K12 Health cover provides up to Php 50,000 worth of coverage for emergency cases due Dengue Fever, Leptospirosis, and COVID-19.
It is accepted in more than 500 IHC-accredited hospitals nationwide, including the *Top 6 hospitals.
This health voucher is applicable to individuals 1 to 20 years old and is valid for 12 months or up until used whichever comes first.
The Php 50,000 benefit limit covers these items:
✓ Doctor’s professional fee
✓ Ward Room Accommodation
✓ Laboratory and diagnostic procedures
✓ Medicines as medically needed
✓ Use of operating room, recovery room, and ICU
✓ Surgery and surgeon’s fees when medically necessary
✓ Special Modalities as medically needed subject to Php 5,000 sublimit● Laparoscopic procedures
● Magnetic Resonance Angiography
● Magnetic Resonance Imaging (MRI)
● Computerized Tomography (CT) Scans
● Endoscopic Procedures (Therapeutic)
● Pain Management
● Arthroscopic Procedures, Orthopedic Arthroscopy
● Other medically necessary modalities not mentioned above and those for which there are no comparable, conventional or traditional counterparts
Things to Note:
"Emergency" shall mean the sudden, unexpected onset of illness or injury having the potential of causing immediate disability or death or requiring the immediate alleviation of severe pain and discomfort.
This health voucher is applicable to adults, 1 to 20 years, and is valid for 12 months or up until used whichever comes first. The final medical diagnosis shall be the basis for a Member's eligibility to emergency care benefits under the Agreement. PhilHealth is required for the availment of this health voucher during hospital confinement.
*Top 6 Hospitals – Asian Hospital and Medical Center, Cardinal Santos Medical Center, Makati Medical Center, St. Luke's Medical Center (QC and BGC) and The Medical City
1. What does K12 Health Cover cover?
It provides up to Php 50,000 worth of coverage for emergency cases due Dengue Fever, Leptospirosis, and COVID-19. This voucher is accepted in more than 500 IHC-accredited hospitals nationwide, including the Top 6 hospitals
2. How can I register my K12 Health Cover voucher?
Upon purchase, you can register online at https://services.insularhealthcare.com.ph/.
3. When can I start using K12 Health Cover?
10 days from the day you register (“registration date”), the health voucher will be activated 10 days after successful registration. Your health voucher is valid for 12 months or up until used which ever comes first.
Example: Registration date is Day 0. If you register on August 1, your health voucher will be activated on August 11. It will then be valid from August 11, 2023 to August 10, 2024 or up until used which ever comes first.
4. When can i register my product?
You have to register a name to your prepaid plan within 90 days from purchase date. The serial code will be valid up to then. After which, your serial code will no longer be available for register.
5. If the benefit limit is not be wholly consumed, can I use the health voucher again in the future?
K12 Health Cover is for one-time use only, regardless if the total annual benefit limit is consumed or not. The advantage of this health voucher is its high benefit limit, affordability, and convenient registration process.
6. If I already have an existing Insular Health Care plan that covers health diagnostic benefits, can I still register for K12 Health Cover?
No. You cannot register for K12 Health Cover if you are already enrolled in IHC’s other health care programs, even if your total benefit limit has already been consumed.
7. Can I register a K12 Health Cover health voucher for someone else?
Yes, as long as you know the personal data of the individual and obtained his/her authorization to be registered. We have prepaid health vouchers that can be given as gifts to your loved ones. The data required for registration are as follows:
a. Full name
b. Birth date
c. Home address
d. Email address
e. Mobile number
8. Can I transfer K12 Health Cover to another person?
K12 Health Cover is transferable as long as it has not yet been registered. This also lets you purchase the health vouchers as gifts.
9. Can I use K12 Health Cover in hospitals not on the health voucher’s provider list?
No. This health voucher can only be used in IHC accredited hospitals.
Terms and Conditions
Dengue Flex and K12 Health Care Agreement
This is the Health Care Agreement for the following products. The complete terms and conditions of the benefits under these products are contained in this guide.
DENGUE FLEX and K12 HEALTH CARD SERIES
|DENGUE FLEX 50||For Adults||With Access to Top Hospitals|
|K12 HEALTH CARD 50||For Minors||With Access to Top Hospitals|
The products under the Dengue Flex and K12 Health Card Series are generally suitable for those who are relatively healthy and would like to be covered for emergency care medically necessary for dengue, leptospirosis and COVID-19 cases.
The products under the Dengue Flex and K12 Health Card cover health risks to which most everyone is exposed, only in varying degrees. Insular Health Care wants to offer coverage to those who need it while in the Philippines, so these products are also available to non-Filipinos. Please note that the emergency care will be rendered by medical professionals and facilities within the Philippines.
