IMS Wellth Care, Inc.

Benefit and Guidelines

Detailed Benefit Provisions and Availment Guidelines

Pre-existing Conditions (PEC)

​A disability which is diagnosed before enrollment or during the first year of membership; which presented signs and symptoms of which the member was aware of; and illnesses whose pathogenesis had started prior to enrollment or during the first year of cover even if the member was not aware thereof.
 
The following are automatically considered as Pre-Existing Conditions:

  • Hypertension and other cardiovascular diseases
  • Goiter and other thyroid disorders
  • Cataracts/Glaucoma
  • Diseased tonsils and sinus conditions requiring surgery
  • Asthma/Chronic Obstructive Lung disease
  • Cholecystitis/Cholelithiasis
  • Hernia/Benign Prostatic Hypertrophy
  • Hemorrhoids/Anal Fistula
  • Tumors/Cyst of internal organs
  • Gastric and Duodenal Ulcers
  • Pathological abnormalities of nasal septum or turbinates
  • Endometriosis
  • Tuberculosis
  • Hallux valgus
  • Calculi
  • Tumors/Cyst on skin, muscular tissue, bone or any form of blood dyscracias
  • Diabetes Mellitus
  • Cerebrovascular Accident/Transient Ischemic Attack 

Note for Dependent Members:
To have equal waiver of PEC with principals, at least 80% of the total population of principals must enroll their dependents. If the 80% rule is not met, pre-existing condition of dependents shall not be covered.

Membership Eligibility

Principal Member

18 to 65 years old (maximum entry age 64; exit age 65)

Dependents

a. Married Principals
Spouse first, aged 65 years old & below, followed by eldest to the youngest child aged 5 years old up to 23 years old

b. Single/Unmarried Principals
Acknowledged natural children first aged 5 years old up to 23 years old, parents aged 65 years old and below.

Over-aged and Extended Dependents (parents and siblings of married principals, nephews, nieces, cousins, in-laws, grandchildren, housemaids, drivers, etc.) not eligible to enroll.

Enrollment of dependents must be within 30 days from effectivity date of membership. Newly regularized/hired may enroll their dependents within 30 days from the date of regularization/hiring.

Exclusions

General Exclusions

  • Service from Non-Accredited Physicians and/or Non-Accredited Hospitals and other health medical providers, including adverse medical conditions arising from treatment of the same except those stipulated under the provisions on emergency care services;
  • Long term rehabilitation, custodial, domiciliary, covalescent, intermediate and psychiatric care;
  • Cosmetic treatment/ reconstructive surgery to treat congenital deformities/abnormalities, e.g. herniorraphy, except reconstructive surgery necessary to treat a functional defect resulting from an accidental injury;
  • Maternity care and other conditions as a result of pregnancy (unless otherwise specified in the plan);
  • Physical examinations required for obtaining/continuing school, employment, insurance and government licensing;
  • Experimental medical procedures, acupuncture, organ transplant, speech therapy, psychiatric care and rehabilitation;
  • Sophisticated procedures such as but not limited to, thallium scintigraphy, angiography, sleep test. stereotactic radio surgery, brachytherapy, intraoperative radiation therapy, Auditory Brain Stem Response (ABR), Electronystagnography (ENG), Bone Mineral Density Measurement (BMD) and similar equipments; hyperalimentation; radiotherapy and chemotherapy for malignancies, allergy testing and treatment materials (unless otherwise specified);
  • Services to diagnose and reverse infertility or fertility;
  • Corrective devices, artificial aids, prosthetic devices such as nailing, pinning or bracing, oxygen dispensing equipment and oxygen outside of covered in-patient care;
  • Treatment and diagnostic work-ups of congenital deformities, physical disabilities (such as but not limited to scoliosis, slipped disk, spondylosis and spinal stenosis) and abnormalities affecting functions of individuals, including complications;
  • Treatment of injuries or illnesses resulting from self-destruction or attempted suicide (whether sane or insane), attributed to gross negligence, misconduct, reckless imprudence, intemperate use of drugs/alcoholic drinks, vicious and immoral habits and unnecessary exposure to imminent danger or hazard to health;
  • Treatment of injuries or illness resulting from war, or any combat related activities while in military services;
  • Sexually transmitted diseases like, AIDS, gonorrhea and syphilis;
  • Oral surgery for purposes of beautification, including dental care following accidental injury to teeth;
  • Treatment of injuries or illnesses caused directly or indirectly by participation in any hazardous sport or activity which includes, but is not limited to, sky diving; motor sports (e.g., motorbike racing, jet skiing); martial arts (e.g., taekwondo, wrestling); boxing; wrestling; bungee jumping; scuba diving; snorkeling; horseback riding; polo; mountain/rock climbing; and gymnastics;
  • Extra hospital supplies, charges and services such as:
    • Use of video tape recorder, television, electric fan and the like, except when said appliances are part of the room he/she is admitted in;
    • Physical therapy, rehabilitation, services of a private nurse or physician, discharge medication, telephone bills, transportation cost;
    • Other items not related to the medical management of the Member.
  • Corrective eye surgery for error of refraction such as myopia, astigmatism and hyperopia;
  • Professional fees of medico-legal officers;
  • Hospitalization and treatment outside the Philippines
  • Epilepsy, hearing impairment, psoriasis and vitiligo
  • Functional disorders of the mind such as anxiety reaction (psychosomatic, stress induced anxiety, hyperventilation syndrome, neurasthenia) and mood disorders;
  • Auto-immune diseases such as but not limited to Guillain-Barre syndrome, Multiple sclerosis, Demyelinating disease, Parkinson's disease, Alzheimer's disease, Myasthenia Gravis, Epilepsy, Seizure Disorder, Endometriosis, Grave’s disease, Lupus, Peripheral neuropathy, Psoriasis, Rheumatoid Arthritis (RA);
  • Platelets, packed RBC, and plasma transfusions (case to case basis).

