Application No.

______________________________
APPLICATION FOR INDIVIDUAL PLAN Reference No. _______________________________

PLEASE WRITE LEGIBLY IN BLOCK LETTERS. FILL OUT ALL BLANKS / BOXES OF THIS APPLICATION AND ITS ATTACHMENT, WHEN APPLICABLE, AND SUBMIT THEM TO INLIFE HEALTH CARE AS SOON
AS POSSIBLE. ONLY COMPLETELY FILLED-OUT APPLICATIONS WITH OTHER DOCUMENTARY REQUIREMENTS, IF ANY, INCLUDING VALID IDENTIFICATION DOCUMENT (ID), WILL BE PROCESSED.

PART I – PRINCIPAL / PRIMARY APPLICANT’S INFORMATION

LAST NAME** FIRST NAME** MIDDLE NAME SEX (M/F)**
Gelim Juvy Belonias F
AGE** BIRTHDATE (mm/dd/yyyy)** PLACE OF BIRTH HEIGHT** WEIGHT** CIVIL STATUS CITIZENSHIP RESIDENCE TEL. NO. MOBILE NUMBER**

33 11/19/1990 Caloocan 5'4 60 Single Filipino 0977636409

PRESENT NO. & STREET TOWN/BARANGAY CITY/MUNICIPALITY ZIP CODE

ADDRESS** Abango
Block 13 Lot 1 Gentleness St. Rudlin Homes Barugo 6519
COMPANY NAME OCCUPATION / POSITION
☐ SSS No. ___________________________________ or TAX IDENTIFICATION NUMBER**
Emerhub SDR ☐ GSIS No. __________________________________ or
________________________________
☐ National ID No. for Non-Filipinos
COMPLETE BUSINESS
gelimjuvy@gmail.com
E-MAIL ADDRESS**
_______________________________________________
Not Applicable. Reason:
ADDRESS 6/F CYBER ONE BLDG., OFFICE TEL. NO. ☐ Not applicable
☐ Nonresident Alien***
☐ Student with no TIN
11 EASTWOOD AVE.,
* Scanned of photocopy of one (1) official Identification Document of the Applicant must be submitted (e.g. Passport, Driver’s License, PRC ID. Please refer to ‘ Valid Identification Cards for Financial Transactions’
EASTWOOD
under BSP Circular CITY
No. 792, s. 2013). **Required field ***Must not derive any income in/from the Philippines. If deriving income, please secure TIN as required by Philippine laws. Whether or not deriving income in
the Philippines, please provide scanned or photocopy of passport, stamp of last arrival and Philippine visa/ work permit (if applicable).
CYBERPARK,
PART II – INFORMATION ON THE AGREEMENT
PROGRAM TYPE BAGUMBAYAN
  NATIONWIDE QUEZON ACCESS  NATIONWIDE ACCESS  LUZON ACCESS  VISMIN ACCESS
CITY 1110Hospitals and Clinics, including
– Open Access to all Accredited – Open Access to all Accredited
Hospitals and Clinics, excluding
– Open Access to all Accredited
Hospitals and Clinics in Luzon (except
– Open Access to all Accredited
Hospitals and Clinics in Visayas and
*top 6 Hospitals *top 6 Hospitals NCR) Mindanao
* Asian Hospital and Medical Center, Cardinal Santos Medical Center, Makati Medical Center, St. Luke’s Medical Center (QC and BGC) and The Medical City

ROOM ACCOMMODATION  SUITE  PRIVATE  SEMI-PRIVATE  WARD DENTAL COVERAGE

 YES  NO
(Optional Benefit)
MODE OF PAYMENT  ANNUAL  SEMI-ANNUAL  QUARTERLY
PART III – INFORMATION ON THE PAYOR / LEGAL GUARDIAN [To be filled-out only if the applicant is not the payor or the applicant is a minor]1
LAST NAME** FIRST NAME** MIDDLE NAME SEX (M/F)

COMPANY NAME (if Company paid2) / BUSINESS NAME CONTACT PERSON & POSITION TITLE TIN (Company/Payor/Legal Guardian)**

PAYOR / LEGAL GUARDIAN NO. & STREET TOWN/BARANGAY CITY/MUNICIPALITY ZIP CODE
COMPANY ADDRESS 
RELATIONSHIP TO APPLICANT RESIDENCE TEL.NO. MOBILE NUMBER** OFFICE TEL. NO.** E-MAIL ADDRESS **

1
The following documents must be submitted: Photocopy of ‘Valid Identification Card for Financial Transactions’ of Payor, For Guardians, also submit Judicial Declaration of Guardianship or Affidavit of Guardianship
as the case may be, and other proof of Actual Care and Custody of the minor. 2 If company paid, please provide documents (i.e. letter providing that the Company is the Payor with ID of the signatory). **Required field
PART IV – SOURCE OF FUNDS (Check all that apply)
PRINCIPAL / PAYOR / LEGAL GUARDIAN Name of Employer/Business

 SALARY  PENSION  REMITTANCES  COMMISSIONS  OTHERS _________________  BUSINESS _______________________


Emerhub
PART V – BILLING ADDRESS
Deliver Billing Notices to my:  RESIDENCE  OFFICE  EMPLOYER/PAYOR  LEGAL GUARDIAN


 I PREFER PAPERLESS BILLING Paperless Billing is the smart and ecological choice, and we encourage you to use it. But if you ever need a paper copy of your bill, you can make that request easily.

