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Frequently Asked Questions


Tayo po ay may dalawang uri ng miyembro, Regular at Associate.

REGULAR MEMBER

Ito ay uri ng miyembro kung saan sila ay maaaring tumangkilik ng lahat ng serbisyo katulad ng Life Insurance (Damayan), libreng pagbabayad ng bills sa bayad center, lahat ng klase ng loans (Collateralized at Non-collateralized), at pribilehiyo bilang miyembro na MIGS (Members in Good Standing) katulad ng pagboto sa taunang pangkalahatang pagpupulong at eleksiyon ng mga opisyales.

ASSOCIATE MEMBER

Ito ay uri ng miyembro kung saan ang maaari lamang nilang tangkilikin na serbisyo ay ang ating Life Insurance (Damayan), libreng pagbabayad ng bills sa bayad center, Collateralized Loans. Ngunit sila ay hindi maaaring bumoto sa ating taunang pagpupulong.


 New Members:            6 Months Contestability
 Existing Members:            No Contestability

If current member was not able to renew his/her policy for one (1) year, he/she will undergo the 6 months contestability period upon next enrolment

Ang mga miyembro na napapasailalim ng contestability perion ay kinakailangan mag-fill-up ng waiver form for reinstatement bilang patunay na kanilang nauunawaan na sila ay mapapasailalim sa 6 months contestability

ELIGIBILITY
 Entry age for “NEW” Principal Members: 18 – 59 years old
 Entry age for “Existing” Principal Members: 18 – 80 years old
 Exit Age for Principal Members: 80 years and 6 months old
 Entry Age for Dependent Spouse/Parent: 18 – 71 years old
 Exit Age for Dependent Spouse/Parent: 71 years and 6 months old
 Entry Age for Dependent Child/Sibling: 1 – 21 years old
 Exit Age for Dependent Child/Sibling: 21 years and 6 months old

 If Principal is Married, the covered dependents shall be:
* Spouse and two (2) children (max. of 2 children)
 If Principal is Single/Single Parent, covered dependents shall be:
* One (1) Parent and two (2) siblings/children (max. of 2 siblings/children)
PREMIUM
 Existing and New Principal Members (18 – 71 years old) Php600.00
 Existing Principal Members (72 – 80 years old) Php1,200.00
 In case of Married members with covered dependents (spouse and children) who opts to cover their parents, an additional of Php180.00 per parent shall be paid
 Premium for “new” members shall be pro-rated based on the number of months remaining before the group policy anniversary date

• BASIC REQUIREMENTS ON CLAIMING LIFE INSURANCE BENEFIT
 Certified true copy of proof of membership with the cooperative
 Original Certified true copy of Death Certificate
 Notarized Claimant’s Statement
 Attending Physician’s Statement (if died in the hospital)
 Marriage Certificate or Birth Certificate of the beneficiary
 Affidavit of Two Disinterested Persons (if necessary)
 CENOMAR (of both insured and claimant) and Barangay Certificate (indicating their years of living together), if claimant is a common-law-partner

• BENEFITS

Principal Member (18 – 80 years old)           Php100,000.00
Dependents           30,000.00

In case the insured has not declared the names of his or her beneficiaries the following hierarchy of beneficiaries shall be followed:
 Spouse
 Surviving Children
 Surviving Parents
 Surviving Siblings (from eldest to youngest)
 Estate

*Pinagkaiba ng Dependent sa Beneficiary:

 Dependent: ang tinatawag na dependent ay yung mga taong financially dependent sa atin tulad ng asawa, mga anak na 1 years old hanggang 21 years old, magulang at kapatid na 1 years old hanggang 21 years old

     o Ang dependent ay insured

 Beneficiary: ang maaaring tumanggap ng benepisyo mula sa life insurance. Ito ay maaaring asawa, anak, magulang o kapatid

• LIST OF PRE-EXISTING CONDITION, but not limited to:
      Cancer
      Carcinoma in situ including of the cervix
      Ductal Carcinoma in situ of the breast
      Papillary Carcinoma of the bladder and Stage 1 Prostate Cancer
      All skin cancers except malignant melanoma
      Stage 1Hodgkin disease
      Tumors manifesting as complicationsof Acquired Immune Deficiency Syndrome
      Advance heart illness
      Chronic Heart and Kidney Disease
      Tuberculosis
      Fulminant Viral Hepatitis
      Major Organ Transplant
                Kidney
                Lung(s)
                Liver
                Heart
                Bone Marrow
      Paralysis / Paraplegia
      Multiple Sclerosis
      Primary Pulmonary Arterial Hypertension
      Heart Valve Replacement
      Surgery to Aorta
      Coma
      Chronic Liver Disease
      Chronic Lung Disease
      Aplastic Anaemia
      Brain Surgery
      Bacterial Meningitis

• TRANSFER/ WITHDRAWAL OF FUNDS FROM DECEASED ACCOUNT
      A request letter from the beneficiary of the account to be transferred/withdrawn must be submitted
      1 valid government issued ID (photocopy)
      Endorsement by the branch BS that the beneficiary is the legal beneficiary based on the branch’s records
      Clearance and claimants statement

