GoHealth Max

The Insured Person under this coverage may avail of necessary treatment in respect of a covered accident or medically diagnosed with cancer, and other specific illnesses for which the date when symptoms first appeared during the Period of Insurance.

Coverage for the following benefits is on top of PhilHealth and any other insurance coverage from other companies:

• Emergency in-Patient Treatment due to Accident
• Diagnosed Cancer (regardless of the type and stage)
• Diagnosed with Acute Lower or Upper respiratory Infection, Pneumonia, Bronchitis, Urinary Tract Infection, Respiratory Tuberculosis, Gastroenteritis, Diarrhea (Irritable Bowel Syndrome), or Tonsillitis

• Emergency In-Patient Treatment due to Accident: 100% lump sum payment via reimbursement of the Maximum Benefit Limit regardless of the incurred actual medical expenses for covered Accident.   

Or

• Emergency In-Patient Treatment | In-patient Treatment due to Cancer: 100% lump sum payment via reimbursement of the Maximum Benefit Limit regardless of the incurred actual medical expenses for covered diagnosed cancer, regardless of the type and stage if confined in an ICU of a Hospital for at least 10 days. Once the claim is paid, MBL is considered fully exhausted, and coverage is automatically terminated. 

Or

• Emergency In-Patient Treatment | In-patient Treatment due to Specific Illnesses: 100% lump sum payment via reimbursement of the Maximum Benefit Limit regardless of the incurred actual medical expenses for diagnosed covered illnesses if confined in a Hospital for at least 5 days.
  
  To file for reimbursement

  1. The Insured Person to proceed to any clinic/hospital of choice. 

  2. Pay the hospital bills, doctor’s fees, and any other hospital charges. 

  3. Secure all requirements listed in the Notification of Claim (NOC) Form. 

  4. File for reimbursement to Pacific Cross. 

  5. Filing for reimbursement means submission of basic requirements as indicated in the Notification of Claim (NOC) Form. 

Emergency In-Patient Treatment due to Accident | In-Patient Treatment due to Cancer | In-Patient Treatment due to Acute Lower or Upper respiratory Infection, Pneumonia, Bronchitis, Urinary Tract Infection, Respiratory Tuberculosis, Gastroenteritis, Diarrhea(Irritable Bowel Syndrome), or Tonsillitis: 100% lump sum payment via reimbursement of the Maximum Benefit Limit regardless of the incurred actual medical expenses

