‘Suite 1210 B Ermita Center Build CareHealth Plus coe ne SORT pur Systems International, Inc. (0977 804 2137 (Globe) / 0925 652 1927 Sun) My choice. In health care and more.. [Link] a : [Link] ValuePlus Program Your affordable choice ' Enrollment Application hereby apply for enrollment in the Health Care Program of CareHealth Plus Systems International, Inc. (CAREHEALTH PLUS) specified herein in accordance with the Contract Provisions contained in this Application. | agree that this Application and my declarations and answers herein, writen by me or under my direction shal be te basis and considered part of the Contract between CAREHEALTH PLUS and mysel ‘CARDHOLDER’S INFORMATION eee ee [ee RP Oe EER] EE BRE VETERE ae RTE Marie Tae ba ws OER BOTT ge —— Baar Tasca Sas [Wem | re Fete al —D ge widow Fer [ote Cinsrabie | wan Phieann Sots: Eworried a DFlipno Ch others Noninswale_| Dhow Pitestn [occupation (pease iaicate postion ie Employer (Company name / Address) LAN DATA pairs ae ir Pe Tne Pian Name: "No of Units: yr Mx. 1" yt Max, Daily per liness: iRoom Rate: contract Price: Ti Spot Cash [Discount ‘Mode of ChAnnual Oh Quarteriy | No. of Ins- Installment Devel Payment: Semi Annual OMonthiy’ | tallments: Amount: Fest Payment: [TA No.: Ta Date: TR Amount: OR No. [OR Date: (OR Amount: a POD Lose Nome, Fst Name, Midale Nome): eneheany Last Name, Frat Name, Wide Name ave of Br ‘elation to CordHolder enetidany (LastName, Fest Nome, Middle Wome Dare of eh ‘elation to Cavdroaer ‘This Health Care Program Enrollment Application, with the information and data supplied above and the medical declaration and representation given on the succeeding page shall be the basis of the Contract between CAREHEALTH PLUS and myselt | agree that no binding agreement is created by the mere signing of this enrollment application until it is accepted and approved by CAREHEALTH PLUS and until the Health Care Program oe containing the Contract Provisions signed by the duly authorized officials of CAREHEALTH PLUS is radon 2x2" issued. Latest 10. picture Signature of Applicant /CardHolder ‘Signature of Parent/Guardian (Signature ove printed name) {Applicants below eighteen (18) years old) Signature of Sales Counselor / Witness over printed name 2 a a Reviewed by ‘aes ery MaragersCoe [Saks Gp Nanage’sCade | Ses Conse Cale ‘Sirature should no nerd outs he box VP 1141102 | signature over printed Name [ate —MEDICAL DECLARATIONS AND REPRESENTATIONS Please answer al of the following questions with YES or NO. Please Check: 1, Are youcurrently confined in a hospital orreceivinghome health care? Yes ___No 2. Have you had diagnostic testing performed or recommended by a member of the ‘medical profession in the last Twelve (12) months for an unidentified condition? ——Yes ___No 3. Inthe past Twelve 12) months have you used nicotine in any form? Yes No 4, In the past Five (5) years have you been treated for alcohol or substance abuse or advised to reduce consumption of alcohol bya member of the medical profession? Yes ___No In the past Five (5) years, have you been diagnosed or treated by a member of the medical profession for: 5. Dementia, schizophrenia, attempted suicide or have been hospitalized or missed more ‘than One (1) week of workas a result of anxiety, depression or bipolar disorder? Yes ___No 6. Acquired immune Deficiency Syndrome (AIDS), Cirrhosis, Hepatitis C, stroke, brain tumor, leukemia, or cancer? (in case of cancer, answer NO if you only have basal or squamous cell cancer) Yes No 7. Central Nervous Disorder, Amyotrophic Lateral Sclerosis (ALS), lupus, chronic kidney disease, respiratory disorder, heart or circulatory disorder? (Answer NO if you only have asthma orhigh blood pressure). : ——Yes ___No 8, Diabetes or elevated blood sugar? If YES, were you diagnosed with diabetes more than Fifteen (15) years ago or have you had any complications relating to diabetes, such as. ketoacidosis, neuropathy, or nephropathy in the last Five (5) years? Yes No 9, Have you ever applied for or received payment for sickness orinjury? ——Yes __No 10-Have you been rejected for life orhealth insurance or accepted at higher premiumrates? _Yes No Will this Agreement, ifissued, replace any life or health insurance nowin force? ie No (IFES, please list name of company andthe Agreement number tobe replaced). i 11,.Doyouhave a personal history of any ofthe f. (YES, please underline) ‘a. Arthritis /Rheumatism g. Tumor ofinternal organ b. Bone disease / Osteoporosis h. Goiter / Hyperthyroidism / Hypothyroidism . Cataract/ Glaucoma High cholesterol / Dyslipidemia 4d. Congenital heart disease /MVP J. Organtransplant. . Congenitaliliness /Down’ssyndrome/Autism — . Physical deformity ordisability f. Craniotomy/VP shunt 7 |. Psychiatricdisorder / Psychosis | declare that the answers given above are full, complete and true and if found otherwise, | understand that the Health Care ‘Agreement may be invalidated. | hereby authorize any entity or person