Page is best viewed in 1920 x 1080 resolution | 125% scaling
ACCIDENT. A visible, external, sudden and violent event occasioned by a physical or natural cause and occurring entirely beyond the Member's control causing damage to the health of the Member.
ANESTHESIOLOGIST. A specialist duly licensed and registered to administer anesthetic agents and conduct other anesthesia procedures during medical operation.
ANNUAL BENEFIT LIMIT (ABL). The maximum liability that Intellicare shall assume for all covered services rendered to a Member within the one-year term of this Agreement. ABL is replenished upon renewal of this Agreement but not during extension.
ATTENDING DOCTOR. An Accredited/affiliated Doctor who is part of the medical staff of an Accredited Hospital or Clinic, and legally responsible for the care given to a Member while in the hospital or on out-patient basis.
AUTHORIZED REPRESENTATIVE. A person duly authorized by Intellicare to approve the provision of medical services or claims reimbursements to a Member.
CO-INSURANCE. Other insurance or benefits which are paid or are payable in respect of any claims hereunder.
CONFORME LETTER. Intellicare’s offer letter accepted by the Client by affixing his signature on the space labeled as “Conforme”.
DEVELOPMENTAL, CONGENITAL CONDITION, BIRTH DEFECT. A physical or mental abnormality or illness existing at the time of birth as well as neonatal physical or mental abnormalities developing thereafter because of causal factors or conditions present at the time of birth.
10. CONTRIBUTORY/VOLUNTARY MEMBER. A Member whose Membership Fee is fully or partially paid for by the Member.
11. COORDINATOR. The first contact doctor for primary consultation. This includes Assistant Coordinators.
12. COSMETIC SURGERY. Reconstruction surgery or surgery which is not medically necessary or which is performed with the principal objective of improving the appearance of a person or which the person concerned considers or believes will improve his appearance and includes any surgery necessary for psychological reasons, adaptation and personal satisfaction in respect of an illness or accident hereunder.
13. CUSTODIAL CARE. Care provided mainly: (i) For personal needs, comfort or convenience by persons with or without specialized medical training or skills; (ii) To maintain personal needs, rather than improve the medical condition of a person as a prophylaxis precaution for a physical or mental function or to provide a protected environment.
14. DOMICILIARY CARE. Care provided because care in the patient’s home is not available or is unsuitable.
15. DURABLE MEDICAL EQUIPMENT. As determined by the Intellicare, medically prescribed items of medical equipment for repeated use, owned or rented, such as but not limited to crutches and wheelchairs which are placed in the home of a Member to facilitate treatment and/or rehabilitation of Illness or Injury.
16. DREADED DISEASES. Generally “chronic and irreversible” conditions requiring frequent and/or prolonged hospitalization, including those requiring continuous confinement for fifteen (15) days or more.
17. EFFECTIVE DATE. 12:01 a.m. on the date this Agreement takes effect.
18. ELECTIVE CASE. A non-emergency case that needs no urgent treatment and may be deferred without endangering the member’s life.
19. ELIGIBLE EXPENSES. Expenses incurred in the treatment of a covered Illness or Injury which are Medically Necessary and not exceeding the limits in Schedule A - Benefit Coverage.
20. EMERGENCY CASE/ CONDITION. A condition that manifests itself by acute signs or symptoms of sufficient severity that a trained medical professional could reasonably expect that the member’s life or health would be put at serious risk if no immediate attention is provided.
21. EXPIRY DATE. The date the Agreement is scheduled to terminate which is one (1) year from the Effective Date. At
12:00 midnight on the date of termination of this Agreement.
22. GRACE PERIOD. A period or the number of calendar days from the date of receipt of billing. For membership fees the minimum is up to thirty (30) calendar days, for all other fees, it depends on the agreement between client and Intellicare.
23. ID/ MEMBERSHIP CARD. The identification card issued by Intellicare to a Member containing the latter's name,
account number, and other matters pertaining to his Membership.
24. ILLNESS/DISABLITY. All injuries arising from the same event or series of continuous events are considered as one
Illness/Disability.
a) A sickness (a condition or an ailment affecting the general soundness and health of a member’s body) or;
b) A disease (affliction of body organs) having a defined and recognizable pattern or symptoms or;
c) A pathological condition leading to the impairment of normal physiological function and requires medical treatment.
25. IN-PATIENT. Continuous confinement in a hospital for at least six (6) hours (except in an emergency case).
26. INCREMENTAL COST. The amount charge to members who voluntarily upgrade a room higher than their allowed plan.
27. INJURY. Physical damage or trauma arising wholly and exclusively from an Accident or other events of violent or external, and visible nature.
28. INTELLICARE ACCREDITED CLINIC. A healthcare facility which Intellicare has an existing and valid service agreement where a member may avail of out-patient consultations and diagnostic services, duly licensed by the Department of Health and offering diagnostic, laboratory, preventive care and out-patient services, diagnosis, treatment and care of individuals suffering from illness, disease, injury or deformity or in need of obstetrical or other surgical,
medical and nursing care.
