Medical benefits question

Dear ATTY,

Way back in Oct 2011, I was hired by a BPO company, and part of the contract that I signed with them is a 100% medical coverage.  Last year the company was sold. So, there is a new owner.  Our medical benefits used to be inhouse because the original owner also owns hospitals and company clinics that is why we used to just show our ID's and that hospital will take care of us without any payments, so as the clinics where we get our medicines. But now the new owner put us on Medicard.  According to HR, our medical benefits should not change. On Jan 21, 2014 while at work around 1:30 am, I lost the function of my left arm and was advised to see the company doctor, my BP is around 150-170.  The doctor administered brown paper bag, when the function of my left hand did not come back, I was brought to the ER of a hospital at EDSA, my BP was 170 that time and gave me meds to lower it down. I fell asleep in the hospital and at around 5 am, I woke up and the function of my left arm has returned, the doctor discharged me saying it is probably metacarpal syndrome. I went back to work and did my duties, but my left arm lost its function again. But this time there was no doctor nor nurse in the office clinic, the doctor has left and the nurse went to bring another patient in the hospital. So, I was not brought back to the hospital. I went home and when I woke up, I was stumbling to my left side. I had a mild stroke.  I was rushed to a hospital and attended to by three doctors.  The HMO card took care of the bills except for the NEUROLOGIST, you see neurologists do not go by any HMO. after 5 days I was discharged and we have to shell out the PF of the neurologist, buy 1 week of medicines and pay for the succeeding consultation fees for the neurologist. I submitted receipts from the hospital and from the doctor's clinic and medicines for reimbursement to our company.  They forwarded it to the HMO (medicard) but the HMO rejected it, saying we should have filed it within 30 days after hospital discharge.  Now HR is telling me to speak with the HMO, but they told me that the contract between me and my employer is not covered by them.  Since it is no longer 100% covered, is this a possible breach of contract between me and my employer?  Please advise, thank you and God Bless.

Health benefit is not mandated and is given to employees by the employer as an added benefit. When you were hospitalized, did you used your philhealth benefit? That should have covered the neurologist or part of the cost for the neurologist.

How much is your coverage in your medicard?

I did use my philhealth.  Our medical coverage is 100% based on the contract that we signed upon hiring. Whenever an accredited hospital will swipe our HMO card it will come out UNLIMITED.

any other inputs?

michael lactao wrote:Dear ATTY,

Way back in Oct 2011, I was hired by a BPO company, and part of the contract that I signed with them is a 100% medical coverage.  Last year the company was sold. So, there is a new owner.  Our medical benefits used to be inhouse because the original owner also owns hospitals and company clinics that is why we used to just show our ID's and that hospital will take care of us without any payments, so as the clinics where we get our medicines. But now the new owner put us on Medicard.  According to HR, our medical benefits should not change. On Jan 21, 2014 while at work around 1:30 am, I lost the function of my left arm and was advised to see the company doctor, my BP is around 150-170.  The doctor administered brown paper bag, when the function of my left hand did not come back, I was brought to the ER of a hospital at EDSA, my BP was 170 that time and gave me meds to lower it down. I fell asleep in the hospital and at around 5 am, I woke up and the function of my left arm has returned, the doctor discharged me saying it is probably metacarpal syndrome. I went back to work and did my duties, but my left arm lost its function again. But this time there was no doctor nor nurse in the office clinic, the doctor has left and the nurse went to bring another patient in the hospital. So, I was not brought back to the hospital. I went home and when I woke up, I was stumbling to my left side. I had a mild stroke.  I was rushed to a hospital and attended to by three doctors.  The HMO card took care of the bills except for the NEUROLOGIST, you see neurologists do not go by any HMO. after 5 days I was discharged and we have to shell out the PF of the neurologist, buy 1 week of medicines and pay for the succeeding consultation fees for the neurologist. I submitted receipts from the hospital and from the doctor's clinic and medicines for reimbursement to our company.  They forwarded it to the HMO (medicard) but the HMO rejected it, saying we should have filed it within 30 days after hospital discharge.  Now HR is telling me to speak with the HMO, but they told me that the contract between me and my employer is not covered by them.  Since it is no longer 100% covered, is this a possible breach of contract between me and my employer?  Please advise, thank you and God Bless.

I don't see any breach between the employer and employee. Check which part of your contract mentions about health benefits. Generally there are exclusions in HMO coverage and it is possible that certain procedures will really not be covered.

When I was hired, it is stipulated in the contract that our medical benefits is full coverage, as in 100% coverage, before the company was sold we do not have to shell out anything if one is hospitalized, which includes medicines. Now, if your medical condition requires a neurologist, the PF and consultation fee will not be covered, you have to pay them before you can be discharged from the hospital, but way back then, you don't have to pay anything. We never signed a new contract and they told us that our old medical benefits will stay as it is.  The contract we signed says full medical coverage, no limit.  You see, we used to be under the PLDT group of companies, and we also have the same medical benefits just like PLDT employees, until the company was sold. But they told us that our medical benefits will not change, but that is not the case when I had a stroke and needed the services of a neurologist.

In my opinion, you can just reimbuse all of your expenses except the pf & neu.
There are certain procedure that has nothing to do actually with the employer. But they can just
extend help. If they have the same procedure with Maxicare you have to go their office and process the reimbursement. Also, check with your HR what is the coverage, regardless Medicard/health card of any health benefits is for the purpose of sickness. I guess, the only problem is, if you only have "silver" plan,something like that, and the hospital is not accredited. But if the hospital is accredited by your card and the plan, there will be no problem in reimbursement of the expenses.
1. Check the coverage
2. Under what plan
3. Maximum benefit limit.
4. If you are not covered, you should have not issued a card.(clear as that)

coverage is 100% covered, as in no limit, unlimited. Neurologists all over PH is not covered by card but the medical benefits is full coverage no matter what is the sickness. Contract upon signing says medical benefit is full coverage.