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  • Fortunecare agent covering the Opinionology call center at Matina, Davao City has resigned, at present all newly regular employees of that company is not covered by Fortunecare insurance.
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  1. 1. <ul><li>OUR MISSION </li></ul><ul><ul><li>We contribute to uplift the quality of human life by providing efficient, affordable and accessible healthcare service programs to the broadest domestic and international clientele using our vast resources of qualified providers, medical facilities and our people whom we regard as our most important asset. </li></ul></ul><ul><li>OUR VISION </li></ul><ul><ul><li>To become a leader in the market segment we serve as the chosen carrier in the managed healthcare programs addressing a mass based clientele in the Philippines and in the Asia Region. </li></ul></ul>
  2. 2. FORTUNE CARE <ul><li>180 M </li></ul><ul><li>With over P180M in assets, Fortune Care is one of the industry’s leading players </li></ul><ul><li>It’s wide affiliation and attendance include: Charter member of the ASSOCIATION OF HEALTH MAINTENACE ORGANIZATION OF THE PHILIPPINES </li></ul>
  3. 3. FORTUNE CARE <ul><li>Affiliated with over 4,000 accredited medical and dental specialists nationwide </li></ul><ul><li>FORTUNE CARE has 19 clinics and 23 branches all over the Philippines </li></ul>
  4. 4. FORTUNE CARE OWNED CLINICS <ul><li>DE LOS SANTOS MEDICAL CENTER (RM253 Delos Santos Medical Center, 201 E. Rodriguez Blvd., Espana Ext., Quezon City) </li></ul><ul><li>MEGAMALL CLINIC (5/F Bldg. B Megaclinic, Mandaluyong) </li></ul><ul><li>FEU-NRMF Clinic (Rm207 Marian Medical Arts Bldg., Dahlia cor. Regalado Ave., West Fairview QC) </li></ul><ul><li>ST LUKE’S MEDICAL CENTER (RM207 Medical Arts Bldg, E.Rodriguez Ave QC) </li></ul>
  5. 5. FORTUNE CARE OWNED CLINICS <ul><li>PASIG (MAIN) Dominga Bldg, 606 Shaw Blvd., PAsig City </li></ul><ul><li>MAKATI (Dela Rosa cor AMorsolo STs., MAkati City) </li></ul><ul><li>ALABANG (2 nd Floor Joval Bldg., #52 National Road, Putatan Muntinlupa </li></ul><ul><li>MANILA (Trina Place, #507 Salas St., Ermita Manila) </li></ul><ul><li>CALOOCAN (#355 PPI Bldg., BAgong Barrio Caloocan City) </li></ul>
  6. 6. FORTUNE CARE OWNED CLINICS <ul><li>ANGELES (CAP Bldg., Jake Gonzales Bldg., Angeles City) </li></ul><ul><li>BACOLOD(2 nd Flr St Francis Center, Araneta ST Brgy Sincang Bacolod City </li></ul><ul><li>CABANATUAN (2 nd Flr Fortune Group Bldg., Zulueta Maharlika Highway Cabanatuan City) </li></ul><ul><li>CAVITE( Shop 3 & 4 MRDC Bldg., cor Ambrosia St E. Aguinaldo H-way Anabu 1 Imus Cavite </li></ul><ul><li>CEBU (2 nd Flr Fortune Life Bldg, Osmena Blvd, Cebu City </li></ul><ul><li>DAGUPAN CLINIC (G/F Music Warehouse Bldg., Dagupan City) </li></ul><ul><li>DAVAO (Fernandez Germanos Bldg., MAgallanes St Davao City </li></ul><ul><li>ILOILO (G/F Eternal Life Bldg, Ortiz St Iloilo City </li></ul><ul><li>MEYCAUAYAN( 3 rd Fl Aliw Cinema COmplez, McArthur H-way Calvario Meycauayan Bulacan </li></ul><ul><li>TARLAC (553 M.H. Del Pilar St Sto Ni Cristo, Tarlac City) </li></ul>
  8. 8. SISTER COMPANIES of FORTUNE CARE <ul><li>ALC CONGLOMERATE </li></ul><ul><ul><li>MEMORIAL </li></ul></ul><ul><ul><ul><li>Eternal Garden’s Memorial Park Corp </li></ul></ul></ul><ul><ul><ul><li>Eternal Crematory Corp </li></ul></ul></ul><ul><ul><li>BROADCASTING </li></ul></ul><ul><ul><ul><li>Aliw Broadcasting Corp, DWIZ-882 Khz-AM </li></ul></ul></ul><ul><ul><ul><li>Home Radio (97.9FM Station) </li></ul></ul></ul><ul><ul><li>PRINTING & PUBLICATIONS </li></ul></ul><ul><ul><ul><li>Brown Madonna Press Inc </li></ul></ul></ul><ul><ul><ul><li>Philippine Graphic Publication Inc </li></ul></ul></ul><ul><ul><ul><li>Business Mirror </li></ul></ul></ul>
  9. 9. SISTER COMPANIES of FORTUNE CARE <ul><li>ENTERTAINMENT </li></ul><ul><ul><li>ALE Baliwag Cinema & Shopping Complex </li></ul></ul><ul><ul><li>Aliw Cinema Complex </li></ul></ul><ul><ul><li>Movie Houses </li></ul></ul><ul><ul><li>Willand Enterprise </li></ul></ul><ul><ul><li>Music Warehouse (Chick O’Clock) </li></ul></ul>
  10. 10. SISTER COMPANIES of FORTUNE CARE <ul><li>SECURITY SERVICES </li></ul><ul><ul><li>Asian Security & Investigation Agency </li></ul></ul><ul><ul><li>Eastern Defender Security & Protective Services Inc., </li></ul></ul><ul><li>HOTELS </li></ul><ul><ul><li>Cherry Blossoms Hotel </li></ul></ul><ul><ul><li>Citystate Tower Hotel </li></ul></ul><ul><ul><li>Manila Grand Opera Hotel </li></ul></ul>