having knowledge of my health to provide to CAREHEALTH PLUSany information concerning any hospitalization, medical treatment or consultation that | may have undergone. Lurther apply for Insurance as described in the Health Care Program and | agree that said insurance coverage shall be based on the truth of the foregoing representations and medical declarations in accordance with the provisions of the Group Master insurance Policy. INWITNESS HEREOF, Ihave signed this Application on, in. Signature of Applicant / CardHoider Signature of Parent / Guardian (Signature over printed name) (if Applicant is below eighteen (18) years old) Signature over printed name of Sales Counselor / Witness Poge2 of vous PrearomCONTRACT PROVISIONS Art. |. AGREEMENT This Agreement entered into by and between You the Cardholder and CareHealth Plus, your Enrollment Application and all properly authenticated annexes, riders or amendments related hereto comprise the complete Contract between You and Us. Any promise or statement made by any person or agent that is not contained in this Agreement will not be binding or valid 8 ‘The Contract between You and CareHealth Plus shall take effect on the issue date stated herein upon our acceptance of your Enrollment Application and upon issuance of the Proof of Coverage duly sealed and signed by our authorized official, In this Agreement, "We", "Us", "Our" and "CareHealth Plus” shall refer to CAREHEALTH PLUS SYSTEMS INTERNATIONAL, INC. "You" and "Your" shall refer to You the CARDHOLDER named herein and covered under this Agreement. Art. Il. GUARANTEE AND CONSIDERATION In consideration for your payment of the Contract Price and other applicable charges and subject to the terms and conditions specified in this Agreement, we guarantee to provide to You the health care benefits and other services described below at our accredited hospital, clinic or laboratory to be administered by our accredited doctor, specialist or dentist upon the authorization and under the direction of our Medical Director or his authorized representative. Art. l, HEALTH CARE BENEFITS Your health care benefits are classified into Inpatient Services and Special Procedures which shall be made available up to the Medical 8enefit Maximum stipulated herein and Outpatient Privileges which are not deductible from the Medical Benefit Maximum. f 41. Inpatient Services and Special Procedures IF You suffer an illness or injury, CareHealth Plus shall provide or pay for the actual cost of the following health services f medically necessary: a. Hospitalization Benefits 1) Room and board 2) Professional services of an accredited doctor or specialist 3) Laboratory tests, x-rays, and other prescribed diagnostic or therapeutic procedures 4) Dressing, plaster cast and other medical supplies 5) Prescribed drugs and medication used in the hospital 66) Use of medical or surgical facilities and equipment, operating and recovery room, intensive care unit, dialysisand chemotherapy equipment 7) Administration of anesthesia or oxygen 8) Transfusion of hospital-provided whole blood or plasma b. Special Procedures If medically necessary, CareHealth Plus shall provide or pay for the following special procedures, including hospital confinement ifrequired: 41) X-ray 2) Ultrasound 3) Basicmammography 4) Treadmilltest and / or 20 Echocardiography 5) CT (computed tomography) scan 6) MRI (magnetic resonance imaging) 7) Nuclearttest 8) Chemotherapy or Radiotherapy 9) Hemodialysis" 10) Cataract extraction 11) Other special diagnostic or therapeutic procedures that we deem appropriate. Page 30f 8, YalePa rogram Sinan or ii of Crahoerc. Emergency Care Inthe eventofan emergency, defined asa medical condition when Youare in severe pain or imminent danger of death or disability caused by an accidental injury or due to an unexpected onset of an illness, You may secure any medically necessary services right away and You shall be entitled to the following: 1) We shall provide or pay for the actual charges for health services classified under Hospitalization Benefits and Special Procedures above, if emergency care is secured at our accredited hospital or clinic. 2) IFemergency care is secured at a non-accredited hospital or clinic, we shall refund Eighty percent (80%) of the documented actual charges for said health services based on our standard rates. 3) If necessary, transportation or ambulance service from a non-accredited hospital to an accredited hospital shall be refunded provided that the transfer is authorized by our accredited doctor and cleared by your attending doctor. 4) It is important that You notify us within Forty-eight (48) hours from the start of the emergency medical condition either directly or through your representative or else we shall not be liable for any emergency care or service. ‘The charges for health services under Hospitalization Benefits, Special Procedures and Emergency Care described above shall be accumulated and should be kept within the Health Care Benefit Maximum prescribed in Art. IV hereunder. 