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Membership Terms and Conditions

By availing of the services of Maxicare Health Services Inc. ’s (“MHSI”), the Member agrees to abide by the following terms and conditions of membership (“Membership Terms”) as well as the provisions of the Service Agreement between MEMBERSHIP TERMS AND CONDITIONS

By availing of the services of Maxicare Health Services Inc.(“MHSI”), the Member agrees to abide by the following terms and conditions of membership (“Membership Terms”) as well as the provisions of the Service Agreement between MHSI and the Member or the Client:

1. Definition of Terms and Interpretation

  1. Act: Republic Act No. 10173, otherwise known as the Data Privacy Act of 2012, as well as its Implementing Rules and Regulations (“IRR”).
  2. Agreement: The Service Agreement, including all schedules, attachments, endorsements, addenda, Conforme Letter, Membership Application Form, Letter of Authorization, and any other contracts or documents governing the relationship between the Member and/or Client and MHSI.
  3. Card: The Prima Card is a personal and non-transferable health card distributed by MHSI to its members as MHSI membership identification. A Card may or may not be issued, and its features may vary, depending on the type of products or services availed of.  
  4. Contact Center: A customer service call center manned by Customer Care Representatives (CCRs) who handle members’ inquiries and concerns via phone.
  5. MHSI Online Enrollment: A service offered by MHSI to its Members to facilitate electronic enrollment pursuant to the Agreement.
  6. Member: A Person who are eligible and have been accepted for membership by MHSI after complying with the membership eligibility set by the latter.
  7. Member Gateway: A web-based application for Members to conveniently inquire on their plan details and availment summary, request for LOA, file reimbursement claims, and search for providers.
  8. Personal Information: Any information, whether recorded in a material form or not, from which the identity of the Member is apparent or can be reasonably and directly ascertained by the entity holding the information, or when put together with other information would directly and certainly identify the Member.
  9. Prima Staff:  CCRs that are stationed to provide assistance to Members for availments and coverage inquiries.
  10. Primary Care Clinic (PCC): A MHSI service facility who facilitates member availments and Primary Care Physicians specializing in Internal Medicine who are available for out-patient consultations.
  11. Teleconsult: TeleConsult is a dedicated telecommunication channel available to some Members who need to speak to a health counselor / doctor and ask for health advice.
  12. Interpretation:
    1. Unless the context otherwise requires, words importing the singular number shall include the plural and vice versa, and words importing the masculine shall include the feminine and neuter gender and vice versa.
    2. Words denoting persons shall include individuals, corporations, partnerships, joint ventures, trusts, unincorporated organizations, political subdivisions, agencies or instrumentalities.

2. Warranties and Representations of the Member

    1. The Member warrants that he has read and understood the contents of the Agreement, including all procedures, benefits, exclusions, limitations and conditions contained therein, and agree to be bound thereby. Furthermore, by availing the services of MHSI, the Member acknowledges and agrees to abide by the Membership Terms, for which the latest version may be accessed via MHSI website at https://maxihealth.com.ph/member-terms
    2. The Member shall submit a duly accomplished Application Form or Customer Information Form and signed conforme to the Membership Terms. The Member warrants that all information provided to MHSI are true and correct. The Member shall ensure that his personal information and contact details are accurate and kept up to date via periodic updates on the Member Gateway or other means authorized by MHSI. Nondisclosure or falsification of information shall be a ground for termination or suspension of membership, without prejudice to any other legal remedies that may be available to MHSI.
    3. The Member agrees and understands that in the course of providing service/s to him or her, MHSI shall engage the services of, and/or interact with, other third parties, such as, but not limited to its parent company, affiliated companies, subsidiaries, financial advisors, affiliated third parties or independent/non-affiliated third parties and service providers, whether local or foreign (collectively referred to as “Representatives”). In connection with the foregoing, the Member hereby irrevocably authorizes MHSI and its Representatives, being his healthcare maintenance services provider, as his attorney-in-fact to:
      1. Obtain, collect, examine, process, and store copies of my personal information, including sensitive personal information, privileged information, medical records or any other information or material, i.e., picture, voice recording, fingerprints, and etc., relative to hospitalization, consultation, treatment or any medical advice in connection with the benefit/claim availed under the Agreement as may be deemed necessary by MHSI.  Except as otherwise stated hereon, any information obtained relative to the authority herein given shall be strictly confidential. The extent of the collection and processing shall be necessary and incidental to the performance of the services contemplated in the Agreement.
      2. Disclose such information to the Company, its representatives, agents and brokers, MHSI and its Representatives,  including the service providers which will perform the services contemplated in the Agreement, and relevant government agencies in compliance with the Republic Act No. 11223 otherwise known as the “Universal Health Care Act”, its Implementing Rules and Regulations, Republic Act No. 11332 otherwise known as the “Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act” and other relevant issuances of the Department of Health and/or Philippine Health Insurance Corporation, and any amendments to such laws and regulations for any legitimate business purpose as MHSI may deem appropriate, including but not limited to outsourced processing of MHSI transactions, billing of co-pay arrangements, lifestyle and rewards partners/providers, profiling or historical statistical analysis, providing advice or information which MHSI and its Representatives believe may be of interest to me or the Company, to effectively administer or manage my account, enhance customer services, or to communicate with me for any marketing purposes.