  11. 11. SISTER COMPANIES of FORTUNE CARE <ul><li>FINANCIAL SERVICES </li></ul><ul><ul><li>CityState Insurance Corp </li></ul></ul><ul><ul><li>CityState Savings Bank Inc </li></ul></ul><ul><ul><li>Eternal Plans Inc </li></ul></ul><ul><ul><li>Fortune General Insurance Corp </li></ul></ul><ul><ul><li>Key Finance & Investment Corp </li></ul></ul><ul><ul><li>Fortune Life Insurance Co,Inc </li></ul></ul><ul><ul><li>Triple A Southeast Equities </li></ul></ul><ul><li>TRANSPORTATION </li></ul><ul><ul><li>GENCARS, Inc </li></ul></ul><ul><li>REAL ESTATE </li></ul><ul><ul><li>ALC Industrial & Commecial Development Corp </li></ul></ul><ul><ul><li>ALC Realty Development Corp </li></ul></ul><ul><li>FOOD </li></ul><ul><ul><li>Chow Rite Food Inc </li></ul></ul><ul><ul><ul><li>(3 Franchised Chow king Store located at Palanca, MEycauayan, PAterno) </li></ul></ul></ul>
  12. 12. WHAT BUSINESS ARE WE IN? <ul><li>HMO-Health Maintenance Organization </li></ul><ul><ul><li>Fortune Care manages the premium paid by the members </li></ul></ul><ul><ul><li>It has pre-payment mechanism that is defined in terms of the amount of membership fee and payment frequency for a specific period </li></ul></ul><ul><ul><li>Negotiate with the providers the medical and professional services at discounted rate </li></ul></ul><ul><ul><li>It has a team of medical providers </li></ul></ul><ul><ul><li>Looks clients to avail of the healthcare coverage at an affordable cost </li></ul></ul><ul><ul><li>Gives customer care to clients </li></ul></ul><ul><ul><li>Monitor utilization of clients under the supervision of UMC </li></ul></ul>
  13. 13. OUR MAJOR CLIENTS <ul><li>Bureau of Jail Management and Penology </li></ul><ul><li>ABS-CBN Broadcasting Corp </li></ul><ul><li>Department of Foreign Affairs </li></ul><ul><li>Batangas electric Cooperative </li></ul><ul><li>Trade and Investment Corp </li></ul><ul><li>MActan-Cebu Int’l Airport </li></ul><ul><li>Dept. of Education (Nationwide) </li></ul><ul><li>Simon Group of Companies </li></ul><ul><li>San Jose City Water District </li></ul><ul><li>ABC Laboratories </li></ul><ul><li>PAcita Liner </li></ul><ul><li>P.Imes </li></ul><ul><li>East-West Seed </li></ul><ul><li>Hocheng Philippines </li></ul><ul><li>Palawan Electric Cooperative </li></ul><ul><li>Dept. of Justice </li></ul><ul><li>Dept of Agrarian Reform Employees Association </li></ul><ul><li>The SUlo Hotel </li></ul><ul><li>Social Welfare Employee Assoc.of the Phil. </li></ul><ul><li>LGU (Nationwide) </li></ul><ul><li>Phil. MAnsho Inc </li></ul><ul><li>Mekeni Foods Corp </li></ul><ul><li>Dept. of Labor and Employment </li></ul><ul><li>Phil. National Bank Club </li></ul><ul><li>NFA Multi –purpose cooperative </li></ul><ul><li>Commission on Appointments </li></ul><ul><li>Office of the Legal Affairs-Civil Service Commission </li></ul><ul><li>DPWH-Central Office </li></ul><ul><li>Sienna College </li></ul>
  14. 14. FORTUNE CARE <ul><li>CORPORATE </li></ul><ul><ul><li>Must have employer-employee relationship and the account is duly registered with SEC </li></ul></ul><ul><ul><li>TYPE OF ENROLLMENT </li></ul></ul><ul><ul><ul><li>Fully Subsidized </li></ul></ul></ul>
  15. 15. FORTUNE CARE CORPORATE ACCOUNT <ul><li>AGE ELIGIBILITY </li></ul><ul><ul><li>18-64 Years old </li></ul></ul><ul><li>QUALIFIED DEPENDENTS </li></ul><ul><ul><li>Single Principal Payor: </li></ul></ul><ul><ul><ul><li>Parents 60-64 years old </li></ul></ul></ul><ul><ul><li>Married Principal Payor: </li></ul></ul><ul><ul><ul><li>Legal spouse 18 up to 64 years old </li></ul></ul></ul><ul><ul><ul><li>Legal children 90 days -20 years old </li></ul></ul></ul><ul><ul><li>Single Parent </li></ul></ul><ul><ul><ul><li>Legal children 90 days – 20 years old </li></ul></ul></ul>
  16. 16. FORTUNE CARE Corporate Account <ul><li>If count is <50 principal members: </li></ul><ul><ul><li>Partial coverage of PED up to P10,000 </li></ul></ul><ul><li>If count >50 principal members: </li></ul><ul><ul><li>Full coverage of PED </li></ul></ul><ul><li>May or may not follow Published Standard Rates for Corporate, subject to the following: </li></ul><ul><ul><li>If count >100 principal members, please refer to ACTUARIAL </li></ul></ul><ul><ul><li>If count < or = 100 principal members, standard rates </li></ul></ul>
  17. 17. FORTUNE CARE B E N E F I T S <ul><li>Out Patient Benefits </li></ul><ul><li>In Patient Benefits </li></ul><ul><li>Emergency Room Care Services </li></ul><ul><li>Special Diagnostic Procedure </li></ul>
