OCA CIRCULAR NO. 22-2012, March 26, 2012

For the information of all concerned, the Court en bane, in Its Resolution dated January 31, 2012 in A.M. No. 98-8-01-SC (Re: Supreme Court Health and Welfare Plan [re Implementing Rules and Regulations]), approved the hereunder Implementing Rules and Regulations of the Supreme Court Health and Welfare Plan for the Lower Courts:

Implementing Rules and Regulations of the Supreme Court Health and Welfare Plan
for the Lower Courts

I.      OVERVIEW

The Supreme Court Health and Welfare Plan for the Lower Courts is a medical benefits scheme which aims to provide financial assistance to officials and personnel of the Lower Courts (RTCs, MeTCs, MTCCs, MTCs, MCTCs, Shari’a District Courts, Shari’a Family Courts and Shari’a Circuit Courts). Membership to the Plan shall be voluntary. Benefits assistance is, primarily, by way of reimbursement of hospitalization and other medical expenses.

The groundwork for the implementation of the Supreme Court Health and Welfare Plan (SCHWP) was laid down through En Banc Resolution in A.M. No. 98-8-01 SC (Creation and Operation of the Supreme Court Health and Welfare Plan) dated August 19, 1998.
Policy-making and administrative supervision over SCHWP matters shall be exercised by a Board.

Screening and processing for payment of claims for the SCHWP for the Lower Courts shall be done through a complement of workers, collectively called “Secretariat”. Medical Screening Committees evaluate claims prior to approval by the Board. There are three (3) screening committees, Committees “A”, “B”, and C”, headed by a medical doctor, and composed of 3 other members who are representatives of the Office of the Chief Justice, the Office of the Clerk of Court-En Banc, and the Office of the Court Administrator.

II.     MEMBERSHIP/COVERAGE

1.    Membership   to   the   Plan   shall   be   voluntary  for  all  judges, officials   and    personnel   of   first   and   second   level   courts nationwide, including maintenance staff in the Halls of Justice;
2.    Active membership commences once initial monthly dues has been paid.
3.    Payment of monthly dues is through salary deduction;  the rates shall be uniform.

III.   BENEFITS
1.    Hospital Confinement (Medical or Surgical)

Up  to P50,000.00   per  member  per  year,   exclusive  of PhilHealth benefits;
Additional     £ 20,000.00,  if illness  is dreadful  (Total   :  70,000.00 per member per year);
Covers    all    in-patient    services    which    are    medically necessary,  including  room and  board,  professional fees, use  of operating   room  and   recovery  room,  medicines, blood  and  blood  products,  x-ray,  and  other laboratory procedures.

2.    Out-Patient Benefits

Up to P 20,000.00 per member per year deductible from the maximum benefit limit of P 50,000.00 per member per year;
Additional  P  30,000.00,   if  illness   is  dreadful   (Total   : P50,000.00 per member per year);
Includes professional fees and charges for consultation, prescribed diagnostic procedures, treatment of minor injuries, emergency care, and prescribed vaccinations and/or medications excluding vitamins and food supplements.

3.    Special Out-Patient Procedures

The following  special  procedures may be  reimbursed  up to £ 50,000.00 event as out-patient:
Cataract extraction including cost of lens and professional fees;
Extra Corporial shock wave lithotripsy;
Chemotherapy,   radiotherapy,   bracchytherapy,   and   other similar modalities for treatment of a dreadful condition;
Hemodialysis and/or peritoreal dialysis;
Coronary   angiography,   angioplasty   and   other   similar
procedure either for diagnostic or therapeutic.

4.    . Dreadful Illnesses
The following ailments shall be considered as dreadful:

Cerebrovascular accidents (thombo-embolic or hemorrhagic) with resultant coma or paralysis;
Central    nervous    system    tumor   or    infections    (e.g., encephalitis, meningitis and the like);
Complicated cardio-vascular conditions;
Chronic obstructive pulmonary disease stages III and IV;
All forms of malignancy (in any stage);
Chronic kidney failure, stages  IV and V;
Decompensated Liver Cirrhosis;
Gastro-intestinal    tract    bleeding    and     other    related
conditions    requiring    exploratory    laparotomy/intestinal
resection and/or anastomosis;
Blood dyscrasias, (e.g., Leukemias, lymphoma, idiopathic
thrombocytopenic purpura, and the like);
Major forms of trauma with attendant complications such
as paralysis and/or similar conditions.
NOTE: Any Nlness/condition(s) not among those mentioned above shall not be regarded as dreadful, unless medical evaluation shows otherwise.
5.     Burial Assistance
P 20,000.00 per member.

