Be careful. You thought that health cards provide total peace of mind and convenience. The truth is, there are limitations. Here’s a list of pre-existing condition rules per HMO insurance that I have found.
What Hmo Type Is Right For You?
Select one of the following options:
Why Worry?
A pre-existing condition is any health problem that is present before the activation of a member’s health plan account.
It includes any symptoms that were obvious even before the diagnosis. If you have been treated or are being treated by the time you apply for a health plan, the health problem will be considered pre-existing.
Many HMOs will NOT cover the full amount of expenses related to such conditions.
Here are some of the popular HMOs that offer coverage for existing health problems.
| Maxicare | – Is pre existing condition covered by Maxicare? Yes but with limitations – Plans cover 10% for dreaded and non-dreaded conditions in year 1 – Plans cover 100% for non-dreaded and 10% for dreaded in year 2 – Pre-existing condition coverage in Eready Advanced – Maxicare Prima Gold is a prepaid health card that covers pre-existing conditions Things we like: This HMO has one of the most extensive hospital networks in the country. I can easily find a nearby hospital accredited by Maxicare. Therefore, it is easy to avail your benefits. |
| Medicard | – Standard Plan, covers Php 5,000 for CT scan, ultrasound and MRI subject to pre-existing condition coverage – VIP Plan covers hypertension, goiter, cataracts, glaucoma, gastritis, tuberculosis, arthritis and more (limit of Php 5,000 to Php 20,000 depending on plan. – Medicard prepaid does not cover pre-existing conditions especially the ExER which is primarily for consultations Things we like: One thing I like about Medicard is the pricing. You will notice that they can offer even prepaid plans less than Php 7,000 for the whole year. If you already have an existing health problem, you can use it for consultations especially after a medical procedure. |
| Philcare | – Consultations for pre-existing conditions are covered Things we like: The strongest advantage of Philcare’s offers is price. You can find a health card for as low a Php 800. The terms are different per plan but I noticed that there is a coverage of up to Php 10,000 subject to confirmation. |
| Valucare | – Covers pre-existing condition after 12 months of membership – 50% of MBL on the 2nd year – 100% of MBL on ther 3rd year (75% for kidney and gall stones, dreaded disease not covered ) – 100% MBL on 4th and succeeding years Things we like: Although there exists a rule before you get covered, the HMO still offers help for pre-existing conditions. There is a gradual increase in coverage which covers your illness up to 100% of MBL as long as you are loyal to them. |
Video about Pre-Existing Condition
What conditions are not covered?
Dreaded diseases and conditions are the most common exclusions in any health card package. Here are some of the conditions NOT covered by most health cards.
- AIDS/HIV
- Arthritis
- Asthma
- Cardiovascular Diseases (heart attack, cardiac arrest)
- Chronic Kidney Disease (CKD stage 5 kidney disease)
- Depression
- Diabetes
- Epilepsy
- Hypertension
- High cholesterol
- High triglycerides
- Long term pains
- Mental health
- Neurological conditions
- Obesity related
- Pregnancy (maternity related)
- Psychological health problems
- Stroke
- Tuberculosis
No health card specifically covers an existing illness. However, special accounts or requirements may eventually lead to the coverage of a member. These are some of the example terms included in most plans.
- Prepaid Health Cards: Existing conditions are covered especially during Emergency Room services, confinement and consultations.
- Coverage of up to Php 5,000 or Php 20,000 only: Some diagnostic procedures like CT Scan, MRI, ultrasound and X-ray are covered up to a specific amount.
- Full coverage on the second year of membership: Health cards may cover the full expenses on the 2nd year of membership.
- Tiered coverage: Some HMOs will cover 50% on the second year and 100% on the third year subject to the maximum benefit limit.
Each of these cards may have a set of specific terms and conditions in your policy contract that are different from the posted details. However, you may maximize your plan by using your card for the usual covered services like consultations, annual physical exam, free lab tests (in their home clinics), dental services (if included) and discounts on lifestyle and wellness services.
Moreover, most of these HMO plans cover your emergency treatment expenses even including accident and death benefits in some accounts.
Are there any other options?
If you have the budget and would like to cover your current health problem, health insurance may provide more benefits. These plans may give you millions worth of coverage. While the premium rates are higher, you get to enjoy coverage for existing health concerns.
Moreover, dreaded diseases such as heart attack, stroke and cancer are covered by a full health insurance plan. Try to balance out your decision between choosing an HMO or a health insurance company by knowing your health risks first.
If you are aware of any health conditions that you have, it is best to declare them prior to the application of a health card. This way, you will be able to set your limitations when it comes to getting treatment and availing medical services.
References:
Bridging the healthcare gap with comprehensive and affordable medical access for Filipinos
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