20230117032741premier Brochure Full - 2023-01 (January 17)
20230117032741premier Brochure Full - 2023-01 (January 17)
20230117032741premier Brochure Full - 2023-01 (January 17)
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? Some things all applicants should know:
As with all insurance, there are some important points you should know before entering into a contract. In this section, we
identify some key Policy provisions.
1. Your coverage begins 30 days after the date shown on your Policy. However, you already have immediate coverage for
accidental injury.
2. A Pre-Existing Condition is a disability or illness which existed before the commencement of cover. The existence of a
Pre-Existing Condition can be medically determined given its natural history or the manner of development of a disease, which
means you may or may not be aware of its presenting symptoms. Pre-Existing Conditions are also those that are known to
you because you have felt its signs and symptoms regardless if this prompted you to seek for treatment, medication, advice
or diagnosis. When you answer our Medical Questionnaire, please ensure that you tell us about all your medical conditions
and symptoms happening at any time in the past and/or present, known and/or suspected, whether or not treatment or
professional advice was sought. If you are able to provide details and submit corresponding medical reports, consideration
to cover declared pre-existing conditions on the first year of your Policy will be subject to the Company’s underwriting
guidelines.
3. While your Policy is issued in the Philippines, it can provide Emergency Coverage when you are overseas. The maximum
period of cover should not exceed more than 30 days per trip during the Policy year.
4. Certain conditions are permanently excluded from being covered. These conditions include:
• Congenital conditions, birth defect, and abnormalities
• Durable medical equipment, grafts, prosthetic devices, and corrective devices other than artificial limbs
• Cosmetic surgery or related complications, contact lenses, hearing aids and prescriptions thereof, except those that may
be required for reconstructive surgery
• Suicide, attempted suicide, or intentional self-inflicted injury
• Pre-Existing Conditions unless such have been declared and approved by the Company
• Sexually Transmitted Diseases (STDs)
5. Your contract is guaranteed renewable up to age 100. However, we reserve the right to adjust your premium and other
Policy conditions upon written advice 45 days prior to each renewal.
6. Your contract contains a provision on the Insured Person’s right to Free-Look Period.
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CORE BENEFITS (In-Patient & Emergency)
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SURGICAL BENEFITS WARD SEMI-PRIVATE PRIVATE
Operating Theater & Recovery Room As Charged As Charged As Charged
Surgeon’s Fee ₱60,000 ₱90,000 ₱180,000
per disability, per year limit of
Anesthesiologist’s Fee ₱24,000 ₱36,000 ₱72,000
not to exceed 40% of the approved Surgeon’s Fee.
Artificial Limb As Charged As Charged As Charged
including rental of mechanical devices (as approved by Pacific Cross) excluding
implantable devices.
Medical Implant Due to Accident ₱25,000 ₱25,000 ₱25,000
covers the cost of implantable devices necessary for a surgical procedure to treat a
covered injury resulting from accident wholly occurring during the Period of Insurance.
Per disability, per year limit of
EMERGENCY BENEFITS
Emergency Out-Patient ₱5,000 ₱6,000 ₱7,000
for treatment of emergency cases/conditions not leading to confinement provided by
the Out-Patient department of a hospital or a licensed doctor in his clinic for a covered
disability. Maximum limit per disability, per year.
Emergency Dental Services As Charged As Charged As Charged
due to a covered accident.
Emergency Local Ambulance Service As Charged As Charged As Charged
from place of occurrence to the nearest hospital facility or from hospital to hospital
using land transportation service.
(If local land transportation facility is not available, other transportation facilities are allowed subject to the
approval of Pacific Cross. Maximum limit per disability, per year is ₱15,000.)
Emergency Overseas Coverage Up to Maximum Benefit Limit subject to the inner
worldwide cover is included for no more than 30 days per trip for travel overseas during limits of the In-Patient/Hospitalization and Emergency
the Policy year. Reimbursement of overseas medical expenses is for emergency cases only. Out-patient Treatment that are based on currently
applicable medical rates of the Company’s
pre-determined Philippine tertiary hospital.