2. Outpatient Privileges a. Outpatient Services 1) Upto Fifteen (15) medical consultations peryear 2) Upto Twelve (12) pre or post natal consultations per pregnancy 3) Treatment of minorilinesses orinjuries 4) Minor surgeries, ie. those not requiring hospital facilities 5) Eye, ear, noseand throat treatment . Annual Physical Examination (APE) after atleast Three (3) months from the issue date, to include: 1) Takingof medicalhistory 2) Medical examination 3) Chest x-ray (posterior or anterior) 44) CBC (complete blood count) 5) Stoolandurine examination 6) Uricacidtest 7) FBS (fasting blood sugar) 8) ECG (electrocardiogram) for Thirty 30) years old and above 9) Pap smear for Thirty (30) years old and above . Preventive Health Care 1) Periodic monitoring of health problems ; 2) Consultation on exercise, diet and otherhealthful habits 3) Counseling on family planning. 4) Vaccination but excluding cost of drugs or vaccine 5) Attendance at company-sponsored health seminars d. Dental Care 1) Upto Six(6} consultations per year 2) Semi-annualoral prophylaxis after at least Three (3) months from the issue date 3) Tooth extraction but excluding surgery 4) Temporary filling or recementation 5) Treatment of orallesions, wounds and burns. Page $f 8, VoePu rrom Spare or i of Crae. Other Services 1) Twenty-four (24) hour assistance by phone 2) Discounts on non-covered health services at selected clinics, laboratories, drug stores or optical shops 3) Up to Six (6) medical or dental consultations per year for One (1) pre-designated dependent qualified as such under the SSS Law (RA8282) Art. IV, HEALTH CARE BENEFIT MAXIMUMS ‘ 1. Medical Benefit Maximum During the paying period of two (2) years and the paid up period of one (1) year, the Medical Benefit Maximum shall be provided by CareHealth Plus forall health services utilized by You that are included under Hospitalization Benefits, Special Procedures and Emergency Care and shalll be made available for every unrelated illness or injury suffered by You within each year inclusive of the corresponding maximum daily room rate. The Medical Benefit Maximum will depend on the number of units that You purchase and shall be determined in accordance with the following schedule: ‘3-Year Coverage Year Maximum Maximum per Iliness Daily (Paying per year Room Rate Period) per Unit per Unit 1 5,000.00 100.00 2 6,000.00 140.00 (Paid up) 3 7,000.00 180.00 Should the actual charges exceed the Medical Benefit Maximum, CareHealth Plus shall not shoulder or advance ‘the excess. Similarly, ifthe room that You occupy has a rate or classification higher than the maximum specified above, we shall not answer forthe difference. It shall be your obligation to settle all excess charges before You are discharged, including any incremental charges for other health services that may result due to the higher room classification, Art. [Link] PROCEDURES : 1, You will be allowed to choose your health service provider, namely: the doctor, specialist, dentist, hospital, medical / dental clinic or laboratory from among those accredited by CareHealth Plus. However, You must first secure a Prior Authorization Number (PAN) from us before any consultation, treatment or confinement except ‘when Youare in an emergency condition. 2. Wewill pay directly the health service provider after receiving the statement of account. We will also give arefund if proof of an earlier payment by You is submitted within Thirty (30) days from the date of payment together with the necessary supporting documentation. 3. We shall not be liable for any health services after your discharge has been authorized or if You refuse to followthe recommended treatment or procedure or after itis established that no professionally accepted treatment still exists. 4, Benefits that are coverable by PhilHealth or ECC shall be deductible in determining the health benefits covered under this Agreement. We shall have no obligation to pay or advance said PhilHealth or ECC benefits and it shall be your responsibilty to answer for said health services. 5. CareHealth Plus shall be subrogated to the rights and claims that You may have against any third party who may be liable for any health servicesrendered under this contract. Page $f 8 YlePus rogram Sonar or of Crater —Art. VI. PRE-EXISTING ILLNESS OR INJURY An illness or injury is considered pre-existing if, before the issue date of this Contract, it has been diagnosed as such or it has manifested certain signs and symptoms. Non-disclosure of a pre-existing condition shall be a ground for us to declare this Contract null and void from the beginning, forfeit as liquidated damages whatever payments You may have made or seek refund of the cost of health services or qther expenses we may have incurred, Nevertheless, we may decide to accept for enrollment an applicant with a pre-existing illness or injury but we have the Tight to enforce any of the following options: 1. Provide Inpatient Services and Special Procedures for said pre-existing condition only on the second year of enrollmentor only on the third year of enrollment ifitwould require a major surgery. 