IV.    EXCLUSIONS

Not covered under the benefits are the following:
1.    Herbal     medicines  and  medicinal   products  not  licensed   by BFAD;
2.    Alternative   methods  of  health   care  which   include   but  not limited to acupuncture, acupressure, chiropra.ctics, nutritional therapy,   and   other  similar  methods  of  treatment  are   not reimbursable under this plan, unless the method was availed as remedy when conventional methods of cure have proven to be ineffective. To be reimbursable, the availed method should have been prescribed and/or undertaken under supervision by a licensed physician and/or chiropractor;
3.    Dental   procedures,   such   as   tooth   extraction,   root   canal treatment, oral prophylaxis, gum treatment, prosthesis and the like except surgical removal of impacted tooth when indicated as certified by attending Orthodontist;
4.    Expenses for optical and hearing aid devices;
5.    Pregnancy-related   expenses   including   pre-natal   check-ups, normal spontaneous delivery, caesarian section, dilatation and curettage due to spontaneous abortion, and post-delivery care;
Note: In cases when spontaneous delivery is attended by complication such as uncontrolled vaginal bleeding with resultant emergency hysterectomy (removal of the uterus) the expenses incurred for said procedure i.e. hysterectomy, may be   reimbursable   upon   thorough   evaluation   by   the   SCHWP Screening Committee.
6.    Treatment   of   any   injury   attributable   to   a   member’s   own
misconduct, gross or contributory negligence, intemperate use of drug or alcoholic beverages, vicious or immoral acts, direct or indirect participation in the commission of crime, violation of law or ordinances;
7.    Treatment   of   injuries   or   illness   resulting   from   suicide   or self-destruction whether sane or insane;
8.    Cosmetics    services,    plastic    and    reconstructive    surgery,experimental    procedure,    sex   transformation    and    services related to fertility, infertility, artificial insemination circumcision and organ transplant;

Note: In case of severe trauma wherein restoration of the anatomical function of the affected part is deemed necessary, reconstructive surgery may be considered upon thorough evaluation of the SCHWP committee.
9.    Congenital defects;
10.    Sexually transmittable diseases, such as, but not limited to the   following:    Gonorrhea,   Urethritis   (gonococeal   or   non-gonococeal),    Penile/Vaginal    Warts,    and    the    like,    except HIV-related diseases, such as AIDS;
11.    All other items not directly related to the medical management of the member-employee such as extra bed, extra food, extra television and other amenities.

V.     RULES ON FILING CLAIMS

1.    Claims   should   be   filed   within   the   reglementary   period   as follows:
a.    Out-patient Claims
File within 30 days from date of availment/payment of doctor’s fee, purchase of medicines and/or payment of laboratory fees);
b.    Hospital Confinement
File within 60 days from date of discharge;
c.    Dreadful diseases
File within 90 days from date of discharge for hospital confinement claims or date of availment/payment of doctor’s fee, purchase of medicines and/or payment of laboratory fees for out-patient claims;
d.    Burial
File within 365 days from date of death.
2.    If the claim is directly filed at SCHWP Secretariat, the date of receipt at SCHWP is the date of filing.
3.    If a  claim  is  mailed,  the date  of mailing  indicated  in  the envelope shall be the date of filing.
4.    All   necessary   documentary   requirements   shall   be   complied with   upon  filing.   Claims filed   with   incomplete  documentary requirements shall outright be disapproved.
5.    If   an    illness    is    continuing,    medical    certification,    and/or prescription for said illness should be updated at least every 6 months.
6.    Claims    filed    beyond    the    reglementary    periods    shall    be disapproved.
7.    Motion for Reconsideration of denied claims shall be filed within ten (10) working days from receipt of a notice of disapproval.