Persons experiencing chronic conditions, now or in the past, should carefully review the services offered by these products. The Dengue Flex and K12 Health Card do not cover pre-existing conditions and/or chronic conditions. Many persons with pre-existing and/or chronic conditions control and manage their illnesses while leading active lifestyles. If they want to benefit from coverage that provides emergency medical care arising from the specific conditions mentioned above, they may consider availing of this product for themselves for those contingencies.
Please refer to Section 2 for the details on the coverage and benefits.
How to use this information
There are several benefits under each health care product and the information contained in this booklet includes full details of them all. To understand the coverage, first identify the product under which the Member is or will be registered, and then read this booklet alongside the personalized Voucher and the Frequently Asked Questions (FAQ). If there is any discrepancy between this Health Care Agreement and FAQ, the Health Care Agreement will prevail.
By reading this booklet, one will understand:
- The accidents and illnesses that are covered by the above-mentioned Insular Health Care products
- How to purchase products under the Insular Health Care Dengue Flex and K12 Health Card
- How to register a person under the Insular Health Care Dengue Flex and K12 Health Card
- When is it medically appropriate to seek emergency care
- Where one should go to avail of emergency care
- What to expect at the Emergency Room of a hospital accredited by Insular Health Care
- What to do if the medical diagnosis/diagnoses is/are covered
- What to do if the medical diagnosis/diagnoses is/are not covered
- With which medical professional and where to seek non-emergency medical consultation
- How to self-generate a Letter of Authorization for the consultation
- How to ensure that a person is always covered under the Insular Health Care Dengue Flex and K12 Health Card
By registering or using this product, as the Purchaser and/or Member, you certify that you have read, understood and agree to this Health Care Agreement and the Return, Replacement and Refund Policy which can be viewed at https://www.insularhealthcare.com.ph/returnrefundpolicy/.
Replacement and Refund Policy which can be viewed at https://www.insularhealthcare.com.ph/privacy-policy/ and https://www.insularhealthcare.com.ph/returnrefundpolicy/
Section 1 – Purchasing and Registering
The Insular Health Care Dengue Flex and K12 Health Card can be purchased online by visiting shop.insularhealthcare.com.ph/. We offer a range of products and services on the shop. One should read and understand each product before selecting it for purchase. Please be mindful of the following:
- The service/s that it offers
- The places where the service/s can be availed
- The medical diagnosis/diagnoses that is/are covered and not covered
- The age requirement, if any
- The gender requirement, if any
- The information about the person to be covered required for registration
- Other limitations of the product
For the Dengue Flex and K12 Health Card, the covered ages are as follows:
|Insular Health Care Product||Age Eligibility|
|K12 Health Card Series (For Minors)||1 to 20 years old|
|Dengue Flex Series (For Adults)||21 to 70 years old|
Purchasers who want to seek advice on the medically appropriate health care product for his/her requirements and those of his/her family, may chat with us online, send a private message on Facebook or request for a return call via a Facebook private message.
Online Purchase: Purchaser, Buyer’s Web-Based Account
When the Purchase has made a selection and is ready to check-out, he/she will be asked to open a free Insular Health Care Buyer’s web-based account to proceed. Insular Health Care will use the information that the Purchaser has submitted to us through this account to fulfill the purchase; e.g. send an email to confirm the purchase. The Purchaser may also use this account when he/she wants to purchase from the Insular Health Care store again. As the Purchaser, he/she will be able to see all of the products he/she has purchased and the status of each. The Purchaser will be able to view the following information:
- If a person has been registered under a specific product
- If the product is expired
- If a person has been registered, the Purchaser will know whether the coverage is inactive or active
- If a product is used.
In the process of check-out, the Purchaser has to select the payment method and make the payment. After receipt of payment is confirmed, Insular Health Care will send the Purchaser an email to confirm the purchase. The email will contain the product serial code that one needs to be able to register the person to be covered by the product.
The Purchaser can be registered under a product by registering himself/herself under a specific product. The Purchase is not covered under any product unless he/she has registered under it.
Online Registration of the Person to be Covered: Becoming a Member, Activation Period, Start Date of Coverage, Coverage Period, and Free-look Period
Registering is the process by which one identifies and submits the details of the person to be covered by the Insular Health Care product. This person who will be covered shall be called the Insular Health Care ‘Member’. Without a successful registration, no coverage can be provided by the Insular Health Care product to a Member. The Purchaser or the prospective Member must register the prospective Member under the purchased product as soon as possible so that the registration process can begin. Insular Health Care will send confirmation of the successful registration and details thereof to the Member. There is a maximum of 90 calendar days from purchase date to register the person; after which, a person can no longer be registered under the product. The product will be forfeited, and the payment will not be refunded.