2. Impose a Waiver of Coverage for said pre-existing condition until the end of the paying period of Two(2) years. Art. VII. EXCLUSIONS FROM COVERAGE ‘We shalll not be liable for health services that may be needed under the followingsituations: 1, Injury or illness that is induced or self inflicted or if arising out of attempted suicide or in connection with your commission of acrime or violation of law or due to unnecessary hazardous activities. 2, Medical services not related to the treatmentoof anillness or injury, employment and medico legal fees. \cluding physical examination for insurance or 3. Treatment of a drug or alcohol related dependency. 4. Cosmetic treatment or surgery and other forms of surgery for beautification; procurement of eyeglasses, braces, hearing aids, prosthetic appliances or the lke. 5. Home or rehabilitation services, recuperative care, and take-home medicine or medical supplies. 6. Pregnancy related medical care, childbirth, miscarriage or abortion; sex transformation, artificial insemination, treatment of infertility or sexsterilization, 7. AIDS, AIDS related and sexually transmitted diseases. 8. Counseling, psychotherapy, and treatment of psychiatric or mental disorders or psychosomatic illnesses. 9. Open heart surgery, percutaneous transcoronary angioplasty, pacemaker insertion, complicated hypertension, organ transplant or hyperalimentation. 10. New modalities of diagnostic or therapeutic procedures unless deemed appropriate by, and upon prior approval of, CareHealth Plus. - ‘Art. Vill. INSURANCE BENEFITS We shall insure You under a Group Master Insurance Policy underwritten by a reputable and duly authorized insurance company provided that, at the time of signing the Enrollment Application, You are in good health and at least Seven (7) but ‘not more than Sixty-five (65) years old, as follows: 1. Term Life Insurance - If You pass away before your 75th birthday, your Beneficiary shall be paid Two Hundred percent (200%) of the number of units purchased by the CardHolder, which is Ten Thousand Pesos (P10,000) per unit, upon approval of the claim by the insurance company. 2, Accidental Death Insurance - If You pass away before your 70th birthday, as a result of an injury sustained in an accident and death happens within One hundred eighty (180) days after sustaining said injury, your Beneficiary shall be paid an additional Two Hundred percent (200%) of the number of units purchased by the CardHolder, whichis Ten Thousand Pesos(P10,000} perunit, upon approval ofthe claim by the insurance company. pone 60f8 VovePsPoaram3. Waiver of installments due to Disability - If You become totally disabled during the paying period and before your, 65th birthday, and such disability continues for at least Six (6) months, we shall not collect the installments becoming due during the period of your disability. You are deemed totally disabled when, as a result ofan illness or injury, You are totally prevented from engagingin a gainful occupation. We may also require submission of proof of continued disability. Complete loss of sight in both eyes and|oss of both limbs shall be considered total disability, « Claims for any of the above insurance benefits shall be contestable as provided for by law but for a reduced period of One (2) year from the date of issue or reinstatement of this Contract. ‘Art. IX, MEMORIAL SERVICE BENEFIT Inthe event of your untimely demise, your Beneficiary shall be entitled to secure the services of CareHealth Plus in making arrangements for your dignified memorial service and for this purpose to utilize the anticipated proceeds, or a portion thereof but not less than Fifty percent (50%), from the Term Life Insurance benefit stated in Art Vill, No. L above. Itshall be ‘the prerogative of your Beneficiary to select the memorial service provider from among those accredited by CareHealth Plus and to decide on the specific service package including its cost. Art. X. TRUST FUND GUARANTEE CareHealth Plus shall maintain trust accounts with reputable and duly authorized banks and deposit therein such funds as would be needed to comply with, and for the exclusive purpose of discharging its obligations under this Contract. Art. XI. CONTRACT PRICE, LAPSATION, REINSTATEMENT AND CANCELLATION 1, You commit to pay the Contract Price and other applicable fees over a period of Two (2) years following the selectedmode of payment on or before the specified due date without need of notice or reminder. Payments should be made to CareHealth Plus a any of its offices or through its authorized representative and wil be binding onlyif covered by its offical receipt. 