• ELIGIBILITY
     o Principal Member
           18 – 65 years old
           Pumasa sa lahat ng kailangan upang makapagpa miyembro
           Lahat ng kahilingan sa pagiging miyembro ay kinakailangan pang aprubahan ng Coop Health
     o Beneficiary
           18 – 45 years old

     • LOSS OF MEMBERSHIP
          o Pagbibitiw bilang miyembro ng kooperatiba, kahit napapaloob pa sa effectivity period
          o Pag ang miyembro ay nag-edad 65 years old birthday
     • PREMIUM
          o Php3,600.00 para sa isang buong taon
          o Members in Good Standing (MIGS) ay maaaring mag avail ng deferred payment scheme
     • TRANSFERABILITY
          o Membership is non-tranferrable
     • COVERAGE
          o Annual
     • REQUIREMENTS
          o Duly accomplished HMO membership form
          o Photocopy ng SMMPC ID
     • BENEFITS
     Preventive:
o Annual Physical Examination:
           Chest X-Ray
           Complete Blood Count (CBC)
           Urine Test
           Stool Test
           Physical Examination

Note: Annual Physical Exam ay maaari lamang ma- avail sa pangalawang taon ng pagiging miyembro

o Confinement/In-patient:
           Maximum Benefit Limit (MBL) – 60,000/illness/year
           P 30,000 single confinement
           Net of Phil Health
           Doctor’s fee, room accommodation, gamot, laboratories at iba pang test na kinakailangan ayon sa rekomendasyon ng doktor
           Nationwide coverage sa lahat ng emergency confinement
Note: Ang mga gamot na nireseta upang inumin sa bahay ay hindi covered
o Out-patient:
           Libreng check-up sa mga accredited clinic
           Libreng Laboratories examination (hindi kasama ang intensive laboratory para sa outpatient) Example: MRI, CT Scan etc.
           Follow up check up
           Kailangang mga gamut sa loob ng clinic o ospital

Note: Ang mga gamot na nireseta upang inumin sa bahay ay hindi covered

o Out-patient:
           Libreng check-up sa mga accredited clinic
           Libreng Laboratories examination
(hindi kasama ang intensive laboratory para sa outpatient) Example: MRI, CT Scan etc.
           Follow up check up
           Kailangang mga gamut sa loob ng clinic o ospital

Note: Ang mga gamot na nireseta upang inumin sa bahay ay hindi covered

o Emergency Care Service
           Emergency care service na hindi nangangailangan ng confinement ay maaaring ma-avail sa lahat ng accredited and non-accredited na ospital (hanggang sa maximum amount na Php10,000 kada insidente pero di tataas sa Php20,000 kada taon)
                    • Doctor’s services
                    • Medicine, x-ray, laboratory examinations and blood transfusions during emergency
                    • Oxygen and intravenous fluids
                    • Dressing, casts and sutures
                    • Iba pang emergency services at treatment na kinakailangan ayon sa rekomendasyon ng attending physician
o Dental
           Bunot (hanggang sa dalawang (2) bunot kada buwan)
           Pasta (temporary)
           Annual Prophylaxis (after payment of 12 months’ worth of membership fees
           Recementation of loose jackets, crown, in-lays & on-lays
           Treatment of mouth lesions
           Konsultasyon sa dentista
                    • Bunot na may kasamang surgery o may kumplikasyon ay hindi na covered