PART VI – LIFE (GROUP TERM) INSURANCE

DESIGNATION OF BENEFICIARIES:
 The PRIMARY (P) beneficiary shall receive the death benefit should the insured individual die ahead of him/her. A PRIMARY beneficiary may be designated as REVOCABLE or
IRREVOCABLE beneficiary.
 If the beneficiary designation is IRREVOCABLE (I), the insured individual cannot change the beneficiary nor exercise any right under the policy without the consent of the
irrevocably designated beneficiary.
 If the primary beneficiary is designated as REVOCABLE (R), the insured individual may exercise all his rights under the policy without the consent of the designated revocable
beneficiary.
 The CONTINGENT (C) beneficiary shall receive the death benefit should all the Primary beneficiaries die before the insured individual. A Contingent beneficiary designation is
considered as revocable.
 If the insured individual fails to indicate the designation of his/her beneficiaries, default designation will be “Primary” and “Revocable”.
 Unless otherwise stated, the primary beneficiaries shall share equally in the insurance proceeds.
 For minor beneficiaries, the representative of the minor beneficiary must secure and submit a court-approved Affidavit of Legal Guardianship.
Designation
NAME OF BENEFICIARIES 3 Relationship Birthdate Exact Amount / Percentage of Sharing
Sex (Please read the notes above before Age
(Surname, First Name, Middle Initial) with Applicant (mm/dd/yyyy) (Optional)
ticking off the boxes below)

Codilan,Catalea Marie EveF P R I C Daughter 03/22/2013 10

P R I C
3
The following are recommended beneficiaries: spouse, son/daughter, parent, brother/sister

AUTHORIZATION. I hereby authorize any person, organization or entity that has any record or knowledge of my health to give to Insular Health Care, Inc. (“InLife Health
Care”) any or all of such records or information in his/her/its possession. These include, but is not limited to, records or information relating to any medical examination, consultation,
diagnosis, hospitalization, treatment or availment of other healthcare services. I also authorize InLife Health Care to process my personal and sensitive personal information in
accordance with its Data Privacy Policy, including its subsequent amendments, as published in its website: https://www.insularhealthcare.com.ph/privacy-policy/. I am aware that
should I have any privacy concern regarding my personal data, I may consult InLife Health Care’s Data Protection Officer at dataprivacy@insularhealthcare.com.ph or Tel: 813-0131
loc 8505, or the National Privacy Commission at https://privacy.gov.ph

I understand that the consent I am giving through this form is in addition to any other consent that I may have already given InLife Health Care and its affiliates regarding the
processing of my personal data. I further understand that the consent I have given shall remain in full force until revoked in writing except to the extent that action has already been
 taken based therein. I hereby release InLife Health Care, its affiliates and partners from any liability arising from any disclosure and/or processing made in accordance with the consent
I have given. A photographic copy of this authorization shall be as valid as the original.

[Maaaring humingi ng tulong kung hindi nakakaunawa ng Ingles. Huwag pumirma kung mayroong hindi naiintindihan.]

Juvy B. Gelim
__________________________________ 11/8/2023
_______________________ __________________________________ _______________________
Printed Name & Signature of Applicant Date Signed Printed Name & Signature of Employer/ Payor/ Legal Date Signed
Guardian

PART VII – QUESTIONNAIRE \

YES

NO


1. Are you now actively at work on a regular full-time basis or actively performing daily normal activities of life? 



2. Do you engage in any hazardous sport or avocation? 




3. Are you presently covered under any hospitalization or medical plan? 



4. Have you ever been rejected for insurance, including healthcare plans, or been offered insurance at a higher or rated premium? 



5. Have you had any deferment, rejection, or discharge from any outfit because of any physical or mental condition?
 
6. Do you have any physical abnormality such as lumps or growths on any part of your body, impairment of sight or hearing, loss of any part of your body, or other physical
 

defects?  
7. During the past years, have you:  
a. Consulted, been treated or operated on by a physician or medical practitioner? 



b. Had any medical examination or check-up? 




8. Have you ever been confined in any hospital or clinic for medical treatment or surgical operation? 



9. Have you ever consulted or been treated for high blood pressure, heart trouble, diabetes, cancer, liver disease, asthma or peptic ulcer? 



10. Are you now taking any regular medication or undergoing medical treatment or observation?  
11. For women only:
10/28/2023
a. Date of last menstrual period: ______________________________
03/22/2013
b. Date of last delivery: __________________________________
c.Are you pregnant? If yes, state number of months: _____________  
d. Have you ever delivered by caesarian section or experienced any abnormality in your pregnancies?  
Please explain fully a “NO” answer to Question 1 and any “YES” answer to Questions 2-11 above. You may use an extra sheet if needed.

Please indicate details of all known illnesses/injuries. Only health conditions declared in the application shall be covered; provided that, these conditions are not part of
the permanent exclusions to the program or these are not otherwise illnesses/injuries excluded in the underwriting process of your application. Genuinely unknown (and
therefore undeclared) health conditions will be evaluated for possible consideration; provided that, these are not concealment cases. Any information contained herein
shall be considered final.
Q1-Q6

(Q7-Q11) Chief Complaints and Diagnosis Date, Duration, Treatment and Results Name and Address of Physician and Hospital