2. This Contract shall lapse if no payment is made on the due date. However You will be granted a grace period of One (2) month to pay the due installment. Benefits may be provided during the grace period, but only after thedue installmentis aid. 3. Ino payment is made after the end of the grace period, this Contract shall be terminated and shall be without any force or effect, You will have no more rights and privileges except the right to reinstate, subject to the usual requirements for anew applicant for enrollment in effectat that time, 4, Youmay til reinstate this Contract within Two (2) years from the first unpaid due date. fno reinstatementis made within that time, we will unilaterally cancel this contract without need of notice to You and forfeit as liquidated damages all payments that You may have made. ‘i 5. This Contract maybe reinstated upon your request and after complying with te following requirements: a. Filing of an Application for Reinstatement, surrender of the lapsed Agreement and payment of the reinstatement fee. . Payment of all unpaid installments plus surcharge of One (1) percent per month from the due date of each Unpaid installment. f reinstatement by re-dating is chosen, payment of One (1) installment, subject to the ‘then prevailing rates and other conditions being by enforced by CareHealth Plus. Once your request for reinstatement is approved, You will be considered a new CardHolder particularly in regard to the provisions on Pre-Existing lliness or injury (Art. VI) and contestability of insurance coverage (Art. Vill) Art. XIl, TRANSFER AND TERMINATION 1, While this Agreement isn effect, You may transfer your rights herein at any time upon submission of your written request, surrender of this Agreement, submission of an Enrollment Application accomplished by the Transferee and payment of the processing fee. However, the Transferee shall be considered a new CardHolder subject to our acceptance. If accepted, the Transferee shall be bound by the provisions on Pre-existing lliness or Injury (Art. VI) and contestabilty ofinsurance coverage (Art. Vill). one 7018, vluesus Pesan “Sitar arnt of Croer2. You may also terminate this Contract at any time while the same is in force and You shall be entitled to termination benefits, asfollow: a. Ifthis Contract is terminated during the paying period, PaymentsonContractPrice(PoCP) Termination Benefit . Less than 50% PoCP None 50% but less than 100% PocP 110% of the Payments on Contract Price b. Ifthis Contractis terminated after fullayment ‘Year after Full Payment Termination Benefit 1stYear 20%of the Payments on Contract Price . IF You pass away at anytime while this Agreement is in force, this Agreement shall be terminated and your Beneficiary shall be entitled to the corresponding termination benefits in accordance with a and b. Art. Xill. UNFORESEEN EVENTS 41, We shall not be liable for any loss, damage or other adverse condition that You may endure due to fire, earthquake, war or civil disturbance, extraordinary economic upheaval, strikes or labor disputes, acts of God, government legislation or regulation or other event beyond our control, in connection with the discharge of our obligations under this Agreement. 2, Both You and CareHealth Plus expressly waive the applicability to this Agreement of Art. 1250 of the Civil Code of ‘the Philippines (RA 386), which provides: "In case an extraordinary inflation or deflation of the currency should supervene, the value of the currency at the time of the establishment of the obligation shall be the basis of payment. ..” 3, Should a new tax or fee be imposed by law or ordinance in the future affecting this Contract, the Contract Price, or the charges to the health care services and other benefits guaranteed herein, You shall be liable for the same, ‘Art. XIV, ARBITRATION CLAUSE Pursuant to Executive Order 192 all questions or complaints against a Health Maintenance Organization (HMO) shall first be referred to the Association of Health Maintenance Organization of the Philippines (AHMOPI) for submission to the grievance machinery established for the purpose, provided that the HMO complained against is a member of the Association. Complaints against non-member HMOs shall be directed to the Insurance Commission, In the first instance, the Insurance Commission shall assume jurisdiction over a case only upon certification by the Association that no settlement has been reached within Thirty (30) days after the same has been submitted to the grievances machinery, The Insurance Commission shall settle all questions or complaints within Sixty (60) days from receipt thereof ‘Art. XV. VENUE AND PRESCRIPTION Notwithstanding the above, the venue for any legal action that may be filed with respect to this Agreement shall be exclusively in the City of Manila, Philippines. No such legal action shall be filed beyond the period of Five (5) years from the time the cause of such action shall have arisen. Page Bf, vastus rogram Snare rio Cray