Note: Ang mga gamot na nireseta upang inumin sa bahay ay hindi covered

o Tulong Pinansyal:
           Death Benefit:
                    • Natural Death - P 10,000.00
                    • Accidental Death – P 20,000.00
o Paano mag-Claim para sa confinement sa mga non accredited na ospitals/clinic
                    • Ang Coop Health ay dapat ma-notify
bago magpa-admit for confinement
                    • I-sumite ang lahat ng dokumento na magpapatunay na ikaw ay na-confine sa loob ng sampung (10) araw ng pag-labas ng ospital
                    • Original copies of the following:
                              o OR
                              o Statement of Account
                              o Charge Slips
                              o Clinical Abstract and operative records duly signed by the attending physician, including histopathological report
                         Payment of Claims
                                  • Maliban na mag-sumite ng sulat kahillingan, ang approved claim ay babayaran sa miyembro sa pamamagitan ng Koop
o Mga sakit na covered sa unang taon pa lang ng pagiging miyembro
        Acute Pancreatitis
        Acute Bronchitis
        Acute Apendicitis
        Allergies (except Asthma)
        Amoebiasis and other forms of Gastroenteritis
        Bacillary Dysentery
        Brucellosis
        Chickenpox
        Constipation
        Conjunctivitis (Sore Eyes)
        Dengue Fever
        Heart Burn
        Hepatitis A (Viral)
        Impetigo
        Intestinal Parasitism
        Influenza
        Iron Deficiency Anemia
        Laryngitis
        Malaria
        Measles
        Migraine (common and classical)
        Otitis Media (Acute)
        Pharyngitis
        Roseola Infantum
        Scarlet Fever
        Sinusitis (not requiring surgery)
        Tonsillitis (not requiring surgery)
        Typhoid Fever and other enteric infections
        Urinary Tract Infection
        Whooping Cough
        Upper and Lower Respiratory Tract Infections
        ACCIDENTS
              • Accidental Poisoning
              • Minor Burns
              • Lacerations
              • Motor Vehicle Accidents (on a reimbursement basis only)
o Pre-Existing Conditions (covered after 12 months of active continuos membership)
        Incisional Hernias (all hernias resulting from previous surgeries and Acquired Inguinal Hernias, Scrotal Hernias, Hydrocoele, etc)
       • Tumors of different organs (benign and malignant)
       • Endomerriosis and other Chronic Gynecologic diseases (e.g. Chronic Cervicitis)
       • Endocrine Diseases:
       • Diseases of the anterior pituitary and posterior pituitary (SIADH, Diabetes Insipictus)
       • Hyperthyroidism, Thyroiditis, Thyroid nodule
       • Primary and Secondary Hypothyroidism
       • Diabetes Mellitus (except complications under the list of exclusions)
     Chronic Obstructive Pulmonary Disease, Bronchial Asthma and its complications
     Tuberculosis and its complications
     Acute and Chronic Cholesystitis, Stones of the Hepato-Biliary System
     Stones of the Urinary System
     Gastric and Duodenal Ulcers; Chronic Gastritis
     Cardiovascular Diseases
     Chronic Liver Disease
     Cerebrovascular Accident or Stroke
     Collagen Disease (Arthritis)
     Prostate Disorders
     Glaucoma
     Hemorrhoids and Anal fistulate requiring surgery
     ENT conditions requiring surgery
     Cataract requiring surgery
     Seizure disorders except benign fabrille seizures
     Chronic dermatological conditions
     Varicose veins
o EXCLUSIONS
     Case to case basis base sa rekomendasyon ng attending physician
       • Congenital Defects
       • Correction of all physical deformities
       • MS, Guillan-Barre Syndrom, Epilepsy and other autoimmune neurological disease
       • Psoriasis and vitiligo
       • Plastic and reconstructive surgery for cosmetic purposes
       • Physical examination required for obtaining or continuing employment, insurance or government licensing
       • Experimental medical procedures and acupuncture
    • Abortion, sterilization, ligation, fertility or impotence treatment
    • Psychiatric care, rehabilitation treatment, physiotheraphy and speech therapy
    • Open heart surgery, organ transplant
    • Injuries or illnesses resulting from participation in war-like or combat operations, brawls, riots and civil disturbances, except those resulting from unprovoked assaults
    • Hazardous job-related illness or injury
    • Self-inflicted injuries
    • Any injury sustained under the influence of alcohol
    • Maternity care and other conditions as a result of pregnancy
    • Custodial, domiciliary, convalescent, and intermediate care
    • Sexually Transmitted Disease
    • Adverse medical conditions arising from treatment by non-accredited physicians, clinics and hospitals
o Dreaded Diseases (mga sakit na covered ng Maximum Benefit Limit maliban sa mga sakit na napapaloob sa pre-existing conditions)
    Neurological diseases
    Blood Dyscrasias
    Collagen/Immunologic disorders
    Cirrhosis of the liver
    Chronic Pulmonary
    Cardiovascular diseases
    Cancer
    Any condition which will necessitate the use of the ICU
    Accidental injuries or burns
    Etc

   • Ano po ba ang LPPI (Loan Payment Protection Insurance)       

o Ang LPPI o Loan Payment Protection Insurance ay ang insurance para sa mga loan, na kapag po si member ay nawala, babayaran po ng buo ni Insurance Provider ang loan ni member. At kung si member ay mayroon nang naibayad sa kanyang loan, yun ay ibabalik ni Simbayanan sa kanyang beneficiary at ang kukunin lang ay ang pangbayad sa kanyang remaining balance

   • Hanggang ilang taon lang ba ang mayroon pang LPP?
      o 69 years old pa dapat sya sa maturity ng kanyang loan
   • Ano po ang requirements para sa LPPI Claim?
      o Claims request form
      o Claimants Statement (notarized)
      o Death Certificate (Certified true copy)
      o Police report (kung aksidente ang dahilan ng pagkamatay)
      o Attending Physicians (kung sa hospital namatay)
      o Birth Certificate (kung ang anak ang beneficiary)
      oWaiver of Rights (kung may mga mga kapatid pa ang idineklarang beneficiary)
   • Gaano katagal ang claim ng LPPI?
      o 2-4 weeks po ang hihintayin para sa Authorization to deduct na ibibigay ng ating Insurance Provider

COMPREHENSIVE INSURANCE

• COMPUTATION OF INSURANCE FOR Car (Private/ Commercial) / Motor (Member & Employee)?