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This is applicable to crew and dependents of Aboitiz Jebsen, TESMA Philippines, Alliance Marine, Van Oord , Kyokuto, Beltships and WG&A.
Seafarers – Coverage will start upon vacation up to 2 months only
Legal Spouse– Up to 65 years of age
Children – Legitimate, legitimated, legally adopted 30 days old but not more than 21 years old
Coverage will be based on the contract period of the crew
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Room & Board Semi Private
Maximum Benefit Limit 100, 000.00
I. Inpatient Benefit
a) Room & Board
b) Professional fees of accredited attending physicians, and other medical specialists;
c) Medicines used in the hospital, including anesthetics
d) Anesthesia and accredited anesthesiologists fee
e) General nursing services;
f) Dressings, (orthopedic) casts and other medical supplies;
g) Laboratory examinations and diagnostic procedures ordered by the attending physician;
h) Operating and recovery room fees;
i) Transfusion of blood and other blood elements
j) Emergency room expense
k) Confinement in the Intensive Care Unit or Isolation Room up to maximum of fifteen (15 days); and
l) Renal and peritoneal dialysis up to the maximum limit specified under the plan, inclusive of all other hospital expenses
m) All other hospital charges directly related to the medical management of the illness or injury for which the Member was confined
II. Outpatient Benefit
a. Unlimited medical consultations during regular clinic hours, including specialist evaluation
b. Treatment of minor injuries
c. X-ray, laboratory examinations and other diagnostic procedures prescribed by the Company’s accredited physician
d. Minor surgery not requiring hospital confinement
e. EENT and other specialists’ care
III. Dental Benefits
a. Oral Examination every six months;
b. Oral Prophylaxis once a year
c. Simple tooth extraction when indicated, excluding impaction;
d. Consultation and Treatment of simple diseases of the gums and its surrounding
tissues, excluding surgeries;
e. Emergency treatment which included the following:
· Incision of Drainage
· Open drainage
· Post-operative and surgical care
f. Consultations (treatment not included) to planmember’s minor children;
g. Advice on preventive dental care and health promotion
h. Temporary fillings
i. Permanent (amalgam) fillings up to two surfaces per plan year
j. Removal of sutures
k. Recementation of jacket crowns, fixed bridges, inlays or onlays
IV. Emergency Treatment in an Accredited Hospital
· Emergency room fees
· Professional fees of attending Physician
· Medicines used for immediate relief
· Oxygen an Intravenous fluids
· Dressings, Casts and Sutures
· Laboratory examinations, X-ray and other Diagnostic procedures
V.Emergency Treatment in a Non-Accredited hospital including outside the Philippines
Incurred expenses will be reimbursed to the planmember 80% of Cocolife standard rates, subject to the maximum benefit limit
VI. Annual Physical Examination For Dependents
· Taking of medical history
· Physical examination
· Chest xray
· Stool examination
· Urinalysis
· Complete Blood Count
· ECG and/or Pap Smear (for women) when indicate and prescribed by the Medical Consultant
VII. Preventive Health Care
· Immunization (but does not include cost of vaccine and determination of susceptibility)
· Consultation and advice on diet, exercise and other healthful habits
· Health education and wellness program
· Family Planning counselling
· Medical information dissemination through clinics, seminars, newsletters etc.