  18. 18. FORTUNE CARE OUT-PATIENT BENEFITS <ul><li>The out-patient benefits are provided for the diagnosis and treatment of illness or injury which does not require hospitalization. The following Out-Patient Services shall only be availed of in any of our Fortune Care owned clinics or through our Medical Coordinator in Fortune Care affiliated hospitals in the provinces where there are no Fortune Care owned clinics. </li></ul>
  19. 19. FORTUNE CARE OUT-PATIENT BENEFITS <ul><li>Preventive HealthCare Services </li></ul><ul><ul><li>Annual Physical Examination- at any of the Fortune Care full service clinics or authorized accredited medical facilities only </li></ul></ul><ul><ul><ul><li>Medical History Taking </li></ul></ul></ul><ul><ul><ul><li>Physical Examination </li></ul></ul></ul><ul><ul><ul><li>Chest X-ray </li></ul></ul></ul><ul><ul><ul><li>Laboratory </li></ul></ul></ul><ul><ul><ul><li>Complete Blood Count (CBC) </li></ul></ul></ul><ul><ul><ul><li>Stool examination </li></ul></ul></ul><ul><ul><ul><li>Urinalysis </li></ul></ul></ul><ul><ul><ul><li>Electrocardiogram (ECG) </li></ul></ul></ul><ul><ul><ul><li>Pap Smear (for 35 years & above or as recommended by the physicians) </li></ul></ul></ul><ul><ul><ul><li>Fasting Blood Sugar (FBS) </li></ul></ul></ul>
  20. 20. FORTUNE CARE OUT PATIENT BENEFITS <ul><li>APE can be availed even on the first year as long as the equivalent annual premium is paid subject to prior appointment </li></ul><ul><ul><li>Annual Mode -Anytime within the contract year </li></ul></ul><ul><ul><li>Semi-Annual Mode -After paying the 2 nd Semi-Annual membership fee </li></ul></ul><ul><ul><li>Quarterly Mode -After paying the last quarterly membership fee </li></ul></ul><ul><ul><li>Monthly Mode -After paying the last monthly membership fee (12 th month) </li></ul></ul>
  21. 21. FORTUNE CARE OUT PATIENT BENEFITS <ul><li>For APE performed at clinics or hospital with medical facilities other than our Fortune Care owned clinics. Fortune Care shall reimburse the member based on the existing schedules but not to exceed P450.00 after submission of all supporting documents: </li></ul><ul><ul><li>Request letter for reimbursement </li></ul></ul><ul><ul><li>Official receipts (original copy) </li></ul></ul><ul><ul><li>Photocopy of the APE result </li></ul></ul>
  22. 22. FORTUNE CARE OUT PATIENT BENEFITS <ul><li>Preventive HealthCare Services </li></ul><ul><ul><li>Administration of vaccine/immunization (excluding cost of sera/vaccine </li></ul></ul><ul><ul><li>Advice on diet, exercise and other healthful habits </li></ul></ul><ul><ul><li>Family planning and counseling </li></ul></ul><ul><ul><li>Well baby care ( even for member’s unenrolled baby less that 3 month of age t be availed of at Fortune Care full service Clinics only, EXCEPT </li></ul></ul><ul><ul><ul><li>SLMC </li></ul></ul></ul><ul><ul><ul><li>Mega clinic </li></ul></ul></ul><ul><ul><ul><li>DLSMC </li></ul></ul></ul><ul><ul><ul><li>FEU </li></ul></ul></ul>
  23. 23. FORTUNE CARE OUT PATIENT BENEFITS <ul><li>Out Patient Care Services </li></ul><ul><ul><li>Unlimited Consultation (during clinic hours) </li></ul></ul><ul><ul><li>First Aid Treatment of minor lesions, burns, sprains and the like </li></ul></ul><ul><ul><li>Necessary Lab routine tests and commonly available diagnostic procedures, including ECG X-ray, as prescribed by Fortune Care affiliated physicians & specialists. </li></ul></ul><ul><ul><li>Pre and post natal care consultation in FC owned full service clinic only EXCEPT at SLMC, DLSMC, FEU and Megaclinic </li></ul></ul>
  24. 24. FORTUNE CARE OUT PATIENT BENEFITS <ul><li>Out Patient Care Services </li></ul><ul><ul><li>Eye, Ears, Nose & Throat </li></ul></ul><ul><ul><li>First-dose of anti rabies, anti tetanus, anti-venom during emergency cases up to P5,000 per year (single availment only) except ERIG </li></ul></ul><ul><ul><li>Cauterization of warts except genital and sexually transmitted warts up to P2,500. </li></ul></ul><ul><ul><li>Sclerotheraphy up to P5,000 </li></ul></ul><ul><ul><li>Botox injection up to P5,000 </li></ul></ul>
  25. 25. FORTUNE CARE OUT PATIENT BENEFITS <ul><li>Only members with Private, De Luxe and Suite plans have access to St. Luke’s Medical Center, Cardinal Santos Medical Center and The Medical City. </li></ul>
  26. 26. AVAILMENT PROCEDURES FOR OUT-PATIENT SERVICES IN AREAS WITH FORTUNE CARE OWNED CLINICS <ul><li>Go to any FORTUNECARE clinic in MetroManila or in areas with provincial branch clinics. </li></ul><ul><li>Present your Fortune Care membership card for the necessary consultation and treatment of illness; </li></ul><ul><li>For conditions requiring elective or non-emergency confinement secure approval from the Clinic Operations Manager. </li></ul>