*Availment of services through our designated assistance provider, limit per year of As Charged and on top of the Maximum Coverage Limit
*Availment of services not through our designated assistance provider, limit per ₱50,000 ₱50,000 ₱50,000
year of combined limit combined limit combined limit
The actual cost will be paid via reimbursement by the Company subject to the limits
specified which will form part of the Maximum Coverage Limit of the plan provided that
such assistance is a result of a covered illness, accidental injury, or death occurring during
the Period of Insurance.
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WARD SEMI-PRIVATE PRIVATE
AUTO-IMMUNE CONDITIONS
Benefit will apply after five (5) years of continuous coverage under Select Plan(s) and any ₱100,000 ₱150,000 ₱300,000
renewal thereof. It will be subject to the inner limits of In-Patient, Emergency Out-Patient
and Out-Patient Benefits (if any) under a combined Lifetime Limit of
This Mental Health Care Benefit excludes coverage for substance abuse disorders, congenital
or neurodevelopmental disorders, hypersexual disorders, impulse control disorders, and
behavioral addictions such as gambling, and gaming.
The following services are covered excluding medicines and drugs that may be prescribed
during consultation and counselling:
Consultation with a Psychologist, Psychotherapist, Psychiatrist, and other mental health Up to ₱1,000 Up to ₱1,000 Up to ₱1,000
care professionals per visit per visit per visit
Reimbursement of professional fee up to a maximum of 3 visits per Policy year upon
(Subject to 10% co-payment of the Premier Plan)
presentation of final diagnosis
Counselling Up to ₱600 Up to ₱600 Up to ₱600
per session per session per session
Reimbursement of counselling or therapy sessions prescribed by the Mental Health Care
Professional up to a maximum of 3 sessions per Policy year (Subject to 10% co-payment of the Premier Plan)
Companion Allowance ₱100 (per day) ₱200 (per day) ₱300 (per day)
allowance given to companion (maximum of 10 days per Policy year)
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OPTIONAL BENEFITS
OUT-PATIENT BENEFIT STANDARD EXECUTIVE
Pacific Cross pays 50% of eligible claimed amount for reasonable, normal, and customary ₱25,000 ₱50,000
fees. Reimbursement only. Aggregate limit per year.
(50% CO-PAYMENT: Pacific Cross will pay
50% of the approved claim amount.)
Includes:
a. Consultation in Doctor’s Office covers Physician’s and Specialist’s fee
b. Physiotherapist or Chiropractor
c. Diagnostic, X-rays and Laboratory Tests necessary for the treatment of a covered disability
d. Medicines and Drugs prescribed by a Doctor for a covered condition or disability and
procured from a recognized pharmacy
The Documentary Stamp Tax (DST) should be deducted from the Core Benefits Premium before applying any discount and/or loading
(i.e., additional premium). The DST should be added back after all discounts and loadings have been applied.
The DST amounts are as follows: ₱50 (Ward), ₱100 (Semi-Private), ₱200 (Private).
If you are paying on semi-annual mode, please note that 8% surcharge and DST charge will apply. The amounts of your first and second
installment will vary with the former being slightly higher than the latter due to DST.
OPTIONAL BENEFIT
Out-Patient Benefits
AGE STANDARD EXECUTIVE
66 - 70 ₱16,160 ₱20,463
71 - 75 16,512 21,128
76 - 80 18,284 23,555
81 and up Not available
Pacific Cross pays 50% of Normal, Usual and Customary fees. Reimbursement only.
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Pacific Cross Insurance, Inc. is
now ISO 9001:2015 Certified!
Our Companies
Pacific Cross Insurance, Inc. and
Pacific Cross Health Care, Inc.
www.pacificcross.com.ph V01.23_APE