DYNAMIC CARE CORPORATION YOUR HEALTHCARE ADVANTAGE
SCHEDULE OF BENEFITS FOR WELLJOB SOLUTIONS & GENERAL SERVICES INC.
I. IN PATIENT HOSPITALIZATION BENEFITS
HEALTHCARE BENEFITS COVERAGE/LIMIT 1 Room and Board Accommodation Subject to the Member’s Room and Board Limit (Ward) 2 Use of operating room, Intensive Care Unit (ICU), isolation room (if prescribed by Attending Affiliated Physician) and recovery room. 30,000 per single confinement 3 Professional fees in accordance with HMO schedule of rates per physician/specialist. a. Attending Physicians b. Surgeons c.Anesthesiologists d.Cardio-pulmonary clearances before surgery and cardiac monitoring during surgery except CP clearances for all elective surgical cases including OB and Gynecology. 4 Standard Nursing Services 5 Medicines for in-patient use 6 X-ray, laboratory examinations, routine, diagnostic and therapeutic procedures incidental to confinement. 7 Dressings, sutures and other items related to the medical management of the patient. 8 Anesthesia and its administration
9 Oxygen and its administration 10 Standard Admission 11 All other items directly related in the medical management of the patient, as deemed medically necessary by the Attending Affiliated Physician and would not fall under exclusions. 12 Work related illnesses/accidents (except those listed in exclusions) Covered up to MBL 13 Out of Network coverage shall be covered via reimbursement Covered based on the maximum benefit limit per confinement (Reimbursement)
Note: In emergency cases at the time of confinement, the Affiliated Hospital has no available Room in accordance with the MEMBERs room and Board Accommodation, DCC will cover the twenty-four (24) hours of confinement based on the MEMBERs Maximum Benefit Limit
II. EMERGENCY TREATMENT OF ILLNESS & INJURY
HEALTHCARE BENEFITS COVERAGE/LIMIT 1 a. Professional fee of attending Physician and Specialists Maximum of Php 10,000.00/incident but not to exceed Php 20,000.00/year b. Emergency Room Fees c. Medicines used for immediate relief during treatment d. Oxygen, Intravenous fluids, Whole blood/human blood transfusion e. Dressings, Sutures and medicines administered during the emergency f. X-rays, laboratory and diagnostic examinations g. Treatment of minor injuries and burns including administration of anti-tetanus h. Anti-Rabies Vaccine/Anti-Venom Covered up to 5,000.00 per contract year 2 Emergency Care in Non-Accredited Hospital Covered based on the maximum limit per incident (Reimbursement basis)
III. OUT -PATIENT BENEFITS
HEALTHCARE BENEFITS COVERAGE/LIMIT 1 Medical consultation fees General Practitioner’s, Specialists, and Sub Specialists a. GP b. Sub-specialist Unlimited 2 a. Pre-Natal consultation b. Post-Natal consultation (excluding laboratory) Once a month One (1) consultation after delivery 3 Out-Patient OR cases (will base on the RUV code) Covered up to Php 10,000.00/case 4 Routine Laboratory, Xray and other diagnostic procedures requested by the physician on duty Covered up to Php 3,000.00/month 5 Occupational Therapy, Physical Therapy, Speech Therapy, Respiratory Therapy (except for cases of developmental disorder) Covered up to Php 5,000.00
HEALTHCARE BENEFITS 1 Angiography (e.g. coronary, cerebral, retinal, fluorescein, pulmonary, GI, etc.) 2 Pulmonary perfusion scan 3 Test using Nuclear Technologies (e.g. Radionuclide scan/Ventriculography, Thallium stress testing, Pyrophosphate Scintigraphy, Myocardial Perfusion Scanning, etc.) 4 Electromyography, Nerve Conduction Velocity Studies 5 24-Hour Holter Monitoring, 2-D Echo with Doppler 6 Treadmill Stress Test 7 Myelogram 8 Diagnostic Endoscopy and Colonoscopy 9 Diagnostic Athroscopy SPECIAL DIAGNOSTIC PROCEDURES The following complex diagnostic examinations and therapeutic procedures shall be covered up to Php 5,000.00 each member per year subject to pre-existing conditions coverage. (inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure).
10 Adrenocortical Function, Plasma/Urinary Cortisol, Plasma Aldosterone, etc. 11 Mammogram and Sonomammogram 12 Bone Density Scan (Dexascan) 13 Immunologic Studies (e.g. Anti-nuclear antibody (ANA), C-reactive Protein, Lupus cell exam, ESAT- 6 and CFP-10 Antigens, Quanti FERON Tuberculosis (QFTB) 14 Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiography (MRA) 15 Genetic Studies (Alpha Globin/Globulin Genotyping, Beta Globin/Globulin Genotyping, Duolink In- Situ Flourescence Hybridization (DISH)/Array Comparative Genomic Hybridization (aCGH), Epidermal Growth Receptor (EGFR) Mutation Assay/Test, Fluorescence In-Situ Hybridization (FISH), JAK-2 Mutation, KRAS Testing, Philadelphia chromosome) 16 All new diagnostic modalities or methods of treatment for which there are no comparable conventional or traditional equivalent or counterparts subject to the exclusions and limitations of this agreement.
