Philhealth Exclusions — Medical Conditions Not Covered

April 24, 2013 by Nors | Filed under Illnesses, philhealth.

NOT ALL medical conditions are covered by Philhealth.

HINDI LAHAT ng pagkaka-ospital o pagpapagamot ay sasagutin ng Philhealth.

Maraming medical cases na HINDI SASAGUTIN ng Philhealth, kaya pinakamaigi talaga ang mag-ingat, mag-alaga sa katawan, umiwas sa mga nakaka-stress sa isip, magkaroon ng masayahing disposisyon, at magdasal palagi sa Panginoon.

Here are conditions that are NOT Covered by Philhealth:

1.  Hospitalizations without definite diagnosis and without treatment.

Example:   You had a terrible stomach pain and you were confined.  They performed expensive diagnostic tests.  You stayed in the hospital for 3 days while you wait for the results of the tests.  But they did not find what is causing your pain.  Then you are discharged because your pain subsided.  You paid several thousands of pesos because of the tests, the room rates, and the professional fees.

Even if you spent a lot, cases such as this will not be covered by Philhealth because the doctor cannot write a definite diagnosis.  They need to write on the claim forms a code for your illness, but they cannot because they don’t know what is your illness.  They cannot prove your illness using the results of your x-rays or blood tests.

2.  Initial diagnosis which did not turn out as the final diagnosis

Examples: 

Suspected dengue, pero hindi talaga dengue at fever lang

Suspected pneumonia, pero hindi talaga pneumonia at flu lang

Probable typhoid fever, pero hindi naman typhoid fever

3.  Low risk illnesses

Examples:

Low-Risk Pneumonia

Community Acquired Pneumonia I

Asymptomatic Dengue Viral Infection

Asthma Not in Acute Exacerbation

Acute Gastroenteritis Without Signs of Dehydration or Only Mild Dehydration

4.  Cesarean Section without Indication

Example:  You chose to undergo CS even if you could have delivered your child the normal way.

5.   5th Normal Delivery and Subsequent Normal Deliveries

All normal deliveries are counted, even deliveries not covered by Philhealth

6.  Outpatient Diagnostic Tests

Examples are allergy tests, biopsies, cerebral perfusion scanning, ECG, blood tests and other diagnostic tests done as outpatient, whether self- prescribed or prescribed by doctor.

Diagnostic tests performed in the emergency room are not covered if the patient is not confined for treatment and is discharged in less than 24 hours.

Merong free diagnostic tests para sa OFWs under the Enhanced Out-Patient Benefit (OPB) Package for OFWs sa selected government hospitals.

7.  Emergency Room Treatments for Non-Emergency Cases

If you’re brought to the emergency room for treatment and discharged in less than 24 hours, your ER costs will not be covered.  Examples are treatment of light wounds, suspected hypertension, allergies, stomach pains, severe headache, low-risk asthma attacks, etc.

NOTE:  There are certain emergency cases that are covered.  Niri-research ko pa yong specific cases. Stroke or cerebrovascular accident is one example. It’s covered under the Case Rate payment scheme.

8.  Costs at Referring Hospital when Transferred

When you are transferred to another hospital for further treatment, the costs of initial treatment at the first hospital will not be covered.  It’s your costs at the second hospital that will be covered.

The sole exception is maternity care — when the delivering mother needs to be transferred from a maternity clinic to a hospital.

9.  The Same Illness Within 90 Days

If you are hospitalized for the same illness within 90 days, and you have already claimed your benefit for the same illness within the 90-day period, you will no longer be  covered for your 2nd or 3rd confinement.

You are allocated only one set of benefits for the same illness or the same cause of hospitalization within 90 days.  The only thing that can still be covered  is your room and board,  if you have not yet consumed your 45-day allowance for the year.

