purple cow employee benefits 2011 - benefits

4. BENEFITS 4. BENEFITS

Your SECRET to Financial Security Your SECRET to Financial Security

Benefits OverviewLIFE – ACCIDENT – HEALTH

LIFE

1. LIFE * Total & Perm. Disability Income

HEALTH

3. MEDICAL HMO * 21,519 MD, 352 hospitals, 358 clinics

4. DENTAL HMO * 775 dentists, 645 clinics

5. Opt. Annual Physical Exam * 124 hospitals, 241 clinics, 31 mobile

6. Opt. Reimbursement Plan * Prescribed Medicines, Dental & Vision

ACCIDENT

2. PERSONAL ACCIDENT

a. Accidental Death * Murder

b. Disability * Assault

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Benefits

Benefits SummaryLIFE – ACCIDENT – HEALTH

1. Life = 5x MBL 13. Private patient for reimbursement (HMO rate)

2. Total & perm. disability income = 5x MBL 14. 100% Pre-Existing Conditions coverage

3. Accidental death = 5x MBL 15. 100% Congenital Conditions coverage

4. Murder = 5x MBL 16. Benefits on top of Philhealth

5. Accidental disability = __% of 5x MBL 17. Special procedures = 30%/100% of MBL

6. Assault = __% of 5x MBL 18. Dental = HMO (775 dentists / 645 clinics)

7. Medical = HMO (21,519 MD / 352 hospitals / 358 clinics) 19. Dental access to major malls in Metro-Manila

8. Access to Big 5 Hospitals & Healthway 20. 1 permanent filling, 2 oral prophylaxes, etc.

9. HMO buffet of benefits: IP/OP/ER 21. Opt. APE = designated or mobile clinic

10. Combined inpatient & outpatient limits 22. Opt. Reimb. for Rx meds, dental & vision

11. MBL per disability, per year 23. Same benefits for all Employees

12. HMO patient for no-cash-out 24. Same benefits for all Dependents

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Benefits

1. LIFE (worldwide)ASIANLIFE EXCLUSIONS

1. Life1 5x MBL 1. Suicide within the 1st year of coverage

2. Total & Perm Disability Income2 5x MBL

+Principals 18yo-65yo; Dependents 30dy-21yo / 18yo-65yo

1Life insurance = 5x MBL, for death by any cause (suicide covered after 1 year);

2Total & Permanent Disability Income (TPDI) = 5x MBL, in lieu of the Life benefit, after 6 months of TPD, whether sick or hurt. Example:

If MBL = 20T, Life or TPDI = 100,000;




If MBL = 100T, Life or TPDI = 500,000.

Life benefits are payable on top of Personal Accident and Health benefits

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Benefits

2a. PERSONAL ACCIDENT (worldwide)ASIANLIFE

1. Accidental Death1 5x MBL 3. Disability3 _% 5x MBL

2. Murder2 5x MBL 4. Assault4 _% 5x MBL


1Accidental Death = 5x MBL, for death from any type of accident;2Murder = 5x MBL, in lieu of the Accidental Death benefit, for death not due to accident but murder (provoked or not). Example:

If MBL = 20T, Accidental Death or Murder = 100,000;




If MBL = 100T, Accidental Death or Murder = 500,000.


3Disability = __% of 5x MBL, according to a long schedule of disabilities;

4Assault = __% of 5x MBL, in lieu of the Disability benefit, for disability not due to accident but assault (provoked or not).Example:

If MBL = 20T, Disability or Assault = __% of 100,000;




If MBL = 100T, Disability or Assault = __% of 500,000.

Personal Accident benefits are payable on top of Life and Health benefits

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Benefits

2b. PERSONAL ACCIDENT… SCHEDULE OF DISABILITIES

1. Life (same as Accidental Death) 100% 14. Middle finger 6%

2. Both hands or feet or sight of both eyes 100% 15. Ring finger 5%

3. One hand and one foot 100% 16. Little finger 4%

4. Either hand or foot and sight of one eye 100% 17. Metacarpals 1st/2nd - 3rd/4th/5th 3% - 2%

5. Injuries resulting in being perm. bedridden 100% 18. Leg at or above knee 60%

6. Any other injury causing Total Perm. Disab. 100% 19. Leg below knee 50%

7. Arm at or above elbow 70% 20. One foot 50%

8. Arm between elbow and wrist 50% 21. All toes on one foot 25%

9. One hand 50% 22. Big toe 5%

10. Four fingers and thumb of one hand 50% 23. Any toe other than big toe (each) 1%

11. Four fingers 35% 24. Sight of one eye 50%

12. Thumb 15% 25. Hearing - both ears 50%

13. Index finger 10% 26. Hearing - one ear 25%

+Multiple losses from 1 accident will be limited to the highest loss, not to exceed 100%. If a member suffered the loss of 1 hand/foot/eye prior to coverage, the benefit for a subsequent loss of the same will be ½.