29. INTELLICARE ACCREDITED/AFFILIATED DOCTORS. A duly licensed doctor or specialist affiliated by Intellicare and named in the list of Intellicare's accredited/affiliated doctor with whom Intellicare has made arrangements to provide the required services under this Agreement.
30. INTELLICARE ACCREDITED HOSPITAL. A duly licensed health care institution with which Intellicare has an existing and valid service agreement providing patient treatment with specialized staff and equipment, where a member may avail of benefits. The best-known type of hospital is the general hospital, which has an emergency department; and as per Department of Health (DOH) administrative order 147, 2004.
31. OUT-PATIENT. This refers to the services offered on an out-patient basis (e.g. check-up, procedures that does not require confinement in a hospital). A patient not hospitalized, who is being treated in a Clinic, or other ambulatory care facility.
32. MATERIAL INFORMATION. An information is deemed material if its disclosure would have resulted in the
(a) declination of the application for Membership of the applicant,
(b) the assessment of a higher Membership Fee or
(c) the inclusion of additional restrictions and exclusions to the benefits of the Member under this Agreement.
33. MAXIMUM BENEFIT LIMIT (MBL). The maximum liability that Intellicare shall cover and assume per covered Illness or Injury of a Member within the term of this Agreement. MBL is replenished upon renewal of the Agreement by Client but not during any extension thereof.
34. MEDICALLY NECESSARY. A medical service, as determined by Intellicare, which is (a) consistent with the diagnosis and customary medical treatment of the condition, (b) in accordance with the standards of managed care and good medical practice, (c) not for the convenience of the Member or the accredited/affiliated doctor, (d) performed in the most cost effective manner required by the medical condition and (e) consistent with the terms and conditions of this Agreement.
35. MEMBER. A Principal and/or Dependent who is eligible, has been accepted for Membership by Intellicare after complying with the Eligibility provision, and is currently enrolled under this Agreement.
36. MEMBERSHIP. Refers to membership in Intellicare, pursuant to this Agreement.
37. MEDICINES AND DRUGS. Those for which a licensed medical practitioner has prescribed for dispensing, which are specifically required for the treatment of a covered Illness or Injury under this Agreement.
38. NON-CONTRIBUTORY/VOLUNTARY MEMBER. A Member whose Membership Fee is fully paid for by the Client.
39. MEMBERSHIP LIST. The initial listing provided by the Client, detailing who is to be enrolled.
40. OUT-PATIENT MEDICINES. Take-home medicines, drugs, and medical supplies prescribed to, administered to, and/or consumed by members as the result of outpatient consultations. Examples are antibiotics, analgesics, antitussive, plaster casts.
41. SURGEON, SPECIALIST, OR DOCTOR: A person qualified by degree and duly licensed or registered to practice medicine in the geographical area in which he serves. This person must not be a relative of the Member up to the third degree of consanguinity and affinity.
42. PRE-EXISTING CONDITION (PEC). Any illness or condition where:
a) Any professional advice or treatment has been obtained; OR
b) Such illness was evident upon examination; OR
c) The natural history can be clinically determined to have started prior to any availment whether or not the member is aware of such.
43. PRIVATE NURSE. A licensed nurse providing close observation and performing special treatments, which are certified as Medically Necessary by the Attending Doctor.
44. PROFESSIONAL FEES. As distinct from Surgeon and Anesthesiologist's Fees, fees paid to licensed medical professionals including but not limited to an Occupational Therapist, Physiotherapist, Attending Doctor's visits or Pathologists.
45. PREVENTIVE CARE. Nursing or medical care that focuses on the prevention of disease and health maintenance and includes early diagnosis of disease, discovery and identification of people at risk of developing specific problems, counseling, and other intervention to avert a health problem. Annual Physical Examination (APE) and health education programs are common examples of Preventive Care.
46. REFERRAL CONTROL SHEET (RCS). A form issued by Intellicare which facilitates availment of services.
47. RELATIVE VALUE SCALE (RVS). Schedules of charges as agreed between the Association of Health Maintenance Organizations in the Philippines and various recognized Medical Societies.
48. ROOM AND BOARD ACCOMMODATION. The pre-assigned type of hospital room and board by Intellicare to the Member based on the benefit and coverage of the health care plan under this Agreement.
49. STATEMENT OF ACCOUNT (SOA). The statement of account duly issued by Intellicare on or before the due date of payment reflecting Membership Fees and other monetary obligations, if any, payable by Client.
50. SURGERY. The branch of medicine dealing with manual or operative procedures for the correction of deformities and defects, repair of injuries, diagnosis and cure of certain diseases. This includes surgery performed in an out-patient setting for a covered Illness or Injury