10.  Major Surgeries Performed at Level 1 Hospitals

Surgeries such as CS, Hysterectomy, and Appendectomy are not covered if they are done at Level 1 hospitals.  These should be done at Level 2, Level 3 and Level 4 hospitals

The only surgical procedures covered at Level 1 hospitals are:

D & C or Raspa and Normal Delivery of Child

Procedures Covered at Ambulatory Surgical Clinics:

D & C or Raspa

Cataract

Laparoscopic cholecystectomy

Herniorrhaphy

Procedure Covered at Free-Standing Dialysis Centers:

Hemodialysis

Radiotherapy is covered only if done at Level 3 or 4 hospitals

11.   Treatment for Alcohol Abuse and other Dependencies Cosmetic Surgery

12.   Optometric Services

Example:

Pagpagawa ng graded eyeglass

13.   Medicines Taken as  Out-Patient, Even those Prescribed by Doctors

Examples:

Mga gamot na binili pagkatapos lumabas sa ospital, kahit prescribed by doctors at kahit continuation ng pagpapagamot sa hospital.

Mga gamot na binili pagkatapos magpakonsulta sa doctor

14.   Ordinary Dental Services or Cosmetic Dental Treatments

Examples:

Tooth extraction

Teeth cleaning

Braces

Teeth bleaching

15.   Outpatient Consultations with Doctors

Sabi ng Philhealth, magpakonsulta sa health centers o sa government hospitals para libre ang consultation o magbigay lang ng donasyon.

Merong free consultation services for OFWs and their dependents sa selected government hospitals.  Pero free din naman ang consultations sa mga kahit hindi OFWs, basta sa OPD-Charity.

16.   Psychiatric or Mental Illnesses or Behavioral Disorders That Do Not Require Hospital Admission

Patient’s aggressive behavior or manic depression is not a danger to others and to himself or herself and medication side effects are not potentially life threatening.

17. Second or 3rd Surgical Procedure Performed at the Same Site of Primary Surgical Procedure in a Single Operative Session

For 2 or more different surgeries (under the Case Rate scheme) performed in one operative session, Philhealth covers only the main surgical procedure or the one with the highest Case Rate package.

Examples: CS with Bilateral Tubal Ligation, CS with incidental appendectomy or CS with adhesiolysis is paid as CS (coverage is the same as plain CS, which is 19k; no additional coverage)

18. Second or 3rd Illness that Occur During Hospitalization or After Surgery (for Case Rate Conditions)

Examples:
- Diabetes that occur during hospitalization for hypertension — Only hypertension is covered
- Hypertension that occur during hospitalization for diabetes — Only diabetes is covered
- Complications after Surgery (Surgeries Under Case Rate)

19.  Maternity Services for Special Cases Performed at Non-Hospital Facilities

The following conditions are not covered if they are treated at maternity clinics, lying-in centers, health centers or birth clinics:

-  pregnancy under the age of 19
-  first pregnancy at age 35 or older
-  multiple pregnancies
-  ovarian abnormality, such as ovarian cyst
-  uterine abnormality, such as myoma uteri
-  placental abnormality, such as placenta previa
-  abnormal fetal positions, such as breech position
-  history of 3 or more miscarriages or abortions
-  history of 1 stillbirth
-  history of major obstetric or gynecologic operation, such as CS or uterine myomectomy
-  history of medical conditions, such as pre-eclampsia, eclampsia, heart – disease, hypertension, moderate to severe asthma, diabetes, epilepsy, renal disease, thyroid disorder, bleeding disorder, and morbid obesity
-  conditions during pregnancy such as premature contractions and vaginal bleeding

18.  Animal Bites Treated at Facilities Not Accredited by the Department of Health (DOT) as Centers for Animal Bite Treatment

Additional information:

Types of Dengue Covered by Philhealth

Types of Pneumonia Covered by Philhealth

Outpatient Treatments Covered by Philhealth

NOTE:  I am not a doctor and I am not a Philhealth employee.  I based my list on Philhealth circulars and publications and on the comments of people who shared their experiences about their Philhealth claims.

Sources of information:

Philhealth Circular No. 011-A-2011 – Selected Medical Case Rates – Additional Implementing Guidelines

Philhealth Circular No. 011-B-2011 – Selected Surgical Case Rates – Additional Implementing Guidelines

Philhealth presentation titled “The Formal Sector and Universal Health Care”


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