DEFINITIONS

 

• 1. Hospital confinement means a continuous, medically necessary period of time, lasting at least twelve (12) hours, during which the Life Insured is confined in a hospital as an inpatient. The first day of confinement starts at the time of admission to the hospital and each subsequent day of confinement starts twenty-four (24) hours after the start of the previous day of confinement. The day of discharge is considered as a day of confinement if the time of discharge of the Life Insured from the hospital is more than twelve (12) hours from the later of the time of admission to hospital or the end of the previous day of confinement

 

• 2. Injury means bodily injury caused by accident, directly and independently of all other causes, and which is evidenced by a visible contusion on the exterior of the body except in the case of drowning or of internal injury revealed by an autopsy.

 

• 3. Illness means sickness or disease contracted and commencing more than thirty (30) days following the Policy Effectivity Date or the date of last reinstatement.

 

• 4. Confinement must be as an in-patient, medically necessary and at least for 12 hours.

 

• 5. Continuous confinement means that if two (2) or more Confinements are due to the same or related injury or illness, or to any complications arising therefrom, such Confinement shall be regarded as one (1) Confinement if each of them is not separated by more than six (6) months from the paid or payable Confinement which immediately precedes it.

 

• 6. Surgery is defined as a surgical procedure for a reasonable and medically necessary treatment of injury or illness, conducted by a licensed surgeon with or without an anesthesiologist, involving the use of operating room in a hospital.

 

• 7. Surgical Charges include the surgeon's fees, anesthesiologist's fees, operating room fees, and recovery room fees actually charged to the Life Insured for a Surgery performed in the Hospital.

 

• 8. Pre-Existing Condition shall refer to injury, illness or conditions which existed prior to the Policy Effectivity Date or date of last reinstatement of this Policy Contract and for which the Life Insured has been investigated, diagnosed or treated or when its signs or symptoms have manifested and would have caused an ordinary prudent person to seek diagnosis, care or treatment.

 

1.1    Exclusions

 

The complete list of exclusions is in the contract. Following is not an exhaustive list.

 

• 1. Pre-existing dread diseases are permanently excluded throughout entire term of HIPHEALTH GUARD
• 2. 30-day no cover from Policy Effectivity Date or the date of last reinstatement. for confinement due to disease [not injury]
• 3. Outpatient surgery and surgeries performed in a clinic are specifically not covered by this benefit
• 4. Pre-Existing conditions are excluded under Daily HIB, ICU, LTH, SEB unless Life Insured has been continuously covered for twelve (12) months from Effectivity Date or date of last reinstatement, and only for expenses incurred after such continuous cover.
• 5. Exclusions for DHI are also exclusions under ICU, LTH, SEB

 

6.    WHAT ARE THE CRITICAL ILLNESSES COVERED BY THIS PRODUCT?

 

•1.       HEART ATTACK

•2.       STROKE

•3.       CANCER

•4.       MAJOR ORGAN TRANSPLANT

•5.       RENAL FAILURE

•6.       MULTIPLE SCELORIS

•7.       MOTOR NEURONE DISEASE

•8.       HEART VALVE SURGERY

•9.       CORONARY ARTERY BYPASS SURGERY

•10.    PARKINSON'S DISEASE

•11.    MUSCULAR DYSTROPHY

•12.    POLIOMYELITIS

•13.    AORTAL SURGERY

•14.    BACTERIAL MENINGITIS

•15.    BRAIN TUMOR

 

7. Exclusions

Coverage of this rider excludes, and therefore, no payment will be made for any claim on account of or contributed by, either directly or indirectly, the following:

(a)  any Critical Illness existing at the effectivity date or date of approval of the last reinstatement of this rider, though it manifests itself only within 90 days from said effectivity date or date of approval of the last reinstatement;

(b)        pregnancy, childbirth, abortion, or miscarriage or complications thereof;

(c)  psychiatric disorders, drug or alcohol abuse;

(d)        injuries or illness due to military service or suffered under conditions of war whether declared or not, insurrection, rebellion, or mutiny;

(e)  intentional self-inflicted injuries or illness, caused by attempt at suicide, or incurred as a result of or while participating in the commission of a crime;

(f)   Engaging or taking part in driving or riding in any kind of race, professional sports or hazardous sports, underwater activities involving the use of breathing apparatus, flying or aerial activities other than as a fare-paying passenger; and

(g)  AIDS or AIDS-Related Complex.

 

 

 

1.2    Multiple Plan Provision

 

If the Life Insured should also be covered under a separate DHI/LTH/SEB/ICU or other similar benefits issued by us, the total maximum daily benefit payable on all such benefits is only up to the highest benefit or similar benefits offered by us at the time of the hospitalization claim. 

The exact wording of the provision is contained in the contract.

 

.3    Termination Provisions

 

The benefit under this section shall automatically terminate immediately upon the earliest of the following dates:

• 1. the date of death of the Life Insured;
• 2. thirty-one (31) days after due date of unpaid premium;
• 3. the policy anniversary immediately following the Life Insured's sixty-fifth (65^th) birthday;
• 4. the premium due date following our receipt of your written request for termination.

 

 

.4    Product Renewability

 

Renewal is not guaranteed and we reserve the right to decline renewal of the Policy on any policy anniversary but Company will give thirty (30) days prior written notice mailed or delivered to latest address registered with Company.

 

1.5         Other Contract Provisions

• § No cash values. No non-forfeiture options.
• § No cooling off period.

 

 

2              Claims  

2.1    Claim Form

 

                There will be a separate claim form for PruWellnes & HIPHEALTH GUARD.

 

2.2    Claim Filing for Term Insurance Benefit

 

To claim for the death benefit under this Policy, policyholder or claimant must submit the following documents as soon as practicable:

 

• 1. the claimant's statement
• 2. the attending physician's statement(s)
• 3. the original death certificate or certified true copy
• 4. birth or baptismal certificate of the Life Insured and primary beneficiary(ies)
• 5. Policy Contract together Policy Data Page
• 6. Other documents that may be required by the Company

 

 

•2.3                Notice of Hospitalization

 

Policyholder or claimant must give written notice of hospitalization within thirty (30) days of commencement of hospital confinement.

 

 

•1.1.     Claim Filing for Claim Filing for  DHI/ICU/SEB

 

Policyholder or claimant must submit the following documents within ninety (90) days after date of discharge from the hospital:

 

	DHI	ICU	SEB	LTH
the claimant's statement	Ö	Ö	Ö	Ö
the attending physician's statement(s)	Ö	Ö	Ö	Ö
admission summary & discharge clinical abstract summary	Ö	Ö		Ö
duly certified statement of account of hospitalization.	Ö	Ö	Ö	Ö
duly certified ICU record		Ö
complete medical records, laboratory and diagnostic procedures and histopathologic or biopsy results
duly certified operating report			Ö
official receipt for surgeon's fee			Ö
official receipt for anesthesiologist's fee			Ö
Other documents that may be required by the company	Ö	Ö	Ö	Ö

 

 

•2.4                Non-Integration with SSS/GSIS/HMO Benefits

 

Non-integration with SSS/GSIS and HMO benefits paid on the account of the same hospitalization confinement. This means the benefits payable under HEALTH GUARD will not be reduced by any benefits received or receivable from SSS/GSIS/HMO.

 

 

•2.5                Table of Features and Premiums