  27. 27. <ul><li>Proceed to the Hospital Coordinator, Out-Patients Department/Industrial Department/HMO Department </li></ul><ul><li>Present your Fortune Care membership card for the necessary consultation/treatment of your illness </li></ul>AVAILMENT PROCEDURES FOR OUT-PATIENT SERVICES IN AREAS WITHOUT FORTUNE CARE OWNED CLINICS (accredited Hospitals Only)
  28. 28. FORTUNE CARE IN-PATIENT BENEFITS <ul><li>Extended for the treatment of illness/injury requiring hospitalization at </li></ul><ul><li>FORTUNE CARE </li></ul><ul><li>accredited hospitals </li></ul>
  29. 29. FORTUNE CARE IN-PATIENT BENEFITS <ul><li>No admission deposit in affiliated hospitals </li></ul><ul><li>Room and board </li></ul><ul><li>Operating and recovery room </li></ul><ul><li>Services of Physician, Surgeon, w/ surgery </li></ul><ul><li>Administered Medicines and Med Supplies </li></ul><ul><li>Transfusions of Blood </li></ul><ul><li>Maternity assistance benefit </li></ul><ul><li>ICU & CCU </li></ul><ul><li>Hospital Income Benefit (HIB) </li></ul>
  30. 30. AVAILMENT PROCEDURES FOR IN-PATIENT SERVICES IN AREAS WITH FORTUNE CARE OWNED CLINICS <ul><li>For elective or non-emergency confinement secure prior approval from the Clinic Operations Manager. Approval is needed in Metro Manila and in areas with Fortune Care branch clinics. </li></ul><ul><li>Go to information/Admitting Office of accredited hospital; </li></ul><ul><li>Present your Fortune Care membership card/admitting orders from the attending physicians; </li></ul>
  31. 31. AVAILMENT PROCEDURES FOR IN-PATIENT SERVICES IN AREAS WITH FORTUNE CARE OWNED CLINICS <ul><li>1. Member/Patient proceeds to fortune Care clinic to obtain FC approval for the elective major surgical diagnostic procedure. </li></ul><ul><li>2. Member/Patient proceeds to Accredited Hospital/Clinic then present hospital requirements and membership card. </li></ul><ul><li>3. Upon admission, member/patient call Fortune Care within 24 hours –to report your hospital confinement </li></ul><ul><li>PLDT TOLL-FREE: 1-800-10-633-888 </li></ul><ul><li>Manila Hotline: 706-4849 </li></ul><ul><li>4. FC Medical Liaison Officer/Provincial Coordinator visits member/patient and issues Letter of Authorization (LOA) </li></ul><ul><li>5. Member/Patient files Philhealth for Philhealth requiring admission/procedures </li></ul><ul><li>6. Member/Patient signs Statement of Account (SOA) prior to discharge and pays incremental charges (if any) </li></ul>
  32. 32. <ul><li>1. Member/Patient proceeds to the HMO/Industrial section or Medical Coordinator of any FC accredited hospital to secure FC approval </li></ul><ul><li>2. Secure needed admitting orders for the elective procedures. </li></ul><ul><li>3. Upon admission, member/patient call Fortune Care within 24 hours –to report your hospital confinement </li></ul><ul><li>PLDT TOLL-FREE: 1-800-10-633-888 </li></ul><ul><li>Manila Hotline: 706-4849 </li></ul><ul><li>4. FC Medical Liaison Officer/Provincial Coordinator visits member/patient and issues Letter of Authorization (LOA) </li></ul><ul><li>5. Member/Patient files Philhealth for Philhealth requiring admission/procedures </li></ul><ul><li>6. Member/Patient signs Statement of Account (SOA) prior to discharge and pays incremental charges (if any) </li></ul>AVAILMENT PROCEDURES FOR OUT-PATIENT SERVICES IN AREAS WITHOUT FORTUNE CARE OWNED CLINICS (accredited Hospitals Only)
  33. 33. EMERGENCY ROOM CARE SERVICES <ul><li>Out-patient or In-patient services shall anytime be provided to the member when he/she is brought to the emergency room (ER)., ie. The condition is such serious nature that failure to obtain immediate care within 24 hours from the time of the accident injury was sustained or within 12 hours from the onset of symptoms or a serious illness. </li></ul>
  34. 34. How then do we say that we are in Emergency case? <ul><li>Sudden and unexpected onset of illness that would place the patient’s life in jeopardy. </li></ul><ul><li>Cause serious impairment or loss of bodily functions not immediately attended to </li></ul><ul><li>Cases of severe chest and abdominal pain requiring immediate attention as stated in the records of the ER </li></ul><ul><li>Cases of accidental injury </li></ul>