Insert text here

Home Office Endorsement

Do you have any existing HMO carrier, group hospital plan or self-insured policy?  Yes  No
If yes, please specify: ______________________________________________________ Duration of Membership. _______________________________
Submitted Identification Data (ID) Type: ______________________________________ Number: ____________________________________________
Issuing Authority: ________________________ Place of Issue: ____________________ Date of Expiration/Validity: _____________________________
DECLARATION. I hereby declare and agree that all statements and answers contained herein and in any accompanying document (including the Summary of Benefits) are full, complete and true,
and bind all parties in interest under the agreement herein applied for. I understand that payment and receipt of any amount does not constitute acceptance of application and that there shall be no
contract of health care coverage unless and until an agreement is issued on this application and a deposit for the full membership fee according to the mode of payment applied for is actually paid
while I am in good health and during my lifetime. I understand that any concealment or misrepresentation relating to any material fact shall render the health care coverage and life (group term)
insurance null and void.
I also declare that I had been briefed on the salient features as well as the benefits and limitations of the InLife Health Care Program. I accept the InLife Health Care Program as contained herein and
in other accompanying documents (including the Summary of Benefits), and I agree to its terms and conditions. I am aware that no information acquired by any representative of Insular Health Care,
Inc. shall be binding upon said company unless set out in writing in this application; that any physician is hereby expressly authorized to disclose or give testimony at any time relative to any information
acquired by him/her in his/her professional capacity, upon any question affecting my eligibility for health care coverage; provided that, in case of failure by such physician or any entity to furnish said
information despite my authorization, I hereby undertake to personally facilitate acquisition of the same to expedite the evaluation of my application. I further declare that my acceptance of any
agreement issued on this application shall be a ratification of any correction, in addition to this application, as stated in the space for Home Office Endorsement.
TERMS AND CONDITIONS. 1. The proposed member must be in good health and medically acceptable to Insular Health Care, Inc. (under the company’s underwriting rules) on the date of the
coverage applied for is issued. 2. As a pre-requisite to processing this application, it is important that the proposed member should make a deposit equal to at least a full modal membership fee for
the basic health care coverage and any other benefit(s) applied for. Any excess deposit shall be held for the proposed member subject to his/her instructions. The deposit may be in cash. If made
through a check or a bank draft, it shall be considered valid only if honored on first presentation of payment. All payments are treated as deposits only until the Agreement is issued to the proposed
member. Should any of these terms and conditions not be met, no health care coverage shall be in force and the proposed member’s deposit shall be returned.
IMPORTANT NOTICE. Payment of the proposed member’s deposit should be made at the Head Office, at any of the InLife Health Care branch offices nationwide or to a bona fide agent (whose
provisional receipt will be replaced with an official receipt upon remittance to the Head/Branch Office of InLife Health Care). If within ten (10) days after payment has been made and the proposed
member does not receive his/her official receipt, the proposed member should notify the company immediately. Payment can also be made through bank deposit or fund transfer into the bank account
of Insular Health Care, Inc. 2. As stated above, a ‘Summary of Benefits’ forms part of this agreement wherein the proposed member should certify his/her acceptance of the product features and terms
and conditions of the InLife Health Care Program, and submitted to InLife Health Care together with this application.
[Maaaring humingi ng tulong kung hindi nakakaunawa ng Ingles. Huwag pumirma kung mayroong hindi naiintindihan.]

Juvy B. Gelim
__________________________________ 11/8/2023
_______________________ __________________________________ _______________________
Printed Name & Signature of Applicant Date Signed Printed Name & Signature of Employer/ Payor/ Legal Date Signed
Guardian

AGENT’S CONFIDENTIAL REPORT

1. I am ☐ aware/ ☐ not aware of any information on the health, habits or reputation of the applicant, which is not disclosed in this application and which may have a bearing on the risk to be
undertaken by the Company. (If aware, please state information: ____________________________________).
2. I ☐ personally saw the applicant/ ☐ did not personally see the applicant.
3. I ☐ personally asked each question from the applicant exactly as set forth in this application and personally recorded the answers exactly as how they were given to me/ ☐ did not
personally ask the question from the applicant/ ☐ did not ask each question exactly as set forth in this application/ ☐ did not personally record the answers ☐ did not record the answers
exactly as how they were given to me. (In case of any answer in the negative, please explain why: ___________________________________________________________________________).
4. I personally briefed the applicant on the salient features as well as the benefits and limitations of the InLife Health Care Program.
5. I understand that any misdeclaration or falsity in my declarations may result in the termination of my Agency Agreement and/or the forfeiture of any commission or payment due me. I hereby
consent to be solidarily liable with Insular Health Care, Inc. for any damage, liability, expense, claim or judgment arising out of or in connection with such misdeclaration or falsity.

__________________________________ _______________________ __________________________________ _______________________

Printed Name & Signature of Agent/ Date Agent’s Code Printed Name & Signature of Agency Leader/ Date Agency Leader’s Code