If the Purchaser registers himself/herself or his/her child below 18 years old, he/she will receive the Product Voucher through the email address provided. If the Purchaser submits data of another adult, an email will be sent to that person through which he/she will confirm and provide his/her consent to submit the data to Insular Health Care. After he/she has given his/her consent, the Product Voucher will be sent to his/her provided email address.
Please see below for the activation period applicable to each product. Activation period refers to the number of calendar days from the date of successful registration to the start date of coverage. Activation period applies to everyone and cannot be waived for anyone. Activation period starts from the day after successful registration; after it ends, coverage begins.
Please see below the coverage period applicable to each product. The coverage period is defined by a start date and an end date and within this period, as long as the product has been successfully registered and is not terminated prematurely (see below Section 3 on ‘Availment’), the product is available for use by the registered Member, subject to the terms of coverage. The start date or effectivity date signifies the beginning of the coverage period.
|Product||Registration Period||Activation Period||Coverage Period|
|Start Date||End Date|
Dengue Flex and K12 Health Card Series
Within 90 calendar days from purchase date
10 calendar days
|12:01am of Day 1 of the coverage period||
11:59pm of Day
365 of the ensuing year or upon first availment, whichever comes first
Please see below a sample illustration of registration, activation period and coverage period. Once we have confirmed that a person has been successfully registered, coverage will automatically begin according to the activation period applicable to the product registered. Insular Health Care may send further notice that the coverage has begun.
|Sample Product Registration Timeline||Sample Date for Illustration Purposes Only|
|Day 0 is the day of successful registration||31st of March|
|Days 1-10 are the activation period||1st to 10th of April|
|Day 11 is the start date of coverage||11th of April|
|Product Coverage Timeline|
|Day 1||12:01am, 11 April|
|Day 365||11:59pm, 10 April of the following year|
Insular Health Care shall provide a “free-look” period during which the person who has successfully registered under any product may return or cancel the contract, if he/she disagrees with the contract conditions after receiving it, such as the presence of pre-existing conditions and exclusions after reading and evaluating the contract, or if he/she changes his/her mind in buying the product. The amount paid shall be returned in full to the Purchaser. For all Dengue Flex and K12 Health Card variants, the free-look period shall be fifteen (15) days from the start of coverage date.
The product’s free-look feature is no longer applicable at the end of the indicated period or if the Member already availed of any of the product’s benefits, even if the request for return or cancellation falls under the free-look period.
Once successfully registered under a product, the Member will receive a confirmation via email. The declared legal guardian of the registered children (anyone below 18 years old) will also receive the confirmation email. This email contains the important details concerning the coverage. It also includes the Product Voucher needed to be presented at the clinics of our accredited doctors and dentists for consultations, or to accredited hospitals to be able to seek emergency medical care. The Product Voucher also contains the Member ID which has to be given to the telemedicine provider to allow them to validate the telemedicine privilege, if applicable.
The email confirmation summarizes the benefits under the specific product registered. The Product Voucher contains the product name, the Member’s complete name, the Insular Health Care Member ID and the start and end dates of coverage. It is recommended that the Product Voucher be printed and a copy be kept in an accessible place, like one’s wallet. The Product Voucher, personalized with the Member’s details, together with a valid government-issued ID will have to be presented. If the covered person is a child without a school ID, the responsible adult accompanying him/her should present their government-issued ID.
Product Coverage Period and Termination Schedule
Once successfully registered, and after the activation period, the product coverage period begins.
For the Dengue Flex and K12 Health Card series, the product coverage period is 12 months or until availed, whichever comes first.
Please see below the termination schedule of the Insular Health Care products:
|This schedule applies to any variant of the products listed above|
|If the Dengue Flex and K12 Health Card product is availed during the coverage period||Coverage terminates one day following Insular Health Care’s issuance of a Letter of Authorization corresponding to the Dengue Flex and K12 Health Card product|
|If the Dengue Flex and K12 Health Card product is not availed during the coverage period||*11:59pm on Day 365 from the start date of coverage.|
Insular Health Care may send further notice to the Member that the coverage has been terminated. In any case, Members are urged to record and monitor the end date of their coverage so that they can purchase and register it again, on time and their coverage will be without interruption.
Repeat Purchase of Dengue Flex and K12 Health Card
Members can always stay covered with these Insular Health Care products. Simply visit shop.insularhealthcare.com.ph/ and log in to the account previously created to avoid having to input the buyer details again. Select and purchase the products and make the payment. As soon as the Purchaser has received the email from us confirming the purchase, register the person to be covered according to the Schedule below.
If the Dengue Flex and K12 Health Card has not been availed, the Member can register as early as 10 calendar days prior to the end date of coverage for uninterrupted coverage. By uninterrupted coverage, it means that the activation period will coincide with the last 10 days of coverage period which avoids the activation period occurring after the coverage period. If the Dengue Flex and K12 Health Card product has been availed, the Member can register for another product as soon as the day following the availment of emergency care under the Dengue Flex and K12 Health Cardproduct. If the Member has been confined, he/she can still register the day following the date of admission.