Losses refer to total and permanent loss of use or complete severance

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Benefits

2c. PERSONAL ACCIDENT…EXCLUSIONS

1. Bodily or mental infirmity, hernia, ptomaine, bacterial or viral infection (except pyogenic infection occurring with and through an accidental cut or wound)

12. War, invasion, act of foreign enemy or warlike operation (whether declared or undeclared), mutiny, strikes, demonstrations, riots, civil commotion, conspiracy, military takeover, state of siege, or any weapon or instrument employing atomic fission or radioactive force whether in time of peace or war

2. Disease, sickness, parasite, or disorder of the body/ mind

3. Poison, gas or fumes voluntarily or involuntarily taken

4. Insect bites 13. Serving in the armed forces of any country, or international authority, whether in war or peace5. Earthquake, volcanic eruption or tidal wave

6. Atomic explosion, nuclear fission, or radioactive gas 14. Entering, operating, servicing, ascending or descending from any aerial or submarine device or conveyance, except as provided under a passenger aviation provision7. Pregnancy, childbirth, miscarriage or any complications

8. Accident occurring while or because the Insured is under the influence of alcohol or any drug

15. Hunting, motorcycling or pillion riding, mountaineering which necessitates the use of ropes or pitons, racing of any kind, other than on foot, ice or winter sports, water-ski jumping and tricks, yachting beyond 5 km. off a coastline, underwater activities involving the use of underwater apparatus, or using woodworking machinery driven by mechanical power other than portable tools, applied by hand and used solely for private purposes without reward

9. Suicide or any attempted threat while sane or insane, or any intentionally self-inflicted injury

10. Participation in any brawl, or committing any crime or felony

11. Provoked murder / assault or attempted threat [waived]

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Benefits

3a. MEDICAL HMO (nationwide)ASIANLIFE (21,519 MD / 352 hospitals / 358 clinics) TERMS & CONDITIONS

1. HMO buffet of benefits: IP/OP/ER 1. Instant rates, regardless of size

2. Combined inpatient & outpatient limits 2. No franchising required

3. MBL per disability, per year 3. No utilization report required

4. HMO patient for no-cash-out 4. No individual applications required

5. Private patient for reimbursement (HMO rate) 5. Minimum group size = 10

6. Access to Big 5 Hospitals and Healthway 6. Minimum mode of payment = monthly

7. 100% Pre-Existing Conditions coverage 7. Pooled Employee utilization to spread risk

8. 100% Congenital Conditions coverage 8. Separate Dependent utilization to reduce cost

9. Benefits on top of Philhealth 9. Buy now, pay later

10. Special Procedures = 30%/100% of MBL 10. 1st year Virgin promo rate, if applicable +Principals 18yo-65yo; Dependents 30dy-21yo / 18yo-65yo +Same rates for Dependents in 2011

Medical HMO benefits are covered on top of Life and Personal Accident benefits

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Benefits

3b. MEDICAL HMO…PRE-EXISTING CONDITIONS (Dreaded) PRE-EXISTING CONDITIONS (Non-Dreaded)

1. Blood dyscrasias 1. Asthma, pleural effusion or other chronic airway obstruction conditions

2. Benign / malignant new growths 2. Benign cyst / tumor and malignant conditions

3. Chronic cardiac / cardio-vascular diseases 3. Chronic gynecologic conditions

4. Collagen / connective diseases 4. Hemorrhoids and other chronic colonic and ano-rectal illnesses

5. Diseases of the immune system 5. Diseased tonsils requiring surgery, cataracts & other opthalmo-otolaryngologic conditions