FOR HOME USE ONLY

FOR CASHIER FOR MEDICAL UNDERWRITING FOR MEMBERS’ RELATIONS/ CUSTOMER RELATIONS

INSULAR HEALTH CARE, INC. Revised effective 01.13.2023

2/F Insular Health Care Building, 167 Dela Rosa St. cor. Legazpi St., Legazpi Village, Makati City 1229, Metro Manila, Philippines
Tel: (632) 813-0131 Fax: (632) 813-7856 Email: inquiry@insularhealthcare.com.ph Website: www.insularhealthcare.com.ph
 3. Endometriosis, Dysfunctional Uterine Bleeding
4. Hemorrhoids
5. Diseased tonsils requiring surgery
6. Pathological abnormalities of the nasal septum and turbinates
7. Thyroid Dysfunction /Goiter
8. Cataract
9. Sinus conditions requiring surgery;
INDIVIDUAL & FAMILY PLANS 10. Asthma /Chronic Obstructive Pulmonary Disease
SUMMARY OF BENEFITS 11. Cirrhosis of the Liver
12. Tuberculosis
Nationwide Access – Open Access to all Accredited Hospitals and Clinics 13. Anal Fistula
14. Cholecystitis/ Cholelithiasis
Under this plan, a member may have an option to use any Insular Health Care, Inc. (“InLife
15. Calculi of the urinary system
Health Care”) accredited hospital nationwide including or excluding top six hospitals,
16. Gastric or Duodenal Ulcer
namely: Asian Hospital & Medical Center, Cardinal Santos Medical Center, Makati Medical
17. Hallux Valgus
Center, St. Luke’s Medical Center (G.C.), St. Luke’s Medical Center (Q.C.) and The Medical
18. Collagen Diseases /Auto Immune Disease
City.
19. Diabetes Mellitus
Luzon Access – Open Access to all Accredited Hospitals and Clinics (except NCR) 20. Hypertension
21. Cardiovascular Disease
Under this plan, a member may use any Insular Health Care, Inc. (“InLife Health Care”) 22. Hormonal Dysfunction
accredited hospital within CAR, Regions I, II, III, IV-A, IV-B, and V. 23. Seizure Disorder /Cerebral Insufficiency
24. Stroke
Visayas and Mindanao Access – Open Access to all Accredited Hospitals and Clinics 25. Hepatitis
Under this plan, a member may use any Insular Health Care, Inc. (“InLife Health Care”) E. The following health conditions may be covered (either fully or up to certain amounts)
accredited hospital within Visayas and Mindanao regions only, including Cebu Doctors provided pre-existing conditions of an account are likewise covered:
Hospitals, Chong Hua Hospital and Davao Doctors Hospital. 1. Organ transplants and/or open-heart surgery and all services related thereto
(except organ donor services)
Plan Features 2. AIDS and AIDS-related diseases except when sexually transmitted
3. Congenital abnormalities and conditions are covered up to Php 10,000 per year.
1. For primary care (non-emergency cases), entry point to all accredited hospitals
4. Chronic Glomerulonephritis, Guillain-Barre syndrome
SHOULD BE THE COORDINATOR’S OFFICE. During off-clinic hours, and only for
5. Physical deformities (e.g., scoliosis, spinal stenosis, etc.); vitiligo & psoriasis;
genuine emergency cases (as defined in the Agreement), a member may go to the
(Only consultations are covered).
Emergency Room for treatment.
2. Some accredited Metro Manila and provincial hospitals no longer have semi-private
rooms or no longer admit HMO patients to semi-private rooms. For members who PERMANENT EXCLUSIONS (examples)
select the semi-private room accommodation plan and/or use hospitals without 1. Care by non-accredited Physician and/or in a non-accredited hospital/ clinic,
semi-private rooms for in-patient benefits, please be advised that these hospitals will except in emergencies wherein the emergency provision of the Agreement will
automatically admit the member to the next higher room accommodation on a apply
stepladder basis. For genuine emergency cases (as defined in the Agreement), InLife 2. All pregnancy related conditions requiring medical/surgical care and screen tests
Health Care takes care of the difference in upgraded costs for the first 24 hours. After related thereto
the first 24 hours, the member pays for the difference in upgraded costs prior to his 3. All dental related services not expressly stipulated in the Dental Rider
discharge from the hospital. For elective cases, the member pays for the difference Endorsement
in upgraded costs from day one of his confinement prior to his discharge from 4. Sterilization of either sex or reversal of such, artificial insemination, sex
the hospital. transformations or diagnosis and treatment of infertility, and circumcision
3. For Luzon (except NCR) and Visayas and Mindanao options, access to other hospitals 5. Rest cures, custodial, domiciliary or convalescent care
outside of these entitlements shall be allowed only for emergency cases where the 6. Cosmetic surgery, dental/oral surgery and dermatological procedures for the
Emergency Provision shall apply. purpose of beautification except reconstructive surgery to treat a dysfunctional
defect due to disease or accident
MAXIMUM BENEFIT LIMIT (MBL) 7. Psychiatric disorders, psychosomatic illnesses, hyperventilation syndrome, stress
related conditions, adjustment disorders, alcoholism and its complications or
The Maximum Benefit Limit per person per illness or injury per year will depend on the conditions related to substance or drug abuse, addiction & intoxication
Member’s Room Accommodation: 8. Sexually transmitted diseases
Suite – Php250,000 or Php 500,000 Private – Php120,000 9. Medical and surgical procedures which are not generally accepted as standard
Semi-Private – Php100,000 Ward – Php75,000 treatment by the medical profession like acupuncture
10. Procurement or use of corrective appliances, artificial aids, durable equipment,
and orthopedic prosthesis and implants
PHILHEALTH PROVISION
11. Surcharges resulting from additional personal (luxuries/ accommodation)
The Company’s program is integrated with benefits under PhilHealth and/or Employees request or service including special nursing services
Compensation Commission (ECC). InLife Health Care will deduct these benefit 12. Physical examination required for obtaining employment, certification for
entitlements from the amount otherwise payable, and will not pay or advance the costs whatever legal purpose it may serve, insurance or a government license
of such benefits, nor be responsible for filing any claims under PhilHealth or ECC. 13. Injuries or illnesses due to military, paramilitary, police service, high risk
activities, or suffered under conditions of war
In case a Member is not a PhilHealth and/or ECC Member, InLife Health Care shall pay all 14. Reimbursement of procedures obtained through government programs
hospital bills pertaining to availments coverable under the program within plan limits, 15. Injuries or illnesses, which are self-inflicted, caused by attempt at suicide or
including the benefits under the PhilHealth and/or ECC. incurred as a result of or while participating in a crime or acts involving the
violation of laws, administrative order or ordinances
16. Take-home medicines
PRE-EXISTING CONDITIONS (PECs)
17. Valvular Heart Disease and Rheumatic Heart Disease
A. An illness or condition shall be considered pre-existing if before the Effective Date of 18. Medico-legal consultations and confinement
the Agreement: 19. When a member is discharged against medical advice, current and all subsequent
1. Any professional advice or treatment was given for such illness or condition; or benefits/services related thereto
2. Such illness or condition was in any way evident to the member; or 20. Blood/Organ-Donor screening/other screening procedure that are purely
3. The pathogenesis of such illness or condition has already started (which the diagnostic or for screening purposes including, among others, Purified Protein
member may not be aware of). Derivative (PPD), and procedures conducted prior to hormonal replacement
B. PECs are not covered in the first year of coverage. therapy
C. After the member has been continuously covered with InLife Health Care for 12 21. All hospital charges and professional fees after the day and time the hospital
months and the agreement is renewed the following provisions on PECs shall apply: discharge had been duly authorized
1. PECs are covered provided that the PECs are not considered part of the 22. Professional fees of Assistant Surgeon.
“Permanent Exclusions”, and that 23. All confirmatory tests used to document health conditions not covered under the
1.a. such PECs were declared by the member in the original/renewal Agreement
application; 24. Conditions excluded by medical underwriting
1.b. such PECs are unknown to the member (without established medical 25. Concealment cases
history). 26. Diseases declared by the Department of Health (DOH) as Epidemic (except
2. Undeclared PECs with established medical history are excluded from coverage. Covid19).
However, said PECs may be evaluated for possible future consideration. 27. Use of Emergency room Facilities on non-emergency cases or by reason of
3. In case an application is disapproved due to an adverse medical condition, an conditions/injuries not falling under the term “Emergency”. Emergency shall
applicant may still avail of the InLife Health Care program by executing a “waiver” mean the sudden, unexpected onset of illness or injury having the potential of
relinquishing or limiting coverage for the particular adverse condition/s (as stated causing immediate disability or death or requiring the immediate alleviation of
in the provision on Enrollment /Approval of Application). severe pain & discomfort. For the purpose of implementation, the final
diagnosis shall be the basis for a member’s eligibility to emergency care
D. Examples of PECs (inclusive of complications) benefits under the Agreement.
1. Hernias 28. Miscellaneous Fees not related in the diagnosis and treatment of a member’s
2. All tumors and malignancies involving any body organ or system condition such as, but not limited to, nursing fee, waste/biologic hazard disposal
1 of 4