  35. 35. BASIC EXAMPLE OF EMERGENCY CASES <ul><li>Stroke </li></ul><ul><li>Convulsion </li></ul><ul><li>Heart attack </li></ul><ul><li>Massive bleeding </li></ul><ul><li>Acute appendicitis </li></ul><ul><li>Diarrhea with severe dehydration </li></ul><ul><li>Fractures and multiple injuries secondary to accident </li></ul><ul><li>Hypertensive emergency </li></ul><ul><li>Status asthmatics </li></ul>
  36. 36. EMERGENCY ROOM CARE SERVICES <ul><li>BENEFITS IN ACCREDITED HOSPITAL </li></ul><ul><ul><li>Doctor’s services </li></ul></ul><ul><ul><li>Medicines for immediate relief of pain and other symptoms administered in the emergency room </li></ul></ul><ul><ul><li>Oxygen and intravenous fluids </li></ul></ul><ul><ul><li>Dressing, plaster casts, and sutures </li></ul></ul><ul><ul><li>X-ray, laboratory and other tests necessary for patient’s emergency management </li></ul></ul>
  37. 37. EMERGENCY ROOM CARE SERVICES <ul><li>BENEFITS IN NON-ACCREDITED HOSPITALS </li></ul><ul><li>Whether as in-patient or out-patient, FORTUNE CARE shall reimburse 80% of the approved covered fees and charges to a member who has received and paid for emergency care in a non-accredited hospital whether located in the Philippines or abroad but not to exceed the amount of what if could have cost of treatment was done by a Fortune Care physician in an affiliated provider. </li></ul>
  38. 38. AVAILMENT PROCEDURES FOR EMERGENCY CARE SERVICES IN ACCREDITED HOSPITAL <ul><li>Proceed to ER of nearest Accredited Hospital </li></ul><ul><li>Present Fortune Care Card </li></ul><ul><li>If admitted -Call nearest Fortune Care Medical Office within 24 hrs, to report confinement </li></ul><ul><li>Fortune care liaison officer will visit member </li></ul><ul><li>Obtain Philhealth Form from the Company/Patient’s employer (if patient is Philhealth member) </li></ul><ul><li>Pay excess charges (if there are any </li></ul>
  39. 39. AVAILMENT PROCEDURES FOR EMERGENCY CARE SERVICES IN NON-ACCREDITED HOSPITAL <ul><li>Proceed to ER of nearest Non-accredited Hospital </li></ul><ul><li>Call the nearest Fortune Care Medical Office within 24 hrs to report confinement </li></ul><ul><li>Pay Hospital Bill & Professional Fee </li></ul><ul><li>Secure documents </li></ul><ul><li>File reimbursement at Fortune Care branch/Head Office within 30 days from date of discharge </li></ul><ul><li>Fortune Care will reimburse 80% of the total FORTUNE CARE approved hospital bill and professional fees. </li></ul>
  40. 40. CLAIMS:REIMBURSEMENT OF EXPENSES <ul><li>Within 30 days after discharge </li></ul><ul><li>Payment: Within 30 days after receiving complete document </li></ul><ul><li>For Special Corporate Accounts, depends on the agreed time frame stated in the contract. </li></ul>
  41. 41. DOCUMENTS REQUIRED <ul><li>If Out-patient </li></ul><ul><li>Request letter for reimbursement </li></ul><ul><li>Medical Certificate </li></ul><ul><li>Original Copy of the Official receipt </li></ul><ul><li>Police report for accidental injuries </li></ul><ul><li>Result of diagnostic procedure done </li></ul>
  42. 42. DOCUMENTS REQUIRED <ul><li>If in-patient </li></ul><ul><ul><li>Request letter for reimbursement </li></ul></ul><ul><ul><li>Detailed Clinical Discharge Summary </li></ul></ul><ul><ul><li>Operative records/histopathology report if surgical procedure was performed </li></ul></ul><ul><ul><li>Original receipts and invoices </li></ul></ul><ul><ul><li>Statement of account </li></ul></ul><ul><ul><li>Pharmacist’s certification of non-availability of stocks </li></ul></ul><ul><ul><li>Police report for accidental injuries and medico legal cases in which 3 rd Party Liability applies </li></ul></ul><ul><ul><li>Result of Diagnostic Procedure done </li></ul></ul><ul><ul><li>Hospital’s certification of non-availability of room (if applicable) </li></ul></ul>
  43. 43. SPECIAL DIAGNOSTIC PROCEDURE <ul><li>All types of CAT scan (P5,000/availment/ disease) </li></ul><ul><li>All types of Stress Testing (P10,000/year) </li></ul><ul><li>Nuclear imaging(including parathyroid scan- P5,000/disease/year) </li></ul><ul><li>Total Body Scan (P5,000/disease/year) </li></ul><ul><li>Bone Scan (P5,000/disease/year) </li></ul><ul><li>Renal Scan (P5,000/disease/year) </li></ul>
  44. 44. SPECIAL DIAGNOSTIC PROCEDURE <ul><li>Pulmonary Scan (P5,000/disease/year) </li></ul><ul><li>Thallium Scan (P5,000/disease/year) </li></ul><ul><li>Thyroid Scan (P5,000/disease/year) </li></ul><ul><li>Botox injection for non-cosmetic (P5,000) </li></ul><ul><li>All types of ECG (P5,000) </li></ul><ul><li>Flourescein angiography or angloscopy of Eye total P2,500/eye/year </li></ul>