 Processing is hereby understood to include any operation or set of operations performed upon personal information including, but not limited to, the collection, recording, organization, storage, updating or modification, retrieval, consultation, use, consolidation, blocking, erasure or destruction of data. Processing would include both manual and automated handling of personal information and storage and data transfers using various means including but not limited to physical methods as well as electronic via information and communications systems employed by MHSI and its Representatives.

  1. The Member hereby warrants that he understands his rights and obligations pursuant to the Data Privacy Act and its implementing rules and regulations. He understands that he retains the right to be informed, to object, access, complain, and rectify, to request for filtering of certain information, and to the corresponding damages in case of violation of his rights within the corresponding limitations as set forth in the pertinent laws.
  2. The Member hereby represents that, in order to provide the services contemplated in the Agreement, the authorities herein provided shall be valid and existing during the term of the Agreement, including any extensions thereof, and until necessary for the establishment, exercise or defense of any claims arising from the said Agreement.
  3. The Member agrees to hold MHSI and its Representatives free and harmless from and against any and all suits or claims, actions, or proceedings, damages, costs, and expenses, including attorney’s fees, which may be filed, charged, or adjudged against MHSI or any of its directors, stockholders, officers, employees, agents, or Representatives in connection with or arising from the use, processing and disclosure by MHSI or its Representatives of the aforementioned information pursuant to MHSI’s reliance on his consent that MHSI and its Representatives have the authority to examine, use, process, store, share, or disclose, as the case may be, said information for the purposes above-mentioned.

3. Availment of Healthcare Benefits

  1. The Member’s availment of the medical services issued by MHSI’s Prima Staff, Primary Care Centers, Customer Care Representatives, Affiliated Coordinators and Partners, Member Gateway, and/or other MHSI electronic systems, signifies that he agrees with the Membership Terms and the Agreement, and the Member’s signature may not be required.
  2. It is hereby understood that MHSI shall not be responsible for the payment of charges/expenses resulting from:
    1. Availment of the following hospital or medical services/treatment/procedures (diagnostic and therapeutic):
      1. those rendered by non-affiliated physicians/ specialists or a reliever physician;
      2. those not related to this confinement as determined by the Claims Department of MHSI;
      3. those without prior authorization of MHSI;
      4. those miscellaneous items outside of the Member’s healthcare benefit plan;
      5. room accommodation beyond the benefit plan limits; or
      6. co-payment and/or coinsurance defined for the service;
    2. Failure to file PhilHealth benefit claim to cover all PhilHealth costs incurred during confinement;
    3. Member’s personal preference to prolong confinement beyond the attending physician’s prescribed duration of hospitalization;
    4. Amount in excess of the Member’s allowable benefit limit in the professional fee of attending doctor/s with whom Member has prior agreement;
    5. Benefit availment found to be not covered and deemed excluded by the Agreement, including concealment of relevant medical information, even if unintentional or unrelated to the current availment, and those in excess of Benefit Limits set out in the Agreement, even if conditionally approved by MHSI. If at the time of issuance of the LOA, the amount of the Member’s previous availment is not reflected yet, MHSI reserves the right to re-adjudicate the Member’s coverage based on the total remaining balance of the benefit limit; and
    6. Other expenses and charges analogous to the foregoing.

     

        MHSI shall collect from the Member the expenses incurred relative to any availment, if upon post verification by MHSI, any of the above-mentioned circumstances shall be found present. The request for LOA may likewise be denied outright in the event that the availment is not coverable by MHSI.

     

  3. The Member confirms that the benefits and coverage requiring the services of a physician shall only be performed in PCC. The Member is aware that there are agreed standard professional fees for specific medical services between the physicians and MHSI. 
  4. Limitations in Services

      The rights of the Member and obligations of MHSI are subject to the following limitations:

  1. If a major disaster or epidemic causes unavailability of facilities or personnel, or if circumstances not within the control of MHSI such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes, or similar causes occur, MHSI shall not be held liable for any delay or failure to provide services to the Member. MHSI shall, however, exert its best effort to provide services to the Member, as the circumstances permit.
  2. MHSI’s aggregate liability for out-patient, in-patient and emergency care benefits for any one-year period with respect to any particular disease/condition and their complications shall be limited to the Member’s ABL/MBL.
  3. MHSI’s obligation with respect to the professional fees of affiliated physician/specialist for specific medical services shall be limited to the agreed MHSI’s standard professional fees.
  4. If the Member refuses to follow the recommended treatment or procedures and the affiliated physician believes that no professionally acceptable alternative exists, then MHSI shall no longer be responsible to provide care for the condition under treatment while such refusal exists. Further, if the earlier refusal resulted in the aggravation of the medical condition, MHSI shall no longer be responsible for the treatment thereof.
  5. If a Member refuses to comply with established rules, regulations and procedures of the chosen hospitals or clinics and by reason of which services are denied, MHSI shall not be liable for any claims, charges or damages caused to the Member.
  6. MHSI is not liable for any claