aright under any patent, copytght, trade secret, or other intellectual property gh g. Inthe event thatthe Recehing Party discloses, disseminates or releases any Confident Information received from the Disclosing Party, except as provided above, such disclosure, dissemination or release wil be deemed a material breach of this Agreement 5. NEWLY AFFILIATED HOSPITALICLINIC: A newly Affiated HosptalMedical Ciinic by Maxicare shall not be automatically inluded in the network of medical providers that can be accessed by Member. Inclusion of such newly Affiliated HospitalMedical Cinic shall be subject to Maxicare’s evaluation, Maxicare shall notify Member of the options regarding access to the newly Affiated HospitalMedical Cini, 6. TAXES, LEVIES AND GOVERNMENT IMPOSITION: Member shal directly answer and be liable for al taxes, fees, charges and penalties that may be assessed against Maxicare and shal, upon noice or demand from Maxicare, immediately sete and pay all ‘such axes, penalies and charges as may be assessed, in the event that: a. The fees and benefits provided under ths Agreement are made subject fo new taxes, fees, charges or penalties as may be required by law ater the execution of this Agreement b, A new interpretation ofthe law, regulaton or its equivalent should result to changes in the formula or manner of computing taxes thereby resulting in addtional ax obigations onthe part of Maxicare; Member warrants thatthe transaction contemplated herein is not subject toa particular tax, such as Value Added Tax, and the Membership Fee was computed pursuant to such representation; 4. This Agreement is subject to such other taxes, fees, charges or penalties, not otherwise contemplated between the Parties but io which the Parties may become liable under te law. For the avoidance of any doubt, the taxes, levies or fees refered to herein ae only those that alec the quoting of Membership Fees, 7. AMENDMENTS: Maxicare may, at any time and for whatever reason, amend, revise or modify the Membership Terms when deemed necessary and it shall inform the Member of such fact by publication, posting, electronic mail or any other means that Maxicare deems proper. Any and all amendments, revisions or modifications shall be binding upon the Member 8 GOVERNING LAW: This Agreement shall be governed by and construed in accordance wit the laws of the Republic of the Philippines. Page 1 of 18 Form Template Conto: Product DevelopmentJanuary 16, 2020/FO-PD-0.049/Rev.019. ARBITRATION: Any difference arising between the Member and Maxicare shal be referred fo an arbitrator to be appointed by the partes tothe dispute. Ifthe parties are unable fo agree on a single arbitrator, two (2) arbitrators shall be appointed (one by each party) Inthe event of futher disagreement, the arbitrators shall select an umpire, Ifthe diference between the paris required motical knowledge (including any question regarding the appropriate maximum indemnity for any medical service or an operation Not listed inthe schedule of surgical fees) the arbitrators atthe discretion of Maxicare, may be registered medical practitioners and the umpire in such an instance, shall be @ consultant Specialist, Surgeon, or Physician, Determination of an award shall bea Conditon Precedent to any Liability or right of action against Maxicare. 410. ATTORNEY'S FEES AND COST OF LITIGATION: Inthe event of any legal ation or other proceeding brought to enforoe the terms ofthis Agreement, Maxicare shal be ented to reasonable attomey’s fees and other costs incured during that proceeding in adation to any other relief to which itis ented. ‘1, SETTLEMENT OF DISPUTES: Any disputes or disagreements arising out of or relating to this Agreement, which cannot be setled by the Parties on a mutualy satisfactory basis shall be resolved exclusively before the proper courts in Makati Ciy in ‘2ocordance with the laws ofthe Repubic ofthe Pippnes. ‘2, AUTHORIZED SIGNATORY f applicable, the Parties hereby represent that their respective representatives been duly authorized by the Board of Directors to sign, execute and deliver this Service Agreement 18. REFUND: All the provisions pertaining to refund, payment and reimbursement shall not apply if Member, commits any act prejudicial to Maxicare, with or without intent to detaud, including, but not ite to: ‘Creating an account or entity forthe sole purpose of qualifying for enrolment or availing the heath medical coverage; Using the card of a Member o avall ofthe Medical services; ‘Availing unauthorized/unprescrbed services or services no related to the diagnosis; CConsentng to biling fr services not rendered, Duplicating claims; and Other analogous circumstances, ‘4, SEPARABILITY: If any term or provision ofthis Agreement is declared invalid, ilegel or unenforceable under Philippine laws, ‘uch invalidity, legaty or unenforceability shall not affect or render unenforceable any other term or provision ofthis Agreement. 15. AGENCY: Nothing in this Agreement creates any agency, joint venture, partnership or other form of joint enterprise, employment fiduciary relationship between the Parties. Nether Party has any express or implied right or authority to assume or create any ‘obligations on behatf of or inthe name of the other Party orto bind the other Party to any contact, agreement or undertaking with any tid party. 16. NOTICES: All notices, demands and other communications required or permitted hereunder shall be made in writing and sent to the Members or its Authorized Representative, 17. COUNTERPARTS. This Agreement may be executed in several counterparts thal together shall constiule one and the same instrument, 18, RIGHTS OF SUBROGATION. The coverage under this Agreement is extended to cover injuries of the Member caused by third parties) whether liability is determinable or not as in cases of vehicular accdents and other similar instances or related incidents imted to the availed healthcare services which have been paid by Maxicare pursuant tothe Terms and Conditions of, the Agreement and thatthe Member will subrogate his rights of recovery from any other party to the extent ofthe value ofthe services $0 rendered to Maxicare and will undertake to assist Maxicare in the suocessful recovery ofthe total cost of those services, 19, CIVIL CODE ARTICLE 1250 WAIVER: The provisions of Article 1250 of the Civil Code of the Republic ofthe Philippines (Republic Act No. 386) which reads, “incase an extraordinary inftion or deflation ofthe currency stipulated should supervene, the value of the curency at the ime of establishment ofthe obligation shall be the basis of payment’, shall nt apply in determining the extent of lability under the provisions of this Agreement. 20, IMPORTANT NOTICE: The Insurance Commission, wih offces in Manila, Cebu and Davao, isthe government office in charge of the enforcement ofall aws related to Health Maintenance Organization (HMO), and has supervisions over HMOs. Itis ready at all mes to assist the general public in matters pertaining to HMO, pre-need and insurance. For any inquiries or complaints, please contact the Public Assistance and Mediation Division (PAMD) of the Insurance Commission at 1071 United Nations Avenue, Manila with telephone numbers +832-5238461 and email address publcassistance@insurance,qouph. The oficial Pago 180819 Form Template Corto: Product DevelopmentJanuary 16, 2020/F0-PD-.049/Rev.01website of the Insurance Commission is wwrw.nsurance.gov.ph, Maxicare Healthcare Corporation Maxicare Tower, 208 Satcedo Set, Legazpi Vilage, Makati Cy, 122 | Corporate Tunline: 682 7008-6900 247 Customer Care Hote: (2) 682-190 (682) 798-7777 xt Horacio T. Templo Chief Actuarial Officer Page 190118 Form Template Control: Product Development January 16, 2020/F0-PD-0.049/Rev.01