Limitations of the Plan

The charges incurred by the Insured in case of confinement due to Pneumonia are payable subject to the following conditions and to the maximum benefit amount as stated in the Policy Specification Page:

• Only availment due to community-acquired pneumonia (CAP) will be covered. Hospital-acquired pneumonia, i.e. infection acquired in hospitals or long-term facilities, will not be covered under this Policy.
• Moderate-risk CAP and high-risk CAP are the only types of pneumonia that will be covered. Moderate-risk CAP are usually characterized by unstable vital signs, altered mental state of acute onset, suspected aspiration, decompensated co-morbid condition and chest x-rat (Multilobal infiltrates, pleural effusion or abscess)
• Meanwhile, high-risk CAP patients are characterized by all symptoms of moderate-risk CAP and severe sepsis and septic shock. Patients with low-risk are not part of this benefit.
• Availment of hospitalization reimbursement for the Pneumonia benefit has a waiting period of thirty (30) days from the effective date of this Policy or the Insured’s coverage, whichever is later. There will be no coverage during the 30-day waiting period.
• Confinement should be recommended by a qualified physician in the Hospital for a continuous period of at least eighteen (18) hours;
• Only Eligible Expenses that are necessary and reasonable determined by the Company shall be covered. This includes customary Physician’s fees, hospitalization fees, medical supplies and medications incurred in the treatment of the Pneumonia ailment while confined;
• The medical benefits of this Policy is ‘on top of PhilHealth’. As such, completely filled out PhilHealth Form should always be filed within appropriate time during confinement to the appropriate section/person in the hospital. Failure to submit fully accomplished PhilHealth Form to the appropriate section/person in the hospital within the appropriate time prior to discharge does not constitute the Company’s assumption on the coverage of the amount that PhilHealth would have shouldered. Any amount PhilHealth would have covered will be shouldered by the Insured.
• Complications that may arise during hospital confinement is not covered.
• Take-home medicines are not covered under this benefit.