Principal & spouse member – at least 18 to 55 years old (for individual accounts; renewable up to 65 years old) or 18 to 65 years old (for group/corporate accounts) Dependent member (children) – 3 months to 21 years old

•  any professional advice or treatment was given for such illness or condition
•  such illness or condition was in any way evident to the Member
•  the pathogenesis of such illness or condition has started whether or not a Member is aware of such illness or condition
•  An illness, injury or condition shall be considered pre-existing if it existed before the Effective Date of the Member’s coverage, the natural history of which can be medically determined to have started prior to the effective date of coverage or at the time of processing of the Member’s Application, whether or not the Member was aware of such illness, injury or condition.

•  pre-existing illnesses/conditions are not covered by the plan for the first year of the agreement (first 12 months)
•  pre-existing condition shall only be covered after one year from Effective Date of the Member’s coverage provided that there is no failure to disclose, misrepresent or conceal, material information in the original Application or Application for reactivation.  Notwithstanding the disclosure by the Member of a pre-existing condition, may permanently exclude from cover a specific medical condition, Illness or Injury upon written notice to the Member.

Basic Consultation:
1. Requests LOA thru their Mobile Application
2. Presents the LOA generated to the Medical Coordinator’s Clinic or HMO/Industrial Department
3. Hospital/clinic staff writes the LOA # with correct coverage in the provider form
4. Gives the provider form to Member
5. Member avails the consultation/procedure

With OP lab procedure:
1. Doctor makes Referral Slip for Lab procedure (If Lab is required)
2. Member presents HC&D card and Referral Slip
3. Hospital/clinic staff will call HC&D healthcare provider for LOA issuance
4. Perform Lab Procedure

•  Coordinate with the hospital for the availability of the Room Plan
•  Verification of coverage
•  File your PhilHealth upon discharge.
•  Fax final SOA and member alert
•  Hospital will coordinate with HC&D for the settlement of the bills.
•  Pay excess charge if there is any

Required documents when filing for a reimbursement claim:

Admission/Confinement
•  Original Official Receipt(s) of Professional Fees
•  Original Official Receipt(s) of Hospital Bill
•  Hospital Statement of Account (SOA) where member was confined or treated
•  Individual charge slips or itemized breakdown of charges to support Hospital SOA
•  Admitting history report/Clinical Abstract to be obtain from the Medical Records Section of the Hospital

Out Patient
•  Original Official Receipt(s) of Professional Fees
•  Original Official Receipt(s) of Hospital Fees
•  Copy of Doctor’s request (for the diagnostic test)

For Surgical cases (additional if applicable)
•  Operative report and Histopathological report

All claims for reimbursement must be filed using the prescribed claim form (downloadable) and submitted to HC&D Offices within thirty (30) days from the date of availment for out-patient cases, or from date of discharge for in-patient cases.

Required documents when filing for a reimbursement claim:

Admission/Confinement
•  Original Official Receipt(s) of Professional Fees
•  Original Official Receipt(s) of Hospital Bill
•  Hospital Statement of Account (SOA) where member was confined or treated
•  Individual charge slips or itemized breakdown of charges to support Hospital SOA
•  Admitting history report/Clinical Abstract to be obtain from the Medical Records Section of the Hospital

Out Patient
•  Original Official Receipt(s) of Professional Fees
•  Original Official Receipt(s) of Hospital Fees
•  Copy of Doctor’s request (for the diagnostic test)

For Surgical cases (additional if applicable)
•  Operative report and Histopathological report

•  Members are not allowed to use their personal/private doctors in availing the health care services (both out-patient and in-patient)
•  Members can only use accredited doctors, clinics and hospitals included in the list of provider network

•  Members can only access all accredited and affiliated hospitals and clinics included in the list of provider network,
•  In emergency cases, coverage shall be on a reimbursement basis, subject to claims evaluation and approval
•  Reimbursable amount shall be based on the HMO rates and subject to the limits of the plan

•  HC&D Healthcare (HC&D) plan is for Philippine coverage only
•  For emergency cases abroad, HC&D shall reimburse the covered expenses up to the P15,000.00 emergency benefit coverage, subject to claims evaluation and approval