1. The following conditions and all related expenses are not covered under the Pacific Cross Insurance Policy:
2. Confinement required wholly for executive check- ups, routine medical examinations or check-ups or Confinement purely for diagnostic purposes, hearing test or any service and treatment that are deemed unnecessary by the Company to the physical and mental conditions involved, and confinement in a quarantine or isolation facility other than a licensed Hospital.
3. Expenses due to vaccination except the first dose of anti-rabies, anti-venom and anti-tetanus given as an In-Patient treatment in a Hospital.
4. Screening and treatment of congenital, heredo-familial, developmental abnormalities, birth defect and complications arising therefrom.
5. Screening and treatments for Sexually Transmitted Diseases (STD), Acquired Immuno Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), Erectile Dysfunction Syndrome and all complications arising therefrom.
6. Cosmetic Surgery or procedure, or any cosmetic related complication, eye glasses/contact lenses, hearing aids and prescriptions thereof except as may be required for reconstructive Surgery necessitated by Illness or Injury or Accident wholly occurring during the Period of Insurance.
7. Dental care and treatment, braces, dental appliances, dental implant and other dental-related expenses except as provided in the benefits in Schedule 3 of the Policy or as necessitated by Injuries wholly occurring during the Period of Insurance.
8. Durable medical equipment, graft, prosthetic devices, corrective devices other than artificial limb and any form of artificial implant permanent or otherwise unless specified as covered in the Schedule of Benefits.
9. Expenses incurred for Surgery pertaining to perineal repair, sex transformation and enhancement, circumcision and any condition arising therefrom.
10. Expenses incurred for surgical, mechanical or chemical contraceptive methods of birth control or screening and/or treatment pertaining to infertility such as but not limited to sterilization, hormone treatment, artificial insemination, in vitro fertilization or embryo transfer and any procedures and conditions arising therefrom including expenses related to pregnancy and screening.
11. Pregnancy related expenses and screening, childbirth, surgical delivery, miscarriage, abortion including its complications, pre-natal or post-natal care as well as nursing care for a newborn child unless provided for in Schedule 3 of the Policy.
12. Expenses for Out-Patient Medicines, take home Medicines, Professional Fees, procedures and supplies for the continuing phase of treatment after discharge from Hospital confinement unless specifically provided for in the Out-Patient Benefit of Schedule 3 of the Policy.
13. Food supplement; care or treatment by herbalist, bonesetter, hypnotherapist, Chiropractor, Acupuncturist, or any experimental medical procedure or treatment not yet acceptable as a standard of practice unless specifically provided for in Schedule 3 of the Policy.
14. Organ transplantation including follow-up treatment and sequelae whether it is part of an organ or the whole organ itself for donor or recipient
15. Medical expenses or surgical procedures that are not accepted as standard expenses/procedures by the medical profession or treatments subsequent to refusal or failure by an Insured Person to follow recommended therapeutic procedures.
16. Psychotic, mental or nervous/anxiety disorders, degenerative brain disorder including any neuroses and their physiological or psychosomatic manifestations.
17. Auto-immune conditions and their complications arising thereof and the use of immunotherapy.
18. Experimental medical procedures, chelation and laser treatment or non-established medication for various medical conditions except those that are approved by the Company.
19. Professional fees charged by a member of the Insured Person’s immediate family or by a person normally resident in the household of the Insured Person.
20. All Hospital charges and Professional Fees incurred after the day and time the Hospital discharge has been duly authorized.
21. Expenses which are in excess of Normal, Usual and Customary Charges for the geographical area as determined by the Company in consultation with reputable medical practitioners and institutions located in the geographical area.
22. Expenses incurred in rest cures, convalescent, intermediate, domiciliary, and custodial or palliative and hospice care.
23. Injury or Illness arising directly or indirectly out of excessive consumption of alcohol, misuse or irrational use of drugs/medications, solvent/substance or any addicting and habit- forming drug which causes complications that will require treatment or medical intervention. Excessive consumption of alcohol is characterized by the Insured Person’s alcohol level being above the normal rate of such alcohol tests.
24. Treatments or services arising from suicide, attempted suicide or intentionally self-inflicted Injury.
25. Active duty in the military, naval or air forces of any Country or International Authority.
26. Natural Catastrophes; Injuries or Illness arising out of epidemics including military/paramilitary epidemics which are declared by any local, regional or international agency or organization authorized to address health issues in the local and national geographical area or country.
27. Professional fees of medico-legal officer.
28. Charges incurred for provision of all certificates, documentation, information and other pieces of evidence required by the Company including the translation cost of such evidence if other than English in support of an application or claim for benefits.
29. Communication and transportation expenses other than medically necessary telecommunications and local ambulance or transportation services.
30. Injury, or disease arising out of duties of employment or professions with physical hazard.
31. Assault or fighting provoked by the Insured Person; injury or Illness arising directly or indirectly out of any law violation, participation in an illegal and unlawful activity or deliberate exposure to exceptional danger except in an effort to save human life.
32. Ionizing radiations or contamination by radioactivity from any sources like nuclear plant leaks, nuclear waste from process of nuclear fission, or from any nuclear weapon material.
33. Participating in, but not limited to, the following activities including the practice and actual competition: Auto racing, professional sports, Contact Sports, winter sports except recreational skiing within authorized tracks, racing other than foot racing, motorcycling (except daily use for transportation on a paved road), dressage, skydiving, parasailing, hang gliding, flying (other than as a fare paying passenger on a duly licensed commercial aircraft), caving, rock or mountain climbing (with or without the use of ropes or other equipment), bungee jumping, polo, steeplechasing, hitchhiking, sport diving, non-Recreational Scuba Diving as defined in the Policy, or any hazardous activity, unless declared to and accepted by the Company and except for deliberate exposure to exceptional danger not including in an effort to save human life.