VIII. Death Benefit - 10,000 – principal / seafarer only
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1. Care by non accredited physician/s or in non accredited hospitals/clinic, except in cases of emergency wherein the emergency benefit provision will apply
2. All pregnancy related conditions requiring medical/ surgical care except those listed under the maternity benefit
3. Sterilization of either sex or reversal of such, artificial insemination, sex transformations or diagnosis and treatment for fertility/infertility, including tests for perimenopausal/menopausal syndrome
4. Rest cures, domiciliary or convalescent care; confinement purely for check up, rest and recuperation
5. Cosmetic surgery and oral surgery for purposes of beautification, cautery of verucca plana and other viral dermatological facial disorders, except constructive surgery to treat a dysfunctional defect due to disease or accidental injury
6. Alcoholism, drug addiction or abuse, nervous or mental disease or disorder, psychiatric disorders
7. All expenses of the donor in organ transplants
8. Sexually transmitted diseases
9. AIDS and AIDS related diseases
10. Congenital diseases, deformities and defects, inguinal and umbilical hernias and varicocele included
11. Executive check up or any check up and/or confinement which are purely for diagnostic purposes
12. Procurement or use of corrective appliances, artificial aids and durable equipment
13. Purchase, use or lease of durable equipment (medical or otherwise), oxygen dispensing unit and oxygen except during covered in patient cases and upon the recommendation of the attending accredited physician
14. Vaccines, immunizations when done for preventive purposes, except when used as treatment for a confirmed disease
15. Diseases or injuries which are self inflicted, whether the member is sane or insane; caused by suicide or an attempt at suicide or attributable to the members own misconduct, gross negligence, use of prohibited drugs or alcoholic liquor, vicious or immoral habits, participation in the commission of a crime, violation of law or ordinance and unnecessary exposure to imminent danger or hazards to health
16. Disease or injuries when care or reimbursement of expenses is provided by law or government program such as SSS Medicare, ECC, etc., up to the stipulated limits
17. Medical or surgical procedures which are experimental in nature or not generally accepted as standard medical treatment by the medical profession, including but not limited to: chelation therapy, iridology, cell implant therapy, acupuncture, reflexology, laser therapy for myopia and ultraviolet and other modes of radiation used for cosmetic or aesthetic purposes
18. Additional hospital/professional fee charges or incremental costs resulting from taking a room accommodation which is higher than that specified in the membership card; the additional personal comfort items such as telephone, television, admission kit and the like
19. Illnesses or injuries resulting from war, military/police/paramilitary service, rebellion and insurrection, riots, labor disputes and /or civil disturbances
20. Tests for allergies, hepatitis, mammography, pap smear and the like when done purely for screening purposes
21. Outpatient medicines or take home medicines, in case of hospital confinement
22. Services of a medico legal officer
23. Diagnostic work up / procedures and all other expenses related to the above conditions even prior to the final diagnosis are not payable
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A. Inpatient Benefit - Member may proceed to the coordinators office for treatment. Once advised to be confined, the coordinator will issue an admittance slip. Upon discharge, the patient will be asked to sign the document pertaining to the hospitalization and pay excess in cover. The Philhealth benefit requirements must be filed.
B. Outpatient Benefit – Member may proceed to the coordinators office for treatment. If required to undergo medical examination, the coordinator will issue a referral slip to be given to the laboratory department for verification. If referred to a specialist, the coordinator will issue a referral slip. If the specialist requires medical examination, the patient should go back to the coordinators office and secure a laboratory request slip.
C. Dental Benefits – Member may proceed to the nearest accredited dental clinic of The Filipino Doctors Health Alliance
D. Annual Physical Examination For Dependents – Since this should be scheduled with Cocolife accredited clinics, the member should coordinate with Ayala Aon or Cocolife on the preferred date of availment and the nearest accredited clinic.
E. Emergency Treatment in an Accredited Hospital – The member will pay first the expenses and reimburse from Ayala Aon the expenses paid. The following documents are arequired
· Official receipt of professional fee and hospital bills
· Hospital statement of account
· Attending physicians record/operative record
· Medical certificate
· Admitting history
· Charge slips
F. Death Benefit - this benefit covers the crew only while on vacation and in the Philippines up to 10,000 only. The proceeds will be paid to the nearest relatives upon submissin of the following
· Certified true copy and authenticated Marriage contract if married
· Certified true copy and authenticated certificate of live birth if single
· Police report if death is due to accident
· Post Mortem report
· Death certificate
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