  45. 45. SPECIAL DIAGNOSTIC PROCEDURE <ul><li>Breast Scintigraphy (P5,000/breast/year) </li></ul><ul><li>Warts, except genital or sexually transmitted (P2,500/year) </li></ul><ul><li>Magnetic resonance Imaging (MRI) up to a maximum of (P5,000) only. </li></ul><ul><li>Laparoscopic, arthroscopic, and other endoscopic diagnostic procedures shall be covered up to P5,000. </li></ul><ul><li>All other modern modalities of therapeutic procedures not specifically mentioned shall be covered up to P5,000 per member per year. This includes hospital and doctor’s fee. </li></ul>
  46. 46. OTHER FEATURES <ul><li>Dental Care Services (Optional) </li></ul><ul><li>Worldwide Emergency Care </li></ul><ul><li>Third Party Liability (TPL)/Work Related (ECC) and Unprovoked Assault </li></ul><ul><li>Abnormal Pregnancy </li></ul>
  47. 47. DENTAL CARE SERVICE <ul><li>Dental services at any of our FortuneCare owned clinics and in other accredited dental clinics </li></ul>
  48. 48. DENTAL CARE SERVICES (Optional) <ul><li>Any reasonable number of consultations </li></ul><ul><li>Oral prophylaxis (once a year) including Ultrasonic scaling for mild to moderate calcular deposits; </li></ul><ul><li>Dental extraction (except surgery for impaction) </li></ul><ul><li>Temporary filing </li></ul><ul><li>Recementation of jacket crown; inlays & onlays </li></ul><ul><li>Treatment of minor mouth lesions, wounds and burns </li></ul><ul><li>Gum treatment </li></ul><ul><li>All dental services other than the standard benefits prescribed by FORTUNE CARE dentist shall be availed of at discounted prices upon prior arrangement with FORTUNECARE affiliated dentist (10-15% discount). Any treatment beyond the standard dental benefits shall be for the member’s account. </li></ul>
  49. 49. WORLDWIDE EMERGENCY CARE <ul><li>FORTUNE CARE will cover 80% of the total approved emergency treatment and hospitalization charges while in the course of travel incurred by the member when treated in a foreign country not to exceed the amount of what it could have cost if treatment is done by a FORTUNE CARE affiliated physicians in an affiliated hospitals. </li></ul>
  50. 50. THIRD PARTY LIABILITY (TPL)/WORK RELATED (ECC) AND UNPROVOKED ASSAULTS <ul><li>FORTUNE CARE may cover Medical and Hospital Services extended to a member for bodily injuries established to have been cause by any compensable act to a Third Party (Motor Vehicle accidents), work related injuries caused by Unprovoked assaults up to P20,000.00 provided the necessary claim document are duly filed. </li></ul>
  51. 51. MATERNITY ASSISTANCE <ul><li>Abnormal Pregnancy, P5,000.00 annual maximum medical services shall be given to help defray hospitalization charges for abnormal pregnancy: </li></ul><ul><ul><ul><li>Ectopic </li></ul></ul></ul><ul><ul><ul><li>Placenta previa </li></ul></ul></ul><ul><ul><ul><li>Abruptio placenta </li></ul></ul></ul><ul><ul><ul><li>Post-partumatony </li></ul></ul></ul>
  52. 52. LIMITATION ON ROOM & BOARD ACCOMODATION <ul><li>A member may only occupy the type of hospital room specified in his plan </li></ul>
  53. 53. LIMITATION ON ROOM & BOARD ACCOMODATION: St. Lukes Medical City Cardinal Santos Medical Ctr Makati Medical City The New Medical City Asian Hospital Ward Yes Yes Yes Yes No Semi-Private Yes Yes Yes Yes No Private Yes Yes Yes Yes No De Luxe Yes Yes Yes Yes No Suites Yes Yes Yes Yes No
  54. 54. LIMITATION ON ROOM & BOARD ACCOMODATION: <ul><li>If member chooses to stay in a room higher than his specified plan, he will pay for the ff: </li></ul><ul><ul><li>Excess in Room Rate charges </li></ul></ul><ul><ul><li>30% Ancillary surcharges as a result of the room upgrade </li></ul></ul><ul><ul><li>i.e. operating room & recovery room, laboratory & diagnostic procedures, medicines, central supplies, professional fees, etc. </li></ul></ul>
  55. 55. LIMITATION ON SPECIAL SURGICAL PROCEDURES: <ul><li>FC shall provide coverage up to P25,000.00 should the member opt for medical procedure other than the traditional cutting surgery> </li></ul><ul><li>Lithotripsy for Urolithiasis (Kidney) </li></ul><ul><li>Arthroscopic Knee Surgery </li></ul><ul><li>Endoscopic Cholecystectomy (Gallstone) </li></ul><ul><li>Endoscopic Sinus Surgery </li></ul><ul><li>Laparoscopic Pelvic Operation </li></ul>
  56. 56. LIMITATION/CONDITIONS OF A PRE-EXISTING DISEASE <ul><li>A condition, disease o illness is considered pre-existing if during the period prior to </li></ul><ul><li>the effectivity date of Contract or </li></ul><ul><li>Approval date of reapplication in case of a Lapsation: </li></ul><ul><li>a. Any treatment or medical advice was given for such illness/condition prior to enrolment </li></ul><ul><li>b. Such illness/condition has been by the nature, manifestation, and conditions evident to the member </li></ul><ul><li>c. The pathogenesis of the condition can clinically determine the onset of the disease as prior to the date of enrolment. </li></ul>