PLEASE SIGN ON EACH AND EVERY PAGE

 fee, management fee, local taxes, and other analogous fees.  e. Electrocardiogram for members 35 years of Covered
age and above
ENROLLMENT/APPROVAL OF APPLICATION  f. Pap smear for female members 35 years of Covered
age and above
An applicant applying for coverage is required to accomplish an Application Form 2 Consultations and treatment prescribed by an Subject to Maximum
otherwise there will be no coverage despite having paid a deposit for membership fees. accredited physician or specialist. Benefit Limit
Changes in the application may be done prior to the underwriting process or the 3 Treatment for minor injuries and minor surgery Subject to MBL
issuance of the membership card. Exceptions, if any, will be handled on a case-to-case, except outpatient medicines
non-precedent basis. It is understood that InLife Health Care reserves the absolute right 4 Dressing. Conventional casts (Plaster of Paris) and Subject to MBL
to approve or disapprove any application for membership. In case an application is sutures.
disapproved due to an adverse medical condition, an applicant may still avail of the 5 Routine diagnostic examinations and therapeutic Covered up to limits
InLife Health Care program by executing a “waiver” relinquishing or limiting coverage procedures prescribed by an accredited specified in V.2 and V.3
for the particular adverse condition. Non-compliance of underwriting requirements Physician/Specialist. hereunder, subject to MBL
within the prescribed period will mean the exclusion from coverage of the condition for 6 Laser eye therapy only for retinal tear, retinal Up to Php 5,000 per eye
which an underwriting requirement has been prescribed. hole, retinal detachment and glaucoma per year
prescribed by an Accredited Physician/Specialist.
7 Electrocautery (ECT), paring and curettage, and Up to Php 1,000 per year
MEMBERSHIP FEE / BILLING NOTICE other related procedures in the treatment of
warts, molluscum contagiosum, and milia, in any
Membership fee is due and payable on Effective Date of the Agreement. Payment should part of the body prescribed by an Accredited
be on or before due dates corresponding to a mode pre-selected by the Member. Non- Physician/ Specialist
receipt by the Member of a billing notice does not constitute a valid reason for non- 8 Sclerotherapy for varicose veins (except for Up to MBL including
payment of membership fees. Membership fees are payable at any InLife Health Care cosmetic purposes) as prescribed by an medicines
office or through a duly authorized collection agent of InLife Health Care. accredited Physician, to be availed through
accredited vascular surgeons.
Member is given 30 days grace period from due date within which to pay the amount
9 Allergy Testing / allergy screening and other Up to Php 2,500 per year
due. Benefits under the “Agreement” are allowed as soon as the membership fees have related examinations prescribed by an
been paid within the grace period. InLife Health Care will suspend all services under the Accredited Physician.
Agreement if membership fees remained unpaid beyond the grace period. However, 10 Speech therapy for stroke patients only. Maximum of 7 sessions
Member may apply for reinstatement within 30 days from the end of grace period Note: Consultations shall be part of the limit and subject to MBL
subject to payment of membership fee due including arrears and penalty charges, if any, treated as sessions
and subject to approval of InLife Health Care. If for any reason the InLife Health Care 11 Tuberculin Test Up to Php 600
membership is pre-terminated, the Member must surrender to InLife Health Care
his/her membership card. Any misuse of the membership card will be for the account of
the member. III. Emergency Care Benefits

