APPLICATION FORM

Let us start securing your family.

Apply for a PangPamilya Healthcare Insurance for you and your family.

Start Here

SCHEDULE OF BENEFIT & PREMIUMS

IN-PATIENT PLAN – PhilHealth DependentCoverage
Room & Board, per day, max of 31 daysUp to PHP 2,000 per day
Physician’s Visit, per day, max of 31 daysUp to PHP 2,000 per day
Miscellaneous Hospital ExpenseAs Charged
Surgeon’s Fee, as per Surgical Schedule based on RUVAs Charged
Anesthesiologist Fee, 35% of Surgeon’s FeeAs Charged
Specialist Fee, max of 7 daysAs Charged
Ambulance Fee2,500
Out Patient Benefit
ConsultationAs Charged
Prescribed Basic Diagnostic ProcedureAs Charged
Annual Benefit Limit (Shared limit for 1 Principal & 2 dependents)PHP 200,000

COVERED BENEFITS:

  • EMERGENCY CARE
  • FINANCIAL ASSISTANCE
  • DENTAL BENEFITS
  • PREVENTIVE CARE
  • IN-PATIENT BENEFIT
  • OUT-PATIENT BENEFIT
  • SPECIAL PROCEDURES AND NEW MODALITIES OF TREATMENT
  • ANNUAL PHYSICAL EXAMINATION (Basic”7”) For Principal Dependent only

CONDITIONS:

The limit is based on Annual Maximun Benefit Limit to be shared by the principal insured and 2 declared dependents.

  1. Each insured member shall only be limited up to 50% of the total 200K benefit limit. Any charges in excess of the benefit shall be for the account of the insured member.
  2. The Plan is in addition to the benefits provided by PhilHealth. The insured member shall submit the accomplished PhilHealth form prior to hospital discharge for the billing, to be net of PhilHealth Benefits.
  3. Open Room & Board (ward, semi private, private, suite) up to a maximum of chosen daily roon & board limit per day plan option.
  4. Room accommodation more than the room and board limit.
    • During Emergency confinement if there is no available room equal to the Room and Board limit, all eligible expenses on the 1st 24-hour of stay is covered. However, if the Insured opted to still stay even though a room equal to his limit becomes available, he will have to pay the incremental costs, excess or ineligible expenses prior to discharge.
    • During Non-Emergency confinement, should the Insured stays in a room higher than the Room and Board limit, the Insured shall pay for any excess, ineligible expenses and/or corresponding incremental costs incurred prior to discharge.
  5. Excess, ineligible expenses and/or incremental costs prior to discharge from the hospital, the Insured should settle any of the following:
    • Excess over the plan limit
    • Ineligible expenses such as but not limited to extra food, extra bed, etc.
    • Incremental costs on professional fees, diagnostic tests, drugs and medicines resulting from taking a room and board accommodation more than the room and board limit of the plan.
    • Should the Insured person is not available to settle any excess, ineligible expenses and/or incremental costs, the Policy holder should settle the Insured’s obligation.

IMPORTANT NOTES:
This application is subject to review. Its
acceptance is based on the Underwiring
guidelines of the Company. Please submit the duly accomplished application form to your Agent.

DISCLAIMER:
The information contained in the application form is just a brief
description of the available coverage under the Pangpamilya program. This is not a statement of contract, the full coverage is subject to the terms, conditions, exclusions and limits of liability stated in the policy contract.

PangPamilya Medical Insurance Application Form

Medical Insurance Application Form

Medical Insurance Application Form

Kindly submit one for each dependent and principal.

Insured Name:
Insured Name:
First
Middle
Last
Name of Principal/ Employee
Name of Principal/ Employee
First
Middle
Last
Name of Dependent Insured
Name of Dependent Insured
First
Middle
Last
Name of Dependent Insured
Name of Dependent Insured
First
Middle
Last
Are you presently in good health, actively at work, and entirely free from any physical or mental impairments or deformities?
Has any person named in this form been admitted to a hospital or had any medical tests done in the last 2 years?
Does any person named in this form anticipate the need or has been recommended to undergo any medical tests or procedures in the next 6 months?
Has any person named in this form been consulted and/or provided prescriptions for any drugs or medication in the last 2 years?
To the best of your knowledge, are all person proposed for membership in good health and free from any impairment or illness?
Has any application for life, accident, health or any other insurance been rejected or had been accepted with higher premiums or with exclusion?
Declaration: I DO HEREBY DECLARE that the person(s) to be insured is/are in good health and free from any physical impairment. I will give notice to the Company of any changes in health and occupation of the person(s).
Declaration: I DO HEREBY DECLARE AND WARRANT the answers given above in every respect are true and correct; and I have not withheld any information likely to affect acceptance of this Proposal; and agree that this Proposal declaration shall be the basis of the Contract between the Company and me. And I further agree to accept the Company’s Policy subject to the terms, exclusions and conditions to be expressed therein, endorsed thereon or attached thereto.
Check the box if you agree with our Data Privacy Policy.

Got a question?

Schedule a consultation with us to know more about our services.

CONTACT US

Menu

Get in touch

US Address:  
East Coast: 100 WEST AVE. SUITE 910 JENKINTON PA 19046

Contact No.: +1 484-215-088

West Coast: 1557 E Amar Rd Ste H, West Covina CA 91792

Contact No.: 626 512 5726

Philippine Address:
RM 106 CLARK WELCOME CENTER OFFICE SUITES BERTHAPHIL 8 CPD., SCTEX ROAD, CLARK FREEPORT, MABALACAT, 2023 PAMPANGA

Contact No.: +63966-750-4548

8AM – 5PM MNL

secure@pangpamilya.org

Follow us