VI.    DOCUMENTARY REQUIREMENTS FOR PROCESSING/PAYMENT OF
CLAIMS    

1.     Confinement:
a.    Application   Form   duly   accomplished,   attested   by   the Judge/Exec.   Judge,  or whenever appropriate,  the  Chief of    Office,    Administrative    Services    –    Office    of   the Court     Administrator,   or  the   concerned   Deputy   Court Administrator;
b.    Medical Certificate (should indicate date of issuance, name of patient, and diagnosis);
c.    Statement      of      Account      (should      indicate      the MEDICARE/PHILHEALTH deduction);
d.    Medical Prescription and Receipts of medicines purchased;
e.    Hospital Bill Receipts – original copy (should the indicate
MEDICARE/PHILHEALTH deduction);
Note: Claimants whose hospital bill has been paid by a private HMO shall submit either a certificate of payment issued by the private HMO or a certified true copy of the receipt issued by the hospital to the HMO. Either of the two documents shall be submitted within sixty (60) days from the date of the filing.
f.    Professional fee receipts – original copy (should indicate
the MEDICARE/PHILHEALTH deduction);
Note: Acknowledgment receipts issued by attending doctors shall not be honored as official receipt.,
g.    Operative and Anesthesia Records – certified true copy issued by the hospital (if necessary);
h.     Histopathology results (if necessary).
Note: Failure to submit above requirements within reglementary period shall be a ground for disapproval.
2.     Out-patient:
a. Application Form duly accomplished, attested by the Judge/Exec. Judge, or whenever appropriate, the Chief of Office,   Administrative   Services   –   Office   of   the   Court
Administrator,      or     the     concerned      Deputy     Court Administrator;
b.    Medical Certificate – original or certified true copy (should indicate date of issuance, name of patient, and diagnosis);
c.    Medical Prescription and Receipts of medicines purchased (should indicate clearly the items purchased) (if medicine expenses are to be reimbursed);
d.    Professional/consultation   fee   receipts   (if   professional/ consultation fees are to be reimbursed);
e.    Doctor’s   request/results   of  laboratory   exams   including original   official   receipt   (OR)  of  the   examination   done (if laboratory fees are to be reimbursed).
3.     Burial:
a.    Application   Form   duly   accomplished,   attested   by   the Judge/Exec. Judge, or whenever appropriate, the Chief of Office,   Administrative   Services   –   Office   of   the   Court Administrator,      or     the     concerned      Deputy     Court Administrator;
b.    Death Certificate (certified true copy);
c.    Marriage   contract   (if   married   at   the   time   of  death, optional);
d.    If the claimant is other than the indicated  beneficiary, proof    of    funeral    expenses    (e.g.    Original    receipts, certification for funeral parlor, etc.) and affidavit of waiver;
e.    Affidavit of Guardianship (for dependents of minor age).

VII. POLICIES IN CLAIM PROCESSING

1.    Only out-of-pocket (OOP) payment claims shall be processed.
2.    Only original official receipts shall.be accepted. VAT-registered cash invoice and sales invoice may be allowed if it indicates the name   of   pharmacy/drugstore,   address,   Tax   Identification Number,  VAT registration  number and  clearly  indicates the item(s) bought; otherwise, it shall not be honored.
3.    Drugs/medicines and laboratory procedures/examinations shall be reimbursed if deemed medically necessary and related to the actual diagnosis as per attached medical certificate.
4.    Prescription  for maintenance  medication  should  be  updated every six (6) months. Non-compliance with this requirement shall be a basis for disapproval of claim.

VIII.POLICIES     ON     DISTRIBUTION     OF     BENEFITS     AND     BURIAL ASSISTANCE OF DECEASED MEMBER

1.    The   burial   assistance   and   medical   reimbursements   of the deceased member shall be equally divided among the declared beneficiaries.
2.    In the absence of declared beneficiaries, the burial assistance and medical reimbursements of th.e deceased member shall be distributed in accordance with the applicable provisions on testate or intestate succession. In the absence of any qualified claimant, the claim shall be forfeited by the SCHWP.
3. Those who paid for the funeral expenses can claim the burial assistance but not the medical reimbursements provided that the claimant shall comply with the requirements indicated in VI.3 herein.

IX.   LIBERAL CONSTRUCTION

In  exceptional  and  meritorious cases, the Board  may relax the application of the rules for the benefit of the claimant.

X.     EFFECTIVITY

These guidelines shall take effect upon approval of the Court En Banc for all SCHWP claims with admission/confinement dates filed thereafter.

Previous memoranda and/or board resolutions inconsistent with these guidelines are hereby revoked or repealed.

March    26 , 2012