6. Chronic hepatobiliary diseases 6. Pathological abnormalities of nasal septum and turbinate

7. Neuro-surgical / neurological conditions 7. Sinus condition requiring surgery

8. Chronic pulmonary diseases 8. Chronic neurologic conditions

9. Chronic genito-urinary diseases 9. Calculus cholecystitis / cholelithiasis and/or urolithiasis

10. Chronic gynecological conditions 10. Chronic conditions of the genitourinary system

11. Chronic gastrointestinal conditions 11. Polyps, ulcers, liver cirrhosis and other chronic gastrointestinal diseases

12. Endocrine abnormalities 12. Endocrine illnesses

13. Antibiotic / chemotherapy-resistant diseases / bactemia / septicemia 13. Seizure disorders

14. Chronic opthalmo-otolaryngologic diseases 14. Moderately to far advanced tuberculosis

15. Chronic musculo-skeletal diseases 15. Chronic musculo-skeletal malignancies

16. Pathological / accidental fractures 16. Malignancies of the blood and bone marrow

17. Illnesses / injuries necessitating the use of isolation room / ICU or other IC facilities 17. Hypertension, coronary artery disease / myocardial ischemia, cerebrovascular accident and other chronic cardiac diseases18. Accidental injuries

19. Second and third degree burns 18. Collagen / connective tissue diseases

20. Surgical procedures requiring application / use of prosthesis for immediate treatment 19. Diseases of the immune system

21. PEC (except congenital ones) subject to the provision on ‘PEC’ in this Agreement [waived] All Dreaded & Non-Dreaded PEC are covered 100% to MBL

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Benefits

3c. MEDICAL HMO…SPECIAL PROCEDURES – 30% of MBL SPECIAL PROCEDURES – 100% of MBL

1. Lithotripsy 1. Dialysis

2. Arthroscopic procedures 2. Chemotherapy

3. Laparoscopic procedures 3. Radiation oncology / therapeutic radiology

4. Laser therapy (excludes use for correcting vision) 4. Sclerotherapy

5. Nuclear / radioactive isotope scans 5. Physical & speech therapy

6. Cost of artificial limbs, joint prosthesis and heart valve prosthesis

6. Angiography

7. Nuclear technologies

7. Other new modalities of treatment for conditions with established etiologies and used as alternatives to conventional or traditional procedures

8. Thallium scintigraphy

9. CT scan / MRI

10. Pulmonary perfusion scan

For the above special procedures, the remaining 70% of your Maximum Benefit Limit per disability per year can be used for conventional treatment of the same condition (unlike other HMO’s which exclude conventional treatment after a special procedure, and limit special procedures to 1x/year).

11. Endoscopy

12. Bone densitometry scan

13. Anti-nuclear anti-body (ANA)

14. C-reactive protein (rheumatic & complications)

15. Lupus cell exam

16. Sleep therapy

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Benefits

3d. MEDICAL HMO…EXCLUSIONS

1. Expenses that should be taken care of by any government programs such as Philhealth 13. Illnesses / injuries attributable to the plan member’s own misconduct / gross negligence / immoral habits, and willful and unnecessary exposure to danger or health hazards 2. Services rendered or supplies provided free of charge

3. Additional hospital charges and/or professional fees resulting from a plan member taking a room accommodation more than his R&B limit (excesses and/or incremental costs)

14. Self-inflicted injuries including, but not limited to, any form of suicide attempt

4. Maternity and maternity-related conditions and/or complications except those benefits that may be provided by the (optional) Maternity benefit

15. Sexually transmitted disease, AIDS, rehabilitative treatment for alcoholism and drug abuse

5. Sterilization of either sex or reversal of such, artificial insemination, sex change, consultation/confinement regarding fertility

16. Acquisition of prosthetic appliances, artificial aids, durable equipment, surgically implanted devices and external prosthetic devices except those that are explicitly covered and enumerated in the ‘Special Procedures or New Modalities of Treatment’ provision of this agreement6. Non-recommended confinement, convalescent / domiciliary / custodial care, rest cures

7. Dental-related cases except those that may be provided by the Dental Benefits and to the extent that are necessary for the repair or alleviation of damage caused solely by accidental injury sustained (and not caused by the plan member)

17. Organ transplant-expense relating to organ donation of the donating party/parties

18. Executive check-ups, unless explicitly provided in the master policy, and/or confinements purely for diagnostic purposes, as well as non-recommended confinements

8. Circumcision, cosmetic / aesthetic procedures except re-constructive surgery to treat functional defects due to a covered disease and/or accidental injury

