Insurance Commission(IC)

February 26, 2019 Dear Gwendolyn Andalis, I refer to my letter of Feb 18, 2019 11:40:08 AM about your request under Executive Order No. 2 (s. 2016) on Freedom of Information in the Executive Branch, for Medical Insurance in the Philippines. In order for us to work further on your request, we need more information from you regarding your query. This Commission's AdHoc Group on HMOs have coordinated with you for purposes of clarifying your request for information. You may use the reply function on the eFOI portal at https://2017annualreport08102018-dot-efoi-ph.appspot.com/requests/aglzfmVmb2ktcGhyHAsSB0NvbnRlbnQiD0lDLTkxMjU4ODk2ODA0Nww, for request with ticket number #IC-912588968047, to respond. During the period of us awaiting your reply/clarifications, your request will be put on hold. If we do not receive a reply on or before May 21, 2019 07:25:45 AM, your request will be closed. We hope to hear from you at the soonest possible time. Thank you. Respectfully, Atty. Alwyn Franz Villaruel FOI Officer

April 1, 2019 Dear Gwendolyn Andalis, Greetings! Thank you for your request dated Feb 18, 2019 11:40:08 AM under Executive Order No. 2 (s. 2016) on Freedom of Information in the Executive Branch. Your Request You asked for Medical Insurance in the Philippines. Response to Request 1. What are the Medical Insurance Companies in the Philippines? To ensure that we are on the same level of understanding, for purposes of this document, we would like to clarify that medical insurance per your query may refer to both medical or health insurance coverage provided by insurance companies and the medical or health services provided by health maintenance organizations (HMOs). The typical health insurance products offered by life and non-life insurance companies provide payment for losses as a result of sickness and injury. For example, a cancer policy provides for payment of lump sum amount upon diagnosis of covered illness/cancer. On the other hand, HMOs provide health services through cashless facility using their network of accredited healthcare providers (e.g., hospitals, clinics, doctors, etc.) The complete list of licensed life and non-life insurance companies and HMOs can be accessed through our website at . 2. How do medical insurance companies communicate with hospitals in terms of patient's claims, availments, accreditation and the like? The typical HMO products pay for the medical expenses directly to hospitals. The HMO enters into a Memorandum of Agreement with the hospital in order for the hospital to be accredited in the provider's network. Under the said agreement, hospitals are usually required to submit a statement of account of the availing member soon after discharge or completion of availment. With regard to claims availment, HMOs may follow different sets of procedures. Availing members usually report their condition to the provider's coordinators so that the appropriate medical procedures may be prescribed. The provider's coordinator will then issue a Letter of Authorization which authorizes the hospital to accommodate said confinement or conduct of medical procedure. However, the procedures mentioned may not be applicable to some HMOs. Each provider may have different arrangements with the hospitals and the stipulations in their agreements may vary. For a more detailed answer to the inquiry, we suggest that you also contact the Association of Health Maintenance Organizations of the Philippines, Inc. (AHMOPI) or Philippine Association of Health Maintenance Organization Companies (PAHMOC). 3. What are the common illnesses clients include in their medical insurance coverage? The most common benefits included in an HMO coverage are as follows: a. In-patient benefits; b. Out-patient benefits; c. Emergency care benefit; d. Preventive care benefit; e. Annual physical examination; f. Executive check-up; g. Dental benefit; and h. Maternity benefit. All types of illnesses are usually included in the HMO agreement, except those stated under the exclusions and limitations provisions (e.g., congenital conditions, epidemics, developmental disorders, etc.). 4. What is the most common illnesses being claimed through medical insurance? Currently, the IC has no available date as regards the most common causes of claims availment in HMO products. Your right to request a review If you are unhappy with this response to your FOI request, you may ask us to carry out an internal review of the response by sending an e-mail to . Your review request should explain why you are dissatisfied with this response, and should be made within 15 calendar days from the date when you received this letter. We will complete the review and tell you the result within 30 calendar days from the date when we receive your review request. If you are not satisfied with the result of the review, you then have the right to appeal to the Office of the President under Administrative Order No. 22 (s. 2011). Thank you. Respectfully, Atty. Alwyn Franz Villaruel FOI Receiving Officer