HEALTHCARE BENEFITS COVERAGE / LIMIT

EFFECTIVITY 1 In Accredited Hospital
a. Physician’s services Subject to limitations in this
The Agreement is deemed to take effect on the effective date shown in the Data Page. Agreement
This may either be 1st or 16th of the month after receipt and evaluation of the b. Emergency Room Fees Subject to MBL
application; receipt of the initial deposit for membership fees; and/or after underwriting c. Medicines used for immediate relief Subject to MBL
requirements, if any, have been complied with by the Applicant and upon delivery of the during treatment
Agreement during the lifetime and good health of the Member. 12:01 am standard time d. Oxygen, Intravenous fluids and blood Subject to MBL
at the address of the Principal Member or Payor shall be deemed to be the effective products
time with respect to any dates referred to in the Agreement. e. Dressings, conventional casts (Plaster of Subject to MBL
Paris) and Sutures
TABULAR SCHEDULE OF BENEFITS f. X-Rays, laboratory and diagnostic Covered up to limits
examinations, and other medical services specified in V.2 and V.3
I. Inpatient Care Benefits related to the emergency treatment of hereunder, subject to MBL
the patient
HEALTHCARE BENEFITS COVERAGE / LIMIT 2 In Non-Accredited Hospitals Reimbursable up to 80% of
1 Room and Board Accommodation Subject to the Member’s hospital bills & professional
Room and Board limit fees based on usual and
customary rates or Php
2 Use of operating room, Intensive Care Unit (ICU), Subject to MBL (Except for
30,000/availment,
isolation room (if prescribed by Attending ICU, Maximum of 14 days
whichever is less
Accredited Physician) and recovery room. or MBL whichever comes
first) 3 Outside the Philippines Reimbursable up to 80% of
hospital bills & professional
3 Professional fees in accordance with InLife Health Subject to MBL
fees based on usual and
Care schedule of rates per physician / specialist.
customary rates or Php
a. Attending Physicians
30,000/availment,
b. Surgeons
whichever is less
c. Anesthesiologists
d. Cardio-pulmonary (CP) clearance before 4 Areas without Accredited Hospital a. 100% on room and board
surgery and cardiac monitoring during charges according to the
surgery except CP clearances for all elective Members Room and
surgical cases including OB and Gynecology Board accommodation.
b. 100% on other hospital
4 General Nursing Services Subject to MBL
bills.
5 Medicines for inpatient use Subject to MBL
c. Professional fees based
6 Blood products transfusions and intravenous fluids, Subject to MBL
on rates for an
including blood screening and cross matching if the
Accredited Physician
Member patient is the recipient excluding
rendering the service in
expenses for donor screening services
an Accredited Hospital.
7 Dressings, conventional casts (Plaster of Paris) and Subject to MBL
5 Ambulance Land Transfer (Hospital to Hospital) Up to Php 2,500 per
sutures
Notes: The ambulance service provided herein conduction
8 X-Ray, laboratory examinations, routine, diagnostic Covered up to limits shall be available regardless of the location
and therapeutic procedures incidental to specified in V.2 and V.3 within the Philippines.
confinement hereunder, subject to MBL
9 Anesthesia and its administration Subject to MBL
10 Oxygen and its administration Subject to MBL IV. Preventive Care Benefits
11 All other items directly related in the medical Covered up to the limits
management of the patient, as deemed medically specified in the
HEALTHCARE BENEFITS COVERAGE / LIMIT
necessary by the attending physician Agreement, subject to
1 First dose of tetanus toxoid Covered
MBL
2 Health education and counseling on diets or Covered
12 Standard Admission Kit Covered
exercise
3 Health habits and Family Planning counseling Covered
II. Outpatient Care Benefits

HEALTHCARE BENEFITS COVERAGE / LIMIT V. Benefits Covered (Whether Outpatient or Inpatient)