  57. 57. The following are considered Pre-existing Disease (PED) <ul><li>Bronchial asthma & systemic allergies </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Chronic cholecystitis/cholelithiasis </li></ul><ul><li>Benign new growths </li></ul><ul><li>Hypertension or whatever etiology </li></ul><ul><li>Endometriosis </li></ul><ul><li>Hemorrhoids, anal fistula </li></ul><ul><li>Hernia </li></ul><ul><li>Urolithiasis and Chronic Glomerulonephritis </li></ul><ul><li>Acid peptic Disease </li></ul>
  58. 58. Pre-existing conditions that require a voluntary execution of “Waiver” <ul><li>Coronary and hypertensive heart disease, valvular heart disease </li></ul><ul><li>Chronic Obstruction Pulmonary Disease (COPD) </li></ul><ul><li>Parenchymal liver disease (hepatomegaly), cirrhosis, newgrowth </li></ul><ul><li>Bone marrow disease/Blood dyscrasias </li></ul><ul><li>CNS lesions (CVA, tumors, epilepsy,slipped disc, post traumatic scars with seizure episode, Parkinson’s Disease, Multiple Sclerosis) </li></ul><ul><li>Collagen disease </li></ul><ul><li>All malignant new growths </li></ul><ul><li>Diabetes Mellitus with vascular, renal and neurologic degenerative complications. </li></ul><ul><li>Kidney Disease with impaired renal function (Obstructive Urophaties, Hydronephrosis, previous Nephrectomy, Nephrotic Syndrome) </li></ul><ul><li>Peptic Ulcer and Chronic GI tract disease that may require surgery (Esophageal Varices, New growths, Radical Bowel Resections) </li></ul><ul><li>Scoliosis, kyphosis and other similar skeletal deformities. </li></ul>
  59. 59. Coverage of a Pre-Existing Disease No. of Membership years 1 st year 2 nd year 3 rd year thereafter Types of Treatment Medical/Minor Surgery No Coverage Covered Covered Covered Major Surgery No Coverage No Coverage Covered Covered Waived Disease No Coverage No Coverage No Coverage No Coverage
  60. 60. Coverage of Consultations and Lab/Work-ups to “Rule Out” (R/O) or “To-Consider” (T/C) a Pre-existing Disease <ul><li>INITIAL CONSULTATION (under program with standard benefits) during contestability period wherein the attending physician’s diagnosis is to R/O or T/C a pre-existing disease is COVERED. </li></ul><ul><li>Note: Regardless whether the patient is seen in our clinic or in our accredited hospitals by our affiliated doctors-MSUs </li></ul>
  61. 61. DREADED DISEASE <ul><li>Any serious illness or injury that may require special treatment or prolonged confinement. </li></ul><ul><li>FC shall cover hospital & doctors’ services up to a certain maximum amount per illness per year </li></ul>
  62. 62. The following are classified as dreaded diseases: <ul><li>Cerebrovascular accident (hemorrhage, thrombosis, embolism </li></ul><ul><li>Cardiovascular conditions: </li></ul><ul><ul><li>Myocardial infarction </li></ul></ul><ul><ul><li>Congestive heart failure </li></ul></ul><ul><ul><li>Cardiac arrthymia </li></ul></ul><ul><ul><li>Cardaic temponade </li></ul></ul><ul><ul><li>Coronary artery disease </li></ul></ul><ul><ul><li>Cardiomyopathy </li></ul></ul>
  63. 63. The following are classified as dreaded diseases <ul><li>Neuro-surgical conditions </li></ul><ul><li>Blood dyscracias </li></ul><ul><li>Renal parechymal disease, renal failure </li></ul><ul><li>Cirrhosis of the liver and acute necrotizing pancreatitis </li></ul><ul><li>Poliomyelitis and its complications </li></ul><ul><li>Collagen diseases </li></ul><ul><li>Chronic Obstructive Pulmonary Disease (COPD) </li></ul><ul><li>Encephalitides and complications/sequelae </li></ul><ul><li>Meningitis and its complications/sequelae </li></ul><ul><li>Malignant newgrowth (including indicated chemo or radiotherapy </li></ul>
  64. 64. The following are classified as dreaded diseases <ul><li>Serious accidental injuries: </li></ul><ul><ul><li>Including 2 nd & 3 rd degree burns </li></ul></ul><ul><ul><li>Injuries to extremeties that may require amputation </li></ul></ul><ul><ul><li>Injuries to vital organs suchas </li></ul></ul><ul><ul><ul><li>Liver </li></ul></ul></ul><ul><ul><ul><li>Pancreas </li></ul></ul></ul><ul><ul><ul><li>spleen </li></ul></ul></ul><ul><ul><ul><li>Kidneys </li></ul></ul></ul><ul><ul><ul><li>Spinal cord </li></ul></ul></ul><ul><ul><ul><li>Intracranial injuries, and the like </li></ul></ul></ul>