Remember that after successful registration, there is an activation period before coverage begins anew.
For concerns or queries relating to registration, please feel free to chat with us or send us an email or private message.
Invalidation of Agreement
Failure to disclose or misrepresent any material information by the Purchaser in the registration or medical examination, whether intentional or unintentional, shall automatically invalidate this Agreement from the very beginning, and liability of Insular Health Care shall be limited to the return of all payments less cost of previous services rendered or amount already refunded plus administration fee.
Section 2 – Benefits, Inclusions and Exclusions
One benefit of a Filipino citizen is universal PhilHealth coverage under Republic Act No. 7875, as amended. Its Implementing Rules and Regulations are available at
https://www.philhealth.gov.ph/about_us/IRR_NHIAct_2013.pdf. It cannot be emphasized enough that it is to one’s greatest benefit to ensure that he/she is covered by PhilHealth and that he/she makes regular contributions, as necessary, to be able to complement one’s HMO coverage.
These are the services and benefits that one can avail under the Dengue Flex and K12 Health Card.
Please read carefully how one’s PhilHealth coverage may help in covering the Member’s medical expenses.
Dengue Flex and K12 Health Card
First, identify the product under which the Member has been registered. Carefully note whether the Member is covered for accidents only and confirm the corresponding limit for the Member’s outpatient and inpatient emergency care benefit.
All variants of Dengue Flex and K12 Health Card include access to the Top 6 hospitals in Metro Manila; namely: Asian Hospital and Medical Center, Cardinal Santos Medical Center, Makati Medical Center, St. Luke’s Medical Center in Quezon City and in Bonifacio Global City (BGC) and The Medical City.
Proceed to read and understand about emergency care and the inclusions and exclusions of coverage.
|What are the benefits of each of the ER Care products?||
Carefully note under which product the Member is registered as each of them have different benefits. The number beside the Product name refers to the Benefit Limit that applies if the Member is hospitalized.
Please see below the details on the benefits of the different products under the Dengue Flex and K12 Health Card Series.
Coverage for Dengue, Leptospirosis, and COVID-19
|Product||Emergency Care Service||Room and Benefit Limit|
|Dengue Flex 50||Outpatient or inpatient emergency care||Ward Room with Php 50,000 Benefit Limit||K12 Health Card 50||Outpatient or inpatient emergency care||Ward Room with Php 50,000 Benefit Limit|
When is it medically necessary to seek emergency care and when is it covered by the Dengue Flex or K12 Health Card?
Seek emergency care when needed. For more life-saving information, visit www.insularhealthcare.com.ph/need-medical-attention-where-to-go.
Under the Dengue Flex or K12 Health Card, the Member can avail of emergency care with benefits at the hundreds of hospitals accredited with Insular Health Care. Availment of emergency care in non-accredited hospitals is also covered but on reimbursement basis.
Insular Health Care shall reimburse up to 100% of the usual customary and reasonable fees which an Insular Health Care preferred/accredited hospital would charge for such treatment/confinement or the product’s benefit limit, whichever is less, provided that the illness or condition is covered.
Only emergency care is covered by the Dengue Flex or K12 Health Card. Nonemergency care is not covered so it is important that the Member only seeks emergency care at the hospital when it is a valid emergency. For example, a 7-year child with cough and colds should be brought to the pediatrician during clinic hours rather than to the emergency room.
What does Emergency Care mean?
For clarity, ‘emergency’ means the sudden, unexpected onset of illness or injury having the potential of causing immediate disability or death or requiring the immediate alleviation of severe pain and discomfort.
The key qualifiers here are that illness or injury must be life-threatening and/or has the potential to cause immediate disability if no medical care is provided, or there is pain and discomfort that one is not able to tolerate.
It is the doctor who will determine if the Member’s case qualifies as a medical emergency. For emphasis, if the case is evaluated by the doctor as a non-medical emergency, the Dengue Flex or K12 Health Card product will not provide coverage.
What are the specific conditions covered by the Dengue Flex or K12 Health Card product?
Dengue Flex and K12 Health Card provides emergency care coverage to individuals suffering from the following specific conditions:
• Dengue (including Chikungunya)
• Leptospirosis COVID-19
Doctors will evaluate whether the Member’s specific case requires hospitalization. In cases where hospitalization is required for the Member’s case, Dengue Flex and K12 Health Card will provide inpatient and outpatient coverage.
|What specific conditions would be excluded from coverage?||
The Dengue Flex and K12 Health Card products provide coverage for specific conditions mentioned above. The incidence of the specific conditions must be within the start and end dates of the coverage period.
The Dengue Flex and K12 Health Card series do not provide coverage for any other conditions other than the specific conditions mentioned above.
