Philhealth Exclusions — Medical Conditions Not Covered

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


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


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

Update 2016:  All normal deliveries are now covered, as long as you have the required number of prenatal checkups.

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 or Clinics

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


Laparoscopic cholecystectomy


Procedure Covered at Free-Standing Dialysis Centers:


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


Pagpagawa ng graded eyeglass

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


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


Tooth extraction

Teeth cleaning


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)

– 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”

36 thoughts on “Philhealth Exclusions — Medical Conditions Not Covered”

  1. If the wisdom tooth is to be operated on because there’s something growing below it, and needs to be removed to treat pain and swelling. Is it covered?

  2. My wife had an accident early this morning. Bigla sya nahilo and tumama head nya somewhere so I rushed her to University of Perpetual Help Medical Center Las Pinas. Her head wound was stitched and it cost us 10K+. According to my friend, dapat daw covered yun ng Philhealth because there was surgery conducted. We tried to wait for the Philhealth representative to clarif things pero 8am daw darating. We were in the ER 3:30am pero natapos lahat ng procedure, 6:45am. Haist…. The ER nurse insist that hindi daw covered ng Philhealth ung expenses so binayaran ko na lang lahat kasi pagod na din ako at that time. If my wife was admitted, then Philhealth will cover some of the expenses, according to the ER nurse. My question is, sagot nga ba ng Philhealth ang stitching procedure done to my wife?

    TIA sa mga makapagbibigay ng payo… Salamat po..

    • Hi Joy, treatments now have really become so expensive. Yes, day surgeries are covered, as long as the one who did the surgery is also Philhealth-accredited. I wished you had waited, but as you said, you were already tired. Thanks for sharing your experience.

  3. I have ovarian cysts in my left ovary. If I use philhealth, how much is my coverage if I have my operation at a private hospital?

  4. i am planning to have my hemorrhoid removed since it is already bleeding. i have not seen my doctor yet but advised by many especially who had hemorrhoid to have it removed. may i know if hemorrhoid surgery is covered by philhealth?

      • hi ms nora. about hemorrhoidectomy, how much is the exact hospital bill for this operation? so we can prepare the amount. excluding the principle amount covered by philhealth Php. 12,120. so how much will we pay. thank you. god bless

  5. good morning. how much is coverage for hemorrhoidectomy surgery? How much will we pay? with philhealth or without. need to decide earlier nextweek. thanks

    • Hi jc, coverage is 12,120 (6,720 for PF and 5,400 for hospital cost). Ask your hospital or your surgeon about their fees and costs. Different surgeons/hospitals charge different fees.

  6. hi po,nung nov.06,2016 my little sis undergo an abscess minor surgery in her lower armpit.sabi po ng nurse sa desk covered po ito ng philhealth.ang pagtataka ko lang po nung binigay sa amin ang bill ay worth 2,000 lahat ang babayaran.1,500 dun PF ng kinabukasan pag reimburse po namin,ang isinauli lang po sa amin ay 500 lang,dahil ayun po sa kanila hindi covered ng philhealth ang doctor’s fee worth 1,500 dahil private nga daw po ang hospital nila.ano po ang maipapayo nyo po sa akin?salamat po.

    • Hi joean, it’s really sad na ganyan nga ang prevalent practice. Usually ang PF is paid as cash, separately, oftentimes directly to the doctor, na walang OR. Nagtataka naman ako sa mga hospitals or clinics na hindi maliwanag ang pag-deduct ng PF, bakit kaya hindi na lang nila sabihing diretso sa pasyente na “3,500 ang total bill; 2k ang Philhealth coverage, bayaran mo ang balance na 1,500” para maliwanag. Tutal wala namang pakialam ang gobierno kung 3500 or 2k ang total bill (dahil sa inis ko na lang ito).
      If you like, you can go to Philhealth and ask about it. Or you can wait for your benefit payment notice, at tingnan mo kung magkano ang ibinayad ng Philhealth, then if you like, you can try to ask for refund again.

    • Hi Michelle, merong colposcopy with biopsy(s) of the cervix and/or endocervical curettage. Total coverage is 8,260.

  7. Mam nag colonoscopy po ako last march 21 , 2018 po
    Ang sabi ng doctor ko 14,500 po
    Then nag pa admit po ako for the procedure
    At nang na ka admit na ako
    Kung anu anu pong test ginawa. My endoscopy,
    2 the echo test po ng hearth
    At ung laboratories po sa blood
    Sabi ko one week ago meron na po ako
    Kasi nga pinagawa na ni Doctora
    And in 24 hrs po ung bill ko po
    Is 91,327 po
    Na bigla po ako
    Sa takot ko po at 50k Lang dala ko
    Nag decide po ako na lumabas na kahit hilong Hilo PA ako
    Nataranta po ako kasi naghiram Hiram pa ako sa mga kilala ko
    From Bicol po ako kaya nahirapan po ako
    Di po updated ung Phil health ko
    Pero meron po ako
    Ang tanung ko Lang po
    Tama po ba ung prices nila?
    Dahil po sa bill nahimatay po ako

    • Hi Mary Jane, dapat tinanong ka muna bago ginawa ang mga procedures na iba, lalo na at diagnostic procedures at hindi naman treatment procedures or emergency case. Nagsabi ba sila sa iyo bago nila ginawa ang mga ibang procedures? May mga pinirmahan ka ba na gagawin nila ang mga procedures na yan. Sa akin lang, kung wala kang consent, at kung wala kang pambayad, huwag mong bayaran (okay lang sana kung merong pambayad), kasi wala naman sa usapan nio ang mga ibang diagnostic procedures. Colonoscopy lang ang usapan nio. Sorry wala pa kasing laws regulating the prices of medical procedures at PFs. Depende sa hospital. Kaya karamihan na patients, kung may time naman at hindi emergency, nagtatanung-tanong kung saan mas affordable ang procedure. Nasa Bicol ka na? Buti nakalabas ka. Pinapirma ka ba ng promissory note?
      Naka-list sa website ng DOH ang patients’ rights, isa dito ang: Right to Informed Consent — the patient will not be subjected to any procedure, whether diagnostic, preventive, curative, rehabilitative or therapeutic, without his written informed consent, except lang sa emergency cases, cases when public health is involved, patient is minor or legally incompetent, when informing the patient affects treatment success, and when the patients waives his right.

    May itatanung lang sana ako kc yong anak ko nahospital ng 3 days yong sakit nya is mouth ulcer nagtataka kc ako ilang percentage ng discount po ang maibigay kapag ganitong case sanay mareplyan nyo po ako salamat

    • Hi camil, hindi percentage ang Philhealth coverage. Meron fixed amount. Pero wala akong makitang mouth ulcer. Merong
      acute necrotizing ulcerative gingivitis or trench mouth — 8,800 (2,640 for doctor; 6,160 for hospital)
      cellulitis and abscess of mouth — 8,300 (2,490 for doctor; 5,810 for hospital)


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