Membership Fees

PAYMENT OF MEMBERSHIP FEES. The Membership Fees are due on the effective date of this Agreement and every month thereafter for monthly mode of payment, every quarter thereafter for quarterly mode of payment and every semester thereafter for semi-annual mode of payment. The Membership Fee due on any due date shall be the aggregate of the Membership Fees for all Members enrolled under this Agreement.

GRACE PERIOD FOR PAYMENT OF MEMBERSHIP FEES. After payment of the initial Membership Fee(s), any Membership Fee(s) due must be paid not later than 30 days after its due date. All claims incurred during the grace period shall be paid to the Member only after the due Membership Fee is paid.

EFFECTS OF NON-PAYMENT OF MEMBERSHIP FEES. Non-payment of the Membership Fees due after the grace period shall entitle IWC to:

a. Suspend all services to members whose Membership Fees have not yet been received, until full payment of all Membership Fees due, including monthly penalty charges;

b. Terminate this Agreement without prejudice to collect the amount due and the corresponding penalty charges that have accrued thereon.

LIFTING OF SUSPENSION. Suspension shall be lifted upon receipt of payment for the Membership Fees due plus penalty charges, subject to clearing of checks. Claims incurred during the Suspension shall not be reimbursed even after the lifting of suspension

REACTIVATION OF AGREEMENT. Upon lifting of the suspension, IWC shall initiate the reactivation of this Agreement to the effect that members can access the IWC’s network of healthcare providers.

Reimbursement Claims  for Emergency Cases

The claims for reimbursement shall apply only in emergency treatments, whether out-patient or in-patient, rendered in non-Affiliated Hospitals.

All claims for reimbursement must be filed using the prescribed claim form and submitted to IWC Offices within thirty (30) days from the date of availment for out-patient or from date of discharge for in-patient. Failure to submit within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time.

The amount to be reimbursed by IWC shall a percentage of total eligible expenses.

All benefits that pertain to a Member will be paid by check to the order of Principal Member, unless the Principal Member requests otherwise, or IWC, in its discretion, considers it preferable to make the payment in another manner. In case of death of a Member, any benefit due but remaining unpaid shall be paid to the first surviving class of the following classes of successive preference of beneficiaries: the Member’s (a) widow or widower; (b) surviving children; (c) surviving parents; (d) surviving brothers and sisters; and, (e) executors or administrators.

If a claim for reimbursement is denied, or the Member is not satisfied/agreeable to the reimbursement paid by IWC, a written request for reconsideration must be filed with the IWC Head Office not later than ten (10) days from 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 IWC, whose decision shall be final. IWC reserves the right to deny Claims for Reimbursement if the procedures and requirements have not been strictly complied with.

General Availment Procedures

General

  1. Hospital/clinic staff calls IWC customer service department to inquire on members benefit.
  2. IWC customer service department provides (faxes/emails) approval number for LOG/LOE on consultation, laboratory, admission and for discharge, E.R. and APE availment. *

Process Flow for Outpatient Dept. & E.R. Dept. Consultation

  1. Hospital/Clinic staff asks for the doctor’s laboratory request and diagnosis.
  2. Follow GENERAL PROCEDURE.
  3. Member proceeds Lab./X-ray/etc.

Laboratory

    1. Hospital/Clinic staff asks for the doctor’s laboratory request and diagnosis.
    2. Follow GENERAL PROCEDURE.
    3. Member proceeds Lab./X-ray/etc.

Emergency Room

    1. Member proceeds to the emergency department.
    2. Follow GENERAL PROCEDURE.

Note: It is advised that before the patient leaves the hospital/clinic an approval number for the availments has been given by an IWC Customer Service Representative.

Process Flow for Admitting Dept. & E.R. Admission

  1. Member proceeds to Admitting/E.R. Dept.
  2. Follow GENERAL PROCEDURE.
  3. Hospital/Clinic staff asks the member to sign on the letter of Eligibility provided by IWC Customer Service.

Discharge

  1. Member proceeds to billing Department and Philhealth Department.
  2. Follow GENERAL PROCEDURE No. 2.
  3. Hospital/Clinic staff asks the member to sign on the letter of Eligibility provided by IWC Customer Service.

    Note: IWC Guarantees Total Hospital Bill on top of Philhealth.

Annual Physical Exam

  1. IWC Member proceeds to Industrial Dept./HMO/Business Office/ Out Patient Dept.
  2. Follow GENERAL PROCEDURE.
  3. Member avails in the accredited clinics. 

Note:

* IWC Approval Number signifies payment guarantee to the hospital/clinic.

* The amount approved, approval no., diagnosis are to be indicated by the hospital/clinic staff on the Consultation/Referral; Laboratory and Diagnostic Procedure Form; the slip is forwarded to IMS Wellth Care for audit purposes. 

* IF MEMBER’S BENEFIT LIMIT IS NOT ENOUGH TO COVER THE PROCEDURE. Hospital/clinic Staff will ask the member to pay amount in excess of his/her benefit before discharge.