1 Annual Physical Examination (To be availed at
IHC-accredited clinics upon full payment of 1. Routine Procedures
membership fees for the current contract year)
 a. Taking of Medical History Covered HEALTHCARE BENEFITS COVERAGE / LIMIT
 b. Chest x-ray Covered 1 Blood Chemistries Actual Cost subject to MBL
 c. Physical examinations Covered 2 Chest X-Ray Actual Cost subject to MBL
 d. Laboratory examinations (Complete Blood Covered 3 Complete Blood Count (CBC) Actual Cost subject to MBL
Count, Stool Examination, and Urinalysis)
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 4 Fecalysis Actual Cost subject to MBL 2 Coronary Angiogram and/or Angioplasty / Subject to MBL
5 Urinalysis Actual Cost subject to MBL Coronary Artery Bypass Graft
3 Conventional/Scalpel Hemorrhoidectomy Actual cost subject to MBL
4 Stapled Hemorrhoidectomy Up to MBL, except cost of
2. Diagnostic Procedures Staple
5 Mammotome/Vacuum Assisted Breast Biopsy Subject to MBL
HEALTHCARE BENEFITS COVERAGE / LIMIT 6 4D Ultrasound except for maternity-related cases Subject to MBL
1 12-Lead Electrocardiogram (ECG) Actual Cos t subject to MBL
7 Esophageal Manometry Subject to MBL
2 24-hour Electroencephalogram (EEG) Actual Cost subject to MBL
8 Intensified Modulated Radiotheraphy Subject to MBL
Monitoring
9 Botox which is not cosmetic in nature nor for Subject to MBL
3 24-hour Holter Monitoring Actual Cost subject to MBL
beautification purpose
4 Adrenocortical Function Actual Cost subject to MBL
10 CT Pulmonary Angiography Up to Php 5,000
5 Anti-Nuclear Antibody, C-Reactive Protein, Lupus Actual Cost subject to MBL
Cell Exam 11 Photodynamic Therapy Subject to MBL
6 Arterial Blood Gas Actual Cost subject to MBL
7 Audiograms and Tympanograms Actual Cost subject to MBL
8 Bone Densitometry Scan (Dexascan) Up to Php 5,000 VI. Modalities of Treatment
9 Bone Mineral Density Studies Actual Cost subject to MBL
10 Cardiac Stress Test (Thallium and Dipyridamole Up to Php 5,000 The following procedures and modalities are subject to the inner limits when
Stress Tests) specified, otherwise Actual Cost, subject to MBL.
11 Diagnostic Radiographs: Actual Cost subject to MBL
HEALTHCARE BENEFITS COVERAGE / LIMIT
g. Biliary tract: Cholecystogram and Actual Cost subject to MBL
1 Laparoscopic Cholecystectomy Actual cost subject to MBL
Cholangiogram
2 Other laparoscopic procedures Up to Php 20,000 per
h. Chest, ribs, sternum and clavicle Actual Cost subject to MBL
session
i. Digestive: Plain film of the abdomen, Actual Cost subject to MBL
3 Hysteroscopic Myoma Resection Actual cost subject to MBL
Barium Enema, Upper Gastrointestinal (GI)
Series, Lower GI Series, Small Bowel Series 4 Hysteroscopically – guided D & C Up to Php 5,000
j. Face (including sinuses), Head and Neck Actual cost subject to MBL 5 Electroshock Wave Lithotripsy Up to Php 30,000 (limited to
k. Urinary: Kidney, Ureter and Bladder (KUB) Actual cost subject to MBL 1 session per year)
Pyelograms and Cystograms 6 Magnetic Resonance Angiography (MRA) Up to Php 5,000 per session,
l. X-ray of the extremities and pelvis Actual cost subject to MBL subject to MBL
m. X-ray of the Spine (cervical, thoracic, Actual cost subject to MBL 7 Magnetic Resonance Imaging (MRI) Up to Php 5,000 per session,
lumbo-sacral) subject to MBL
12 Diagnostic Ultrasounds: Actual cost subject to MBL 8 Computerized Tomography (CT) Scans Up to Php 5,000 per
a. 2D-Echo with Doppler Actual cost subject to MBL session
b. Abdomen Actual cost subject to MBL 9 Thallium Scintigraphy Up to Php 5,000 per
session
c. Duplex Scan Actual cost subject to MBL
10 Nuclear Radioactive Isotope Scan Up to Php 5,000 per
d. Digestive and Urinary Systems Actual cost subject to MBL
session
e. Ultrasound of the Lungs Actual cost subject to MBL
11 Cryosurgery Actual cost subject to MBL
13 Electroencephalogram (EEG) Monitoring Actual cost subject to MBL
12 Endoscopic Procedures (Diagnostic) Actual cost subject to MBL
14 Electromyelography and Nerve Conduction Actual cost subject to MBL
13 Endoscopic Procedures (Therapeutic) Up to Php 5,000 per
Studies
session
15 Fluorescein Angiography Actual cost subject to MBL
14 Functional Endoscopic Sinus Surgery (FESS) Subject to MBL
16 Impedance Plethysmography Actual cost subject to MBL
15 Gamma Knife Surgery Actual cost subject to MBL
17 Mammogram and Sonomammogram Actual cost subject to MBL
16 Percutaneous Ultrasonic Nephrolithotomy Up to Php 20,000 per
18 Myelogram Actual cost subject to MBL
session
19 Pap’s Smear (Traditional) Actual cost subject to MBL
17 Stereotactic Brain Biopsy Php 20,000 per session
20 Perfusion Scan Up to Php 5,000
18 Transurethral Microwave Therapy of Prostate Up to Php 30,000 per
21 Plasma Urinary Cortisol, Plasma Aldosterone Actual cost subject to MBL
session
22 Pulmonary Function Test Actual cost subject to MBL
19 Laser eye procedures as prescribed by an Up to Php 5,000 per eye
23 Radioisotope Scans and Function Studies: Up to Php 5,000 Accredited Physician / Specialist. Laser Refractive per year
a. Cardiac Up to Php 5,000 Surgery or Photorefractive Keratectomy are not
b. Gastrointestinal Up to Php 5,000 covered.
c. Liver Up to Php 5,000 20 Positron Emission Tomography (PET) Scan Up to Php 5,000 per
d. Parathyroid Bone, Pulmonary Up to Php 5,000 session
(Perfusion/Ventilation Lung Scans) 21 Polysomnograms (Sleep Recording) Up to Php 5,000 per year
e. Renal Up to Php 5,000 22 Continuous Positive Airway Pressure (CPAP) Up to Php 5,000 per year
f. Thyroid Scans Up to Php 5,000 titration for sleep study
g. Total Body Scans Up to Php 5,000 23 Pain Management Up to Php 3,000 per year
24 Radionuclide Ventriculography Up to Php 5,000 24 Arthroscopic Procedures, Orthopedic Up to Php 30,000
25 Surface Electromyography (SEMG) Actual cost subject to MBL Arthroscopy
26 Treadmill Stress Test (TMST) Actual cost subject to MBL 25 Other medically necessary modalities not Up to Php 5,000 per year
mentioned above and those for which there are
no comparable, conventional or traditional
3. Therapeutic Procedures counterparts

