FAQS

  1. What is an Emergency Condition? An Emergency Condition is an accidental injury, a life threatening or a sudden and unexpected onset of a condition in which reasonably appears to have the potential of causing immediate disability or death, or which requires the immediate alleviation of pain and discomfort. Maxicare shall depend on the concurrence of the attending ER physician to determine whether a case is emergency in nature or not.
  2. What do you mean by Affiliated Hospital? A hospital with which Maxicare has an existing and valid accreditation contract where a Member can seek medical services. It shall also mean any of the hospitals named in such list as Maxicare may from time to time prepare and distribute to Members, and with which Maxicare’s Medical Coordinator has made arrangements for the provision of medical services to Members pursuant to this agreement.
  3. What do you mean by Affiliated Medical Clinic? Such duly licensed out-patient medical and healthcare facility as Maxicare may establish or designate for the purpose of providing out-patient care to Members. It shall also mean a private medical facility which is capable of providing medical, diagnostic and therapeutic facilities, and with which Maxicare has an existing service agreement.
  4. What do you mean by Affiliated Madical Staff? A group of medical practitioners and other allied health professionals who are affiliated with Maxicare and duly authorized to carry out the delivery of the required medical services to all Members.
  5. What do you mean Affiliated Physician or Specialist? A duly licensed physician or specialist affiliated with Maxicare and named in the list of Maxicare affiliated doctors with whom Maxicare has made arrangements to provide the required services under this Agreement.
  6. What is an Agreement? This Service Agreement executed by and between Maxicare and the client containing the effective date, benefits, coverage, claims and member satisfaction provisions, limitations and exclusion of benefits, mode of payment of membership fees, termination of coverage and other matters relevant to the relationship, betweent the Member and Maxicare. The application for Membership duly submitted by the accepted Member, and the Maxicare Membership Card, form part of the Service Agreement, together with any and all endorsements which may be incorporated thereto.
  7. What do you mean by Alternative Medicine? This is defined as therapeutic practices which are not currently considered an integral part of conventional allopathic medical practice. Alternative medicines include, but are not limited to the following disciplines: folk medicine, herbal medicine, diet fads, homeopathy, faith healing, new age healing, chiropractic, acupuncture, naturopathy, massage, and music therapy.
  8. What is Balance Billing? It is the act of some physicians and other health professionals duly affiliated by Maxicare to charge members for the difference between their desired higher professional fees and the agreed Maxicare standard professional fees for specific medical services.
  9. What do you mean by Confinement or Hospitalization? A person is said to be confined or hospitalized if he is admitted in a hospital as a registered bed patient for at least twelve (12) hours.
  10. What is Convalescent or Rehabilitation Care? The restoration of person’s ability to function as normally as possible after a disabling illness or injury.
  11. What is Custodial or Maintenance Care? Care furnished primarily to provide room and board (which may or may not include nursing care, training, personal hygiene, and other forms of self or supervisory care); or care furnished to a person who is physically or mentally disabled or both; and
    1. Who is not under any specific medical, surgical or psychiatric treatment to reduce the existing disability to the extent medically necessary to enable the patient to live outside an institution providing such care; or
    2. When despite such treatment, there is no reasonable possibility that the disability will be reduced or diminished.
  12. What is Domiciliary Care? Care provided in the patient’s home when in-patient care is not medically necessary
  13. What do you mean by Experimental Medical Procedure? Any device, medical treatment, supply or procedure whose safety and efficacy has not been established and proven is considered experimental/investigational (unproven) and is excluded from the coverage.
  14. What do you mean by In-Patient Medical Services The hospitalization which includes accommodations, medicines and supplies and surgery whenever medically necessary, furnished to a registered bed patient and provided by a duly licensed hospital and are regularly included in its service and procedures.
  15. What do you mean by Latest Modality? A medical procedure defined as:
    1. Available only to one or two tertiary medical care facilities;
    2. Requires the specialized skills from specialized personnel; and
    3. Is sanctioned and recognized as a significant medical update and part of the standard clinical practice guidelines by the corresponding clinical and academic society or association responsible for certifying practicing specialist physicians.
  16. What is the function of a Maxicare Medical Coordinator? A duly licensed physician medical practitioner as Maxicare may designate in an Affiliated Hospital to direct and supervise the provision of medical services to Members in that particular hospital with whom Member may also seek medical consultation, and from whom the Member may request for prescription, referrals to specialist, request for laboratory examination and hospitalization arrangement.
  17. What do you mean by Maximum Benefit Limit (MBL)? The maximum liability that Maxicare shall assume illness/injury per year on a certain Member, not including Annual Check-Ups (ACU) and consultations. In other words, the In-Patient Benefits (PF, HB, ER charges) and Outpatient Routine Diagnostic and Therapeutic procedures done within the one-year term of the Agreement with respect to any particular illness/injury shall be charged against the MBL. MBL is replenished upon renewal.
  18. What do you mean by Medically Necessary? A medical service which is
    1. consistent with the diagnosis and customary medical treatment of the condition,
    2. in accordance with the standards of good medical practice,
    3. not for the convenience of the Member of the Affiliated Physician, and
    4. performed in the least costly manner required by the medical condition.
  19. How do you define Member? Member shall mean an individual who
    1. applied to Maxicare for membership in its healthcare program,
    2. was accepted by Maxicare as member after complying with all the requirement of the membership,
    3. is entitled to the benefits of Membership as stated in this Agreement, and
    4. has not forfeited his status as such Member by termination, lapsation, non-payment premium, voluntary abandonment, exhaustion of benefits or some other cause.
  20. What is a Membership (ID) Card? The card issued by Maxicare to a Member containing the latter’s name and signature, ID reference number, and other matters relevant to Membership.
  21. How do you define Pre-Existing Condition? An illness or condition shall be considered pre existing if, prior to the effective date of the member’s health coverage (Membership Agreement) or prior to the approval date:
    1. any professional advice or treatment was given for such illness or condition;
    2. such illness or condition was in any way evident to the member or upon medical examination in connection with the member’s application; or
    3. the pathogenesis of such illness or condition has started whether or not the member is aware of such illness.

    The following conditions, among others, when occurring during the first year of coverage after the Effective Date, are considered Pre-existing: (a) hernias; (b) cancer or tumor or neoplasms; (c) endometriosis; (d) hemorrhoids; (e) ear-nose–throat conditions requiring surgery; (f)hyphothyroidism/hyperthyroidism/goiter; (g) cataracts and glaucoma; (h) epilepsy; (i) asthma; (j) cirrhosis of the liver; (k)tuberculosis; (l) anal fistulae; (m) cholecystitis/cholelelithiasis; (n)calculi of the urinary system; (o) gastric or duodenal ulcer; (p) hallux valgus; (q) diabetes mellitus; (r) hypertension; (s)collagen diseases (t) cardiovascular diseases.

  22. What do you mean by Reasonable Charges? Professional fees of Non- Affiliated physicians for services rendered to Maxicare Members which do not exceed the standardized professional fees/terms of the Maxicare Affiliated Physicians/Specialists where the services were rendered. Reasonable charges are usually determined by the lowest limit of the actual charge, the prevailing charge in the locality, the physicians customary charge, or the carrier’s usual payment for comparable services.
  23. What do you mean by Related Condition? A condition/disorder/disease entity is said to be related if it is associated with the particular diagnosis in question either as a direct symptom/sign, a risk factor, an underlying cause, a part of a syndrome, or a complication.
  24. What do you mean by Room and Board Accomodation? The type of hospital room and board pre – assigned by Maxicare to the Member based on the plan enrolled in.