IV. DENTAL BENEFITS
HEALTHCARE BENEFITS COVERAGE/LIMIT 1 Simple tooth extractions (except surgery for impacted or ankylosed tooth, etc.) Unlimited 2 Simple Oral Prophylaxis Twice (2) a year 3 Temporary filling Three (3) teeth per month
V. ANNUAL PHYSICAL EXAMINATION
HEALTHCARE BENEFITS COVERAGE/LIMIT 1 Physical Examination The APE will be conducted only at Laguna Industrial Clinic. Covered after (1) one year of continuous membership and conducted by DCC APE Provider 2 Complete Blood Count 3 Routine Urinalysis 4 Routine Fecalysis 5 Chest Xray 6 HbsAg screening 7 Drug Test (Shabu & Marijuana)
PRE EXISTING CONDITIONS Pre-existing condition is an illness, injury or condition shall be considered pre-existing if it existed before the effective date of the coverage, the natural history of which can be medically determined to have started prior to the effective date of coverage or at the time of processing of the application, whether or not the member was aware of such illness, injury or condition. Pre-existing illnesses will be covered after twelve (12) months of continuous membership for newly enrolled members. The following illness are considered as pre-existing: A. Dreaded Diseases listed below except for no. 12 B. Goiter (Hypo/Hyperthyroidism) C. Hypertension D. Bronchial Asthma/Allergy/Urticaria/Tubercolosis E. Benign Tumors F. Hernia G. Hemorrhoids and Anal Fistulae H. Myoma, Ovarian cyst, Endometriosis I. Headache Migraine J. Gastritis/duodenal or gastric ulcers K. Cholecystitis or Cholelithiasis (gall bladder stones) L. Varicose veins M. Cataract/Glaucoma N. Arthritis O. Cataracts/Glaucoma P. ENT conditions requiring surgery Q. Chronic Illnesses R. Buerger’s Disease
DREADED DISEASE Dreaded Diseases are illnesses that are likely or actually a life-threatening condition that may require prolonged or repeated hospitalization or intensive care management. Coverage is subject to the terms of the pre-existing condition. Any and illnesses proven to be related to or is a complication of a certain illness shall share the same the Annual Benefit Limit. The following are considered dreaded disease: DREADED DISEASE COVERAGE/LIMIT 1. Cerebrovascular Accident (stroke) Covered up to MBL 2.Central nervous system lesions (Poliomyelitis/Meningitis/Encephalitis/Neurosurgical conditions) 3.Cardiovascular Disease (Coronary/Valvular/Hypertensive Heart Disease/Cardiomyopathy) 4. Chronic Obstructive Pulmonary Disease (Chronic Bronchitis/Emphysema) 5. Liver Parenchymal Disease (Cirrhosis, Hepatitis (except type A), New growth)
6. Chronic Kidney/Urological Disease (Urolithiasis, Obstructive Uropathies, etc.) Covered up to MBL 7. Chronic Gastrointestinal Tract Disease requiring bowel resection/anastomosis 8. Collagen Diseases (Rheumatoid Arthritis, Systemic Lupus Erythematous) 9. Diabetes Mellitus and its complications 10. Malignancies and Blood Dyscrasias (Cancer, Leukemia, Idiopathic Thrombocytopenic Purpura) 11. Complications of an apparent ordinary illness (e.g. sepsis due to pneumonia, cerebral malaria, etc.) 12. Injuries due to accidents or assaults 13. Single or multiple organ dysfunction and failure 14. Conditions that may require dialysis 15. Any other illnesses that will require Intensive care Unit Confinement
CLAIMS & REIMBURSEMENT PROCESS
REIMBURSEMENT PROCEDURE All claims for reimbursement must be submitted or forwarded to Dynamic Care Corporation within thirty (30) calendar days after discharge from the hospital. Failure to do so shall invalidate the claim, except if it can be put in writing that it was not reasonably possible to furnish such documents within thirty (30) calendar days. Required documents in availing reimbursement: a. Emergency confinement in non-accredited hospital: • Clinical Abstract • Medical certificate to include complete final diagnosis • Official Receipt paid to hospital and doctor • Itemized Statement of Account and corresponding charge slips • Hospital Statement of Account • Police report if due to accident or medico-legal case b. Out-Patient emergency consultation/treatment • Medical certificate to include complete final diagnosis • Official Receipt • Police report if due to accident or medico-legal case
AROWWAI INDUSTRIES. Phone : Email: Address : HOTLINE NUMBERS: LANDLINE: (049) 250-0741 SUN: 09328798747 to 49 GLOBE/VIBER: 09176246825 SMART: 09398910315 EMAIL ADD: info@dynamiccare.com.ph www.dynamiccare.com.ph
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