Emergency Care in the Emergency Room of Accredited Hospitals
The maximum amount of services that can be availed by the Member as a benefit corresponds to the Benefit Limit (BL) of the Dengue Flex or K12 Health Card under which the Member is registered. The same limit applies to the Member’s journey whether it starts in the Emergency Room or with a doctor’s visit and whether the Member is directly discharged from the emergency room or continues into a hospital confinement. The basis of the limit applies to the single incidence of the diagnosis rather than from where it started and the medical treatment that follows to make the Member better.
Dengue Flex and K12 Health Card Series include coverage for the emergency room and when admitted, the coverable hospital charges while the Member is confined. If the Member consults with an accredited doctor and is advised to be admitted, the benefit limit will be used to settle the coverable hospital charges while confined.
Coverable Hospital Charges
At the emergency room, the Member’s benefits will cover the hospital’s fees for the emergency room, professional fees of accredited doctors who attend to the Member in the emergency room, hospital services and supplies that the doctors say that the Member needs to recover and be discharged.
Hospital services and supplies include general nursing care and the drugs and medicines, and supplies prescribed with therapeutic effect while in the emergency room. Notwithstanding, sub-limits on specific services relating to specific tests are applied. These can be viewed at https://www.insularhealthcare.com.ph/healthcareagreement.
For certain outpatient procedures done in the emergency room, based on its own rules, PhilHealth will provide coverage in PhilHealth accredited hospitals. If the Member’s case qualifies, the Member must submit the necessary PhilHealthmandated documents to be able to claim the benefit. If the Member is not yet a PhilHealth member or is unable to complete the document requirements because the Member’s contributions are not sufficient and/or updated, the Member will have to shoulder the portion that PhilHealth would have covered.
The Member’s total hospital bill will be reduced by PhilHealth’s coverage. If there are any discounts, like Senior Citizen or PWD discount that will be applied, it will be deducted after PhilHealth’s coverage.
Insular Health Care will cover the coverable charges in the hospital bill, net of the PhilHealth coverage and other discounts. If the total coverable charges, net of PhilHealth and discounts, are less than or equal to the available benefit limit, the Dengue Flex and K12 Health Card product will cover the whole amount. In case the net coverable hospital charges are greater than the Member’s available benefit limit, the Member will shoulder 100% of the excess.
Inpatient Care in Accredited Hospitals
|Benefit Limit||The maximum amount of services that the Member can avail as a benefit corresponds to the Benefit Limit (BL) of the Dengue Flex or K12 Health Card product under which the Member is registered. The same limit applies to the Member’s journey whether it starts in the Emergency Room or with a doctor’s visit and whether the Member is directly discharged from the emergency room or continues into a hospital confinement. The basis of the limit applies to the single incidence of the diagnosis rather than from where it started and the medical treatment that follows to make the Member better.|
Hospital Room Amenities
|For Dengue Flex and K12 Health Card products, the Member is assigned to a Ward room. The room amenities that are included as standard in the specific hospital where the Member is admitted forms part of the room and board; as such, it does not cost the Member. Amenities not part of the standard that are requested will be for the account of the Member. Please note that room amenities differ by room type and by hospital and Insular Health Care has no influence over the room amenities that are specified by each hospital.|
Importance of Room Type Selection
Hospitals practice socialized pricing; the higher the room type, all hospital products and services and even professional fees, also increase in cost. This is why selecting a room type is important.
If the Member expects that the hospital charges will be significant, and/or the Member wants to avoid paying any coverable charges in excess of the benefit limit of the Dengue Flex or K12 Health Card product under which the Member is registered, one way to maximize the benefit limit is to avoid moving to a higher room type. Insular Health Care will help ensure that the Member will continue to receive the highest standard of medical care in the hospital regardless of the room type. Please note that in certain instances, particularly infectious cases, the doctor may require a private room. This has been particularly observed for children.
No Hospital Rooms Available and Staying Beyond Discharge
If the doctor has admitted the Member for inpatient emergency care, and there is no Ward room available, the Member can still be admitted into a room type higher than that of the Member’s product room.
In case of a choice of multiple room types, Insular Health Care will select the lowest room type option available to better manage the Member’s benefit limit. If there is no choice in room type, the Member will be admitted into the next available room type (from lowest to highest). Refer to Importance of Room Type Selection for more insight on why room selection is important.
Insular Health Care will cover the first 24 hours of the Member’s admission from the room rate and all the therapeutic treatment received. If a Ward room becomes available within the first 24 hours or immediately after the first 24 hours, Insular Health Care will help arrange for the Member’s transfer. The Member will not shoulder any charges for the room or coverable hospital charges in this scenario.
All incremental costs incurred after the first twenty-four (24) hours shall be for the personal account of the Member except when the Affiliated Hospital issues a certification of non-availability of the Member’s Room and Board Accommodation.