  65. 65. The following are classified as dreaded diseases <ul><li>Immuno-compromised clinical conditions that require over-extended or multiple hospital confinements </li></ul><ul><li>Indicated use of Intensive Care Unit or Cardiac Unit (CCU) in confinement </li></ul><ul><li>All vascular and neurologic complications of Diabetes Mellitus </li></ul><ul><li>Nosocomial infections </li></ul>
  66. 66. GENERAL EXCLUSIONS Medical Nature <ul><li>1. Services and hospitalizations in non-affiliated hospitals, attended to by non accredited doctors, except for covered emergency conditions. </li></ul><ul><li>2. Adverse medical conditions arising from treatment by no-affiliated physicians </li></ul><ul><li>3. Plastic or reconstructive surgery for cosmetic purposes. </li></ul><ul><li>4. Dental care following accidental injury to teeth for reconstructive surgery, orthodontic procedures or supply of dentures </li></ul><ul><li>5. Experimental medical procedures, acupuncture and speech therapy </li></ul>
  67. 67. GENERAL EXCLUSIONS Medical Nature <ul><li>6. Hyperalimentation, organ transplant procedures, psychiatric care </li></ul><ul><li>7. All other Cardiometric procedures not enumerated in Article II Section 4 of the contract. </li></ul><ul><li>8. Services to diagnose and reverse fertility or infertility </li></ul><ul><li>9. Sexually transmitted disease, including gonorrhea, syphilis, herpes and AIDS </li></ul><ul><li>10. Alcoholism, drug addiction or test substance abuse and medical conditions attributed to them. </li></ul><ul><li>11. Diagnostic and treatment services for congenital deformities </li></ul><ul><li>12. Confinement which is for purely diagnostic purposes (i.e. Executive check-up) </li></ul>
  68. 68. GENERAL EXCLUSIONS Medical Nature <ul><li>13. Human blood products (fibrinogen, plasma, albumin, immunologic preparations). </li></ul><ul><li>14. Treatment services for injuries, illnesses which are attributable to the member’s own misconduct </li></ul><ul><li>-negligence </li></ul><ul><li>-Intemperate use of drugs/alcohol/liquor </li></ul><ul><li>-Vicious or immoral habits </li></ul><ul><li>-Participation or commission of crime whether consummated or not </li></ul><ul><li>-Acts in violation of law or ordinance. </li></ul><ul><li>-Unnecessary exposure to imminent danger or hazard to life or health </li></ul>
  69. 69. <ul><li>Pregnancy and all pregnancy related conditions requiring medical care </li></ul><ul><li>Treatment of injuries resulting from war (declared or undeclared), riots, demonstrations or while in a military police or parliamentary service. </li></ul><ul><li>Medical care for pre-existing diseases (PED), concealed by the applicant at the time of enrollment regardless of any lapse of time before concealment is discovered. </li></ul>GENERAL EXCLUSIONS Medical Nature
  70. 70. GENERAL EXCLUSIONS Non-Medical Nature <ul><li>Corrective lenses, artificial hearing aids, prosthetic devices and services related to their application. </li></ul><ul><li>Orthopedic hardware used in nailing, pinning, bracing </li></ul><ul><li>Purchase or lease of durable medical equipment, oxygen (except what is actually used during covered in-patient care) </li></ul>
  71. 71. GENERAL EXCLUSIONS Non-Medical Nature <ul><li>Also excluded are other hospital goods and services, such as: </li></ul><ul><ul><li>Services of a private nurse </li></ul></ul><ul><ul><li>Use of extra bed, television, electric fan, etc. </li></ul></ul><ul><ul><li>Toilet article </li></ul></ul><ul><ul><li>Extra food tray </li></ul></ul><ul><ul><li>Discharge (take-home) medications </li></ul></ul><ul><ul><li>Ambulance service </li></ul></ul><ul><ul><li>Items not directly used in the medical treatment of the patient. </li></ul></ul>
  72. 72. PREPARATION OF MANUAL NOTICE TO PREPARE CONTRACT <ul><li>Manual NTPC signed by the: </li></ul><ul><ul><li>Soliciting agent/BGAM </li></ul></ul><ul><ul><li>Marketing Division Head (for new business) </li></ul></ul><ul><ul><li>Approved proposal </li></ul></ul><ul><ul><li>SEC registration </li></ul></ul><ul><ul><li>Letter of Intent </li></ul></ul><ul><ul><li>List of Members </li></ul></ul><ul><ul><ul><ul><li>Soft&hard Copy (excel form) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>All newly closed corporate accounts with a minimum of fifty one (51) enrollees shall submit a softcopy in excel format containing data to Marketing Service Dept. or agent at least fifteen (15) days before the start of effectivity date of the contract. </li></ul></ul></ul></ul>