HEALTHCARE BENEFITS COVERAGE / LIMIT

1 Anti-neoplastic Chemotherapy / Radio Therapy Subject to MBL
2 Arthrocentesis Subject to MBL
3 Dialysis Up to 10 sessions (shared
limit for Inpatient and
Outpatient) subject to MBL
4 Oral anti-neoplastic chemotherapy Covered for Inpatient only
subject to MBL
5 Physical / Occupational Therapy Up to 10 sessions (shared
limit for Inpatient and
Outpatient) subject to MBL.
One body area is considered
as one session.
6 Therapeutic Radiology:
a. Brachytherapy Subject to MBL
b. Cobalt Subject to MBL
c. Linear Accelerator Therapy Subject to MBL
d. Radioactive Cesium Subject to MBL
e. Radioactive Iodine Subject to MBL
7 Thoracentesis Subject to MBL
4. Additional Procedures (shared limit for Outpatient and Inpatient; Professional
Fees, Hospital Bills and other incidental expenses relative to the procedure shall form
part of the limit).
HEALTHCARE BENEFITS COVERAGE / LIMIT
1 Angiography (gastrointestinal, brain, retinal and Actual cost subject to MBL
peripheral vascular)
VII. Additional Benefits
The following procedures and modalities are subject to the inner limits when
specified, otherwise Actual Cost, subject to MBL.
HEALTHCARE BENEFITS COVERAGE / LIMIT
1 Motor Vehicular Accidents Subject to MBL (with police
report requirement)
2 Unprovoked assault, including domestic violence, Subject to MBL
whether initiated by the Member or by a known
or unknown third party
3 Scoliosis including necessary procedures (except Consultations only
physical therapy sessions) whether congenital,
pre-existing, developmental or acquired.
4 Congenital conditions / developmental disorders Up to Php 10,000 per year
including physical therapy sessions.
Note: Physical Therapy sessions shall form part of
the Physical therapy / Occupational therapy limits.
Congenital Hernia Up to Php 10,000 per year
5
6 Chronic Dermatoses (Consultations only) Up to MBL
7 Scabies (consultations and treatments) Up to MBL
8 Hepatitis B except vaccines and screening Up to MBL (if acquired)
9 Coverage of complications/illnesses due to Up to MBL
Covid-19 infection
10 RT-PCR Covid-19 Testing Covered if Symptomatic
(initial only)

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 PRESCRIPTION MEDICINE BENEFIT I attest to the foregoing.

The Member is entitled to prescription medicine up to the amount of Php 1,000

during the contract period of one (1) year relative to treatment of a health condition _______________________________________ ___________________________
that is covered under the Agreement. The medicine must be prescribed by an InLife Signature above Printed Date
Health Care Physician. Name of Agency Leader

The Member must present original receipts for reimbursement and other Insular Health Care, Inc. is the HMO Subsidiary of Insular Life Assurance Company, Ltd.. It is regulated
supporting documents within sixty (60) days from date of purchase. by the Insurance Commission (www.insurance.gov.ph).

LIFE (GROUP TERM) INSURANCE with INSULAR LIFE Revised effective 01.13.2023

In accordance with Insular Life Group Term Policy No. G - 014175 dated 15 January
1999 and all of its succeeding endorsements, each individual shall be insured in
accordance with the following Benefit Schedule:

Room Accommodation Standard Risk Sub-standard Risk

Suite P 50,000 P 25,000
Private P 25,000 P 12,500
Semi-Private P 15,000 P 7,500
Ward P 10,000 P 5,000

Any individual with adverse medical findings shall automatically be covered for one-
half (1/2) of coverage of a standard risk for deaths due to natural causes and one
hundred percent (100%) of coverage for deaths due to accident. However, the
insurance of a child below five (5) years old will be subject to “Child’s Lien”, as follows:

Age of Child at the Time of Death Amount Payable

3 months to less than 1 year
1 year to less than 2 years
2 years to less than 3 years
3 years to less than 4 years
4 years to less than 5 years
5 years and above
One-tenth of the amount of insurance
One-fifth of the amount of insurance
Two-fifths of the amount of insurance
Three-fifths of the amount of insurance
Four-fifths of the amount of insurance
The full amount of insurance

OPTIONAL BENEFIT:
DENTAL RIDER (On Out-Patient basis only)

1. Any number of consultations on dental problems including but not limited to

lesions, wounds, burns, and gum problems
2. Annual Oral Prophylaxis (mild to moderate cases)
3. Unlimited simple tooth extractions, except surgery for impaction or extraction of
impacted tooth or complicated extractions involving the use of other dental
instruments aside from pliers and/or the re-administration of anesthesia
4. Unlimited temporary fillings
5. Re-cementation of jacket crowns, inlays and on lays (limited to 4 abutments)
6. Dental education and counseling during consultations
7. Simple adjustment of denture clasps
8. Any number of consultations/dental examinations including treatment of lesions,
wounds, burns, gum and other dental problems except diagnostics, prescribed
medicines, surgeries and “root-canal” procedures
9. No limit as to the number of abutments covered (on item 5 above)
10. Orthodontic consultations.
11. Aesthetic dental consultations.
12. Emergency desensitization of hypersensitive teeth.
13. Member has the option to choose between three (3) surfaces of amalgam fillings or
two (2) surfaces of “light cure” filling.

I declare that I have read, and I had been briefed on the salient features as well as the
benefits and limitations of the InLife Health Care Program. I accept the InLife Health
Care Program as contained herein and in other accompanying documents, and I agree
to its terms and conditions.

[Aking isinasaad na aking nabasa at ipinaliwanag sa akin ang mga katangian, benepisyo
at limitasyon ng InLife Health Care Program. Tinatanggap ko ang InLife Health Care
Program tulad ng nakasaad dito at sa iba pang kalakip na dokumento. Pumapapayag
din ako sa mga tuntunin at kondisyon na kaakibat nito].

DO NOT SIGN IF SOMETHING IS UNCLEAR.

[HUWAG PUMIRMA KUNG MAYROONG HINDI NAIINTINDIHAN].

________________________________________ Nov 08,2023

___________________________
Signature above Printed Date
Name of Applicant/ Payor
(Thumbmark if unable to sign)

I declare that I had personally interviewed the Applicant/Payor and briefed him/her
on the salient features, benefits and limitations as well as the terms and conditions of
the InLife Health Care Program.

________________________________________ ___________________________
Signature above Printed Date
Name of Servicing Agent

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