For the Member’s own reasons, he/she can choose to stay confined in the hospital after he/she has been discharged by the accredited doctor. However, the Member will be responsible for all hospital charges and professional fees starting from the time of the discharge order. In this scenario, it is certain that the Member will have out-of-pocket expenses to settle
Coverable Hospital Charges and Special Modalities of Treatment
Aside from the Member’s room and board, the Member’s benefits will cover the professional fees of accredited doctors and hospital services and supplies that the doctors say that the Member needs to recover and be discharged, subject to the Member’s plan limits.
Hospital services and supplies include general nursing care and the drugs and medicines prescribed with therapeutic effect. The Member’s benefits will also cover the services and supplies related to the surgery the Member may need, and confinement in the Intensive Care Unit. Notwithstanding, the sub-limits on specific services relating to specific tests and procedures collectively called as “special modalities” will be applied. These can be viewed at: www.insularhealthcare.com.ph/faq .
In one hospital stay, there will be tens to hundreds of items that will be used to help the Member recover. The guiding rule is that the Member’s benefits will cover those that are prescribed by an accredited doctor with therapeutic effect relative to the diagnosis/diagnoses that is covered by the Dengue Flex or K12 Health Card product under which the Member is registered. Services and supplies that are not medically necessary in the Member’s medical management are not covered; examples of these are blood donor screening services, additional meal trays for the Member’s companion or a TV unit if it was not a standard amenity of the room selected.
For certain medical cases, based on its own rules, PhilHealth will provide coverage in PhilHealth accredited hospitals. If the Member’s case qualifies, he/she must submit the necessary PhilHealth-mandated documents to be able to claim the benefit. If the Member is not yet a PhilHealth member or is unable to complete the document requirements because the Member’s contributions are not sufficient and/or updated, the Member will have to shoulder the portion that PhilHealth would have covered.
the Member’s total hospital bill will be reduced by PhilHealth’s coverage. If there are any discounts, like Senior Citizen or PWD discount, that will be applied, it will be deducted after PhilHealth’s coverage.
Insular Health Care will cover the coverable charges in the hospital bill, net of the PhilHealth coverage and other discounts. If the total coverable charges, net of PhilHealth and discounts, are less than or equal to the available benefit limit, the Dengue Flex or K12 Health Card product will cover the whole amount. In case the net coverable hospital charges are greater than the Member’s available benefit limit, the Member will shoulder 100% of the excess.
Emergency Care in Areas without Accredited Hospitals
Emergencies can happen anytime. It can also happen in places where one least expects it. In unfortunate times like this, the Member may avail emergency care services at a vast network of our accredited hospitals which Insular Health Care continues to expand. In case the Member meets a medical emergency in areas Insular Health Care has yet to expand its network to, Insular Health Care will cover the Member’s treatment up to 100% of the usual customary and reasonable fees which an Insular Health Care accredited hospital would charge for such treatment or Benefit Limit of the chosen Dengue Flex or K12 Health Card plan whichever is less, provided that the condition is covered under Dengue Flex or K12 Health Card.
However, since it is out of Insular Health Care’s network of providers, the Member shall settle all expenses incurred at the non-accredited hospital prior to discharge. The Member is required to submit the accomplished Claims Reimbursement Form and original copies of the requirements to Insular Health Care to process the reimbursement of claim.
Emergency Care in Non-Accredited Hospitals
Health emergencies require immediate action, and it is often best addressed at the nearest health care provider. In case of medical emergencies where there are available accredited hospitals in the area, but the Member was provided emergency care treatment in a Non-Accredited Hospital, Insular Health Care will only cover up to 100% of the usual customary and reasonable fees which an Insular Health Care accredited hospital would charge for such treatment or the Benefit Limit of the chosen Dengue Flex or K12 Health Card plan whichever is less, provided that the condition is covered under Dengue Flex or K12 Health Card.
After the emergency treatment has been administered and the Member still require further care under confinement, the Member or a representative must notify Insular Health Care within a period of twenty-four (24) hours from admission. However, in case the Member or the representative is unable to inform Insular Health Care, due to one’s medical condition, the notification period shall be extended for another twenty-four (24) hours from the time the Member or the representative is clinically able to do so.
Insular Health Care reserves the right to transfer the Member to an accredited hospital and to an accredited physician when it is medically safe to do so upon recommendation of the attending physician.
If transfer is not possible, the Member shall settle all expenses incurred at the nonaccredited hospital prior to discharge. The Member is required to submit the accomplished Claims Reimbursement Form and original copies of the requirements to Insular Health Care to process the reimbursement of claim.