9. Psychiatric disorders, psychosomatic conditions, treatment for any mental or nervous disorders, illness / injury / condition / complication arising from the plan member’s excessive alcohol intake and/or use of regulated/prohibited drugs

19. Take-home medicines, unless optional ‘Reimbursement of Prescribed Medicines’ benefit is provided, and vaccines, except for first doses of either anti-venom, anti-rabies or anti-tetanus used for emergency treatment

10. Illnesses and/or injuries arising from the plan member’s participation in brawls, riots, commission of a crime, violation of ordinances, or the like

20. Medico-legal fees including the cost of Medical Certificates that a plan member may require for any purpose it may serve him or her

11. Illnesses / injuries resulting from conditions of war or sustained from combat-related activities

21. Congenital disease / deformity that is evident to the plan member at birth and/or can be clinically determined to be congenital [waived]

12. Illnesses / injuries resulting from the plan member’s active participation in hazardous activities such as, but not limited to, bungee jumping, hang-gliding, scuba diving, mountain/wall climbing, and professional sports

22. Medical / surgical procedures and/or diagnostic tests that are experimental in nature and/or not generally accepted by the medical profession such as, but not limited to, iridology, chiropractic services, and acupuncture

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Benefits

4. DENTAL HMO (nationwide)HEALTH PARTNERS (775 dentists / 645 clinics) EXCLUSIONS

1. (1) permanent filling 1. Dental procedures not included in the dental HMO plan

2. (2) oral prophylaxes1

+No reimbursements allowed (unless you get the optional Reimbursement Plan for Rx Medicines, Dental & Vision).

+Discounts of up to 20% available on procedures not included in the dental HMO plan.

+Dental card and booklet provided, as well as an orientation and an annual utilization report.

3. Unlimited consultations

4. Simple tooth extractions if indicated

5. Temporary fillings when indicated

6. Gum treatment except for alveolectomy/gingivectomy

7. Simple adjustment of dentures

8. Re-cementation of fixed bridges/crowns/jackets/inlays/onlays

9. Treatment of pain/lesions/wounds/burns

10. Emergency dental procedures if necessary

+By appointment only (unless emergency)

Dental HMO benefits are covered on top of Medical HMO benefits

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Benefits

5. Optional Annual Physical Exam ASIANLIFE (241 designated clinics, 31 mobile clinics) EXCLUSIONS

1. Physical examination 1. APE procedures not included in the Basic 5 APE plan

2. Chest X-Ray +You can add additional procedures to your Basic 5 APE: call GRA to help design, source, price, and schedule your APE anytime during your plan year.

+Nationwide (241 clinics, 31 mobile) or Metro Manila-wide (114 clinics, 24 mobile) APE also available to companies with multiple locations, at roughly triple or double the cost respectively (reflecting their average cost of a Basic 5 APE). Otherwise, individual clinics are best, whether designated or mobile.

3. CBC Basic 5 only

4. Urinalysis

5. Fecalysis

+The Annual Physical Exam (APE) is a diagnostic tool, not a cure for sickness or accident. Results can serve as a baseline for referral to specialists who can authorize tests and/or prescribe further treatment.

+By appointment only, 30 days in advance.

+Pay as you go, so you don’t lose it if you don’t use it (don’t pay in advance, as payment is not transferable).

Basic 5 Cost +/- P300 (for designated or mobile clinics).

APE benefits are covered on top of Medical HMO benefits

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Benefits

6. Optional Reimbursement PlanASIANLIFE EXCLUSIONS

1. Prescribed Medicines 1. Vitamins, supplements and/or non-BFAD approved medicines, herbal medicines, and other medicines that have no legal BFAD-approved therapeutic claims2. Dental

3. Vision 2. Dental procedures not included in the dental HMO plan

+Reimbursement for Prescribed Medicines, Dental & Vision benefits within 15 working days of receipt of all documents.

+Reimbursement for Prescribed Medicines covers treatment for any covered sickness or accident.

+Reimbursement for Dental covers the same schedule of benefits as the dental HMO, but with your choice of dentist for full reimbursement up to your aggregate limit.

+Reimbursement for Vision covers tests for visual acuity and prescription lenses.

+The annual aggregate limit for all prescribed medicines, dental and vision benefits together = 1/10 th your MBL.

3. Non-prescription lenses and frames

Rx Medicines, Dental & Vision are covered on top of Medical & Dental HMO benefits

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Benefits

purple cow employee benefits 2011 - benefits

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