If you are employed, you probably have a group medical/health plan. It’s an insurance policy where the payment of a monthly premium can defray some if not all of the medical expenses occasioned by disease. Most health insurance in the Philippines is actually health maintenance policies.  It can be a Godsend in times of emergency, but it can also be a disappointment.  This is my (mis)adventure.

Read the insurance policy carefully. Read it to find out which hospitals in your area are accredited by the health card.  If you get into an accident and you were brought to a hospital that is not accredited by the health card, your medical expenses will not be charged to your health insurance and you will have to shell out cash and not get any reimbursement.

I had a client who suffered a hit and run.  He broke his right thigh and his right forearm when he was thrown five feet into the air in the impact and fell on the concrete pavement.  He was brought to the nearest public hospital.  His wife, relying on the health insurance from her husband’s office, asked that he be transferred to an accredited hospital where he was immediately operated on.  What she didn’t know was that although the hospital was accredited by the health plan, the health plan did not include surgery occasioned by an accident, only disease. She had to pay a third of the hospital bill, sign a promissory note for the rest after having left the duplicate original of the TCT of their home.

Ask questions.  One pertinent question to ask is whether or not your regular physician is accredited with the health plan.  If he is then his lab requests for laboratory tests will be easily approved. My gynecologist is the wife of hubby’s first cousin.  She is a diplomate and fellow in obstetrics having graduated from UP PGH; she is a consultant and tenured faculty member at the UP PGH.  When I presented the lab request she made for me for a blood chemistry work-up and for an ultrasound, it was disapproved because she was not accredited by the health insurance company.  It doesn’t matter how good my doctor is: because she is not accredited with the health insurance company, her diagnosis was questioned and the lab work she requested, disapproved. Gone are the days of the doctor de confianza: your doctor from childhood who is caring and competent; with whom you have carefully formed a relationship.  All your doctor’s credentials are worthless to the health insurance company: only the diagnosis of their accredited doctors is reliable and acceptable.

Another question to ask is the extent of your coverage.  Look at the listed diseases and conditions which are covered.  Look at the tests and procedures covered.  Ask if consultation fees and professional fees are also covered. Ask if the OR or ER fee is covered. Ask if the cost of the hospital room is covered.

We needed to see a dermatologist.  We didn’t know one so we just went to the accredited hospital. The first thing that her secretary asked was if we had a health card.  We showed it to her.  She gave us consultation forms.  We filled it up and presto! We did not have to pay for the consultation fee.  Having a wart removed was a different thing.  Cauterization for a wart on the face costs P500.  If my husband, the principal cardholder, had that problem and he used his card, it would have been approved.  But because I am not the principal cardholder, it wasn’t covered in my policy.Wart removal from the neck or chest area is a covered medical procedure; but wart removal on the face is cosmetologic and elective: not covered.  The doctor asked me if I wanted her to put the request in my husband’s name using his card even if the wart was on my face! (It wasn’t even a wart, it was a milia.) That was insurance fraud, so I said no. To him who knows to do good and doeth it not, to him it is sin… I paid P500 to have a whitehead removed leaving my conscience intact.

Get prior approval for the procedure, test or lab work. When you have been diagnosed by an accredited doctor and he requests lab work for you, go to the hospital the day before and get approval for the lab work.  Approval takes time and there are a lot of other people who want to use their health card.  You might have to wait for an hour minimum before the HMO facilitator can process your request. This involves calling the HMO office and speaking with a coordinator there.  The request will be referred to and evaluated by the doctors at their office. If the lab work includes blood chemistry for which fasting is necessary, you might die of starvation before your request is approved. Once approved, your lab test or procedure can be done within three days from approval. (I read half of Honore de Balzac’s Petty Troubles of Married Life before my requests were approved.)

Be patient and don’t get your hopes up too high. Cost of medicines is usually not covered. Cost of vaccines (except those required for babies and vaccines for rabies) is usually not covered either. Screening tests (medical tests which are performed to rule out a particular disease) might not be covered.  Bring cash just in case your request is disapproved or you suffer a nervous breakdown.

Always remind your doctor to include a complete diagnosis of your condition on the very same prescription pad where he wrote the lab request.  If there is no accompanying diagnosis then the tests he requested may not be approved. Each test must be supported with a diagnosis.

There is always a transactional loophole.  If you run into difficulty, do not be timid or afraid to ask questions from the HMO facilitator.  For instance, I asked for approval for an ultrasound but the doctor did not put the complete diagnosis (It should have been: myoma uteri for possible myomectomy or total hysterectomy). The request was denied. I was about to lose my patience and just pay for the entire thing in cash.  But then I remembered that all I needed was for a doctor from that hospital to put the complete diagnosis on my form.  I asked for a new consultation form.  I went to the ER and I talked with the resident there. He signed the consultation form (evidencing that I had consulted with him) and he requested a transvaginal ultrasound for me.  The request was approved even if it had been denied an hour before that.  When you can’t go through the HMO door, try the HMO window!  It’s not like salvation: Jesus is the only way.

The same thing with hubby’s request: aside from the usual blood work-up, his doctor wanted a screening test for prostate cancer (Men aged 40 and above should have yearly screening for prostate cancer.  Women aged 40 and above should have a yearly mammogram and pap smear to rule out cervical, uterine and breast cancer.) Since the diagnosis written by his doctor did not include any diagnosis for prostate cancer, the test was disapproved.  Again, I went to the ER.  When they saw his age they issued me a diagnosis which stated: “screening for possible prostate cancer related to age.” This is medical language for: we want to make sure he doesn’t have prostate cancer since he is of that age when men usually develop prostate cancer. The request was approved. Mental agility is required to deal with HMOs: they have a language all their own and you have to be sharp.  Be wise as serpents, harmless as doves.

Remember that health cards are insurance policies.  They have coverage for the usual diseases and conditions.  If your condition is rare, it is probably not a risk insured against. It will not be covered. Maintaining health has been reduced by actuarial science to a transaction.  Each transaction must be specifically described and a cost attached to it.  The premiums you pay have been calculated beforehand and determined to be sufficient for all the usual tests you will need in your lifetime. Your health card is just like saving up money in case you get sick (and you will). I have not tried using both the Philhealth and the HMO card…. I hope I won’t need to.  More on this….