Emergency Care in Areas outside the Philippines
|Covered Benefits||Dengue Flex and K12 Health Card plans only cover emergency medical cases in the Philippines. No health care service or reimbursement shall be provided by Insular Health Care under these plans for medical emergencies outside the Philippines.|
Section 3 – Important Information on How to Avail of the Benefits
Availment of Medical Services: Online Letter of Authorization, Diagnostic Procedure Benefits
The Member will need to self-generate a Letter of Authorization to seek face-to-face medical consultation. Please prepare the Product Voucher which contains the Insular Health Care Member ID. The Member ID will be needed to generate the Letter of Authorization.
Availment of Emergency Medical Services: ER at Accredited Hospitals and Letter of Authorization
A medical professional will be able to determine if the Member needs emergency medical care. Please visit www.insularhealthcare.com.ph/need-medical-attention-where-to-go to know when it is medically necessary to seek emergency care and why the Member should avoid the emergency room for nonemergency situations.
At the emergency room, if the doctor determines that the Member’s case is non-emergency in nature and/or the diagnosis is not coverable under the Dengue Flex or K12 Health Card product, the Member will shoulder all the hospital charges.
Also, it is the medical professionals who will attend to the Member who will provide the medical diagnosis of his/her case. They may be able to diagnose the Member within a short period of time or it may take longer, depending on the factors affecting the case. It is not common but it can also happen that they may provide a diagnosis in the beginning and eventually change it as the Member’s condition develops. In the end, it is the final medical diagnosis that will be used to determine if it is covered by the Dengue Flex or K12 Health Card product under which the Member is registered.
To facilitate the Member’s medical care and based on an initial diagnosis, Insular Health Care may already issue a Letter of Authorization (LoA) to the hospital on the Member’s behalf, corresponding to the Dengue Flex or K12 Health Card product benefit under which the Member is registered. In case the initial medical diagnosis changes to one that is not covered under the Dengue Flex or K12 Health Card product under which the Member is registered, the Member will be advised at the soonest possible time that the LoA will be withdrawn from the hospital and that the Member will have to make his/her own arrangements with the hospital. The Dengue Flex or K12 Health Cardproduct will also be reinstated as if it was not used so that it will still be available for future medical availment.
The Dengue Flex or K12 Health Card product is considered availed when Insular Health Care issues a LoA to the hospital. The LoA may be in an amount less than or equal to the maximum amount of benefits of the Dengue Flex or K12 Health Card product under which the Member is registered. Please refer to the table below on how the LoA works to address the coverable charges in the hospital bill. Note that noncoverable charges in the hospital bill are for the Member’s account.
|When the coverable charges in the hospital bill is less than the maximum amount of benefits||The LoA will act as the guarantee of Insular Health Care to the hospital that the coverable charges will be settled by it.|
|When the coverable charges in the hospital bill is equal to the maximum amount of benefits||
When the coverable charges in the hospital bill is greater than the maximum amount of benefits
Availment of Emergency Medical Services: ER at Non-Accredited Hospitals
Insular Health Care cannot issue a LOA as a guarantee to the hospital for Emergency Medical Services provided outside its network of accredited hospitals, which means the Member must directly settle all charges corresponding to the medical care provided to him/her by the Non-Accredited Hospital.
A claim for reimbursement must be filed and received by Insular Health Care within sixty (60) days from the date of availment. The request must be submitted using the prescribed Claims Reimbursement Form, which can be accessed via www.insularhealthcare.com.ph/onlineservices/, and the required documents detailed on the said form. No reimbursement shall be made to the Member unless the original documents are submitted by the Member or a representative or if the Member has already been fully indemnified or reimbursed of medical bills or costs incurred under any other health care coverage or insurance policy or any other similar contracts or agreements. Failure to present the required documents within the filing period shall not invalidate nor reduce any claims if it was not reasonably possible to give proof within such time.
The processing period shall be thirty (30) days upon receipt of all necessary documents required by Insular Health Care. In case an additional requirement is needed, the thirty-day (30) period shall be reckoned against the date when the additional requirement is submitted.
All benefits that pertain to the Member will be paid by check to the Member. For dependents, payment in another manner may be done if Insular Health Care considers it more practicable. In case of death, benefits due but remaining unpaid shall be given to the first surviving class of the following classes of successive preference of beneficiaries: (a) widow or widower; (b) surviving children; (c) surviving parents; (d) surviving brothers and sisters; and (e) executors or administrators.
Request for reconsideration for reimbursement claims
lf a claim for reimbursement is denied, or the Member is not satisfied/agreeable to the reimbursement paid by Insular Health Care, a written request for reconsideration must be filed with the Insular Health Care 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 the authorized personnel of Insular Health Care, whose decision shall be final. Insular Health Care reserves the right to deny Claims for Reimbursement if the procedures and requirements have not been strictly complied with.
Section 4 – Data Privacy
For purposes of properly administering its services, Insular Health Care shall collect, record, organize, store, update or modify, retrieve, consult, use, and in some restricted instances, consolidate, block, erase, disclose (collectively, “process”) personal information (name, address, sex and contact information) and sensitive personal information (age, bank information, medical history, results of medical examinations, diagnosis, abstracts, treatments, utilization, records and information, medication, and other information relevant or connected with one’s HMO coverage from, or of one’s diagnosis, treatment or availment of health care services through Insular Health Care).
By buying our product and/or availing our services and providing one’s personal and sensitive personal information, the Purchaser and/or Member, as the case may be, is specifically:
- Consenting to making one’s personal and sensitive personal information available to Insular Health Care, its affiliates, related entities and partner/ accredited hospitals, clinics, and wellness centers (including their officers, employees, service providers, subcontractors as well as members of their medical staff, house staff, doctors, nurses, allied health care personnel and other clinical staff – “Insular Health Care Related Entities”), and permitting Insular Health Care and Insular Health Care Related Entities to make one’s personal and sensitive personal information available to (i) third parties who provide products and services to Insular Health Care for the purposes described above; and (ii) regulatory authorities and government agencies. Provided, that the sharing of personal and sensitive personal information to Insular Health Care Related Entities shall be subject to (i) the principles of transparency, legitimate purpose, proportionality and data quality and to (ii) appropriate data privacy agreements and the implementation of organizational, physical, technical, administrative, procedural and security measures that are similar or greater than that being observed by Insular Health Care.
- Authorizing their doctor and/or the hospital, clinic or wellness center that have provided the Member treatment to release any information and related documents (including a summary thereof derived from laboratory services and medical consultations) to Insular Health Care or its authorized representatives for the evaluation of the Member’s claims.
- Acknowledging that the personal and sensitive personal information that the Purchase and/or Member, as the case may be, has provided will be retained by Insular Health Care and Insular Health Care Related Entities as prescribed by law, or as long as necessary for the purpose of maintaining one’s medical records and to comply with applicable laws, rules and regulations. The Purchaser and/or Member, as the case may be, has been made aware that he/she and his/her next of kin, dependent or legal representative are entitled to certain rights in relation to the personal and sensitive personal information that may be collected from them, including the right to access, correction, and to object to the processing of the same. They have been made aware that a more detailed description of their rights under Republic Act No. 10173 or the Data Privacy Act of 2012 and its Implementing Rules and Regulations may be accessed and downloaded at privacy.gov.ph. They have likewise been made aware that should they have any privacy concern regarding their personal data, they may consult Insular Health Care’s Data Protection Officer at firstname.lastname@example.org or Tel: 8813-0131 loc 8505, or the National Privacy Commission at www.privacy.gov.ph
- They understand that the consent they are giving is in addition to any other consent that they may have already given Insular Health Care and Insular Health Care Related Entities regarding the processing of their personal and sensitive personal information (e.g. in relation to their HMO coverage/ availment, examination, diagnosis, treatment or procedure). They also understand that the consent they have given shall remain in full force for a period of one (1) year unless revoked in writing except to the extent that action has already been taken based therein.
- Confirming that they understand the foregoing and that they are voluntarily giving their consent to the processing of their personal and sensitive personal information under the terms and conditions provided above.
- If they registered another person, like a child or an adult under their authority like a specially-abled sibling, they certify that the data are accurate and that they have the legal authority to submit personal information and sensitive personal information about them to Insular Health Care. On their behalf, they authorize Insular Health Care to process their personal information and sensitive personal information for the same above purposes.
Section 5 – Resolution of Issues
Insular Health Care is committed to work with our Members to stay healthy and recover from any illness. Insular Health Care will handle the availment of the Member’s benefits in accordance with accepted Philippine medical standards and in cooperation with the Member and its medical partners. If the Member believes that Insular Health Care was not able to correctly and accurately handle the request for availment of benefits, please let us know so that we can review our procedures and correct them accordingly. Please feel free to communicate with us through phone, email or a private message on Facebook. We urge our members to use any of these methods of communication to preserve your privacy. In case the issue shall remain unacted or unresolved, you may request for settlement of dispute under Section 7 hereof.
Section 6 – Keeping in Touch
We want to stay in touch with members. Please do add our email address to your directory to avoid our emails from being classified as spam. Through email, through notices posted repeatedly on our website and social media accounts, we will communicate any information pertinent to the Insular Health Care products you have purchased. Please do update us of any change in your email address and other contact information so that you do not miss out on any important notices. Please find below a list of the notices we may send through email and possibly through SMS.
- Confirmation of your purchase
- Confirmation of your successful registration
- Confirmation of your availment
- Confirmation of your product’s termination
- Notification of your product’s upcoming expiry
- Changes in the Health Care Agreement
In any case, you may opt-out from receiving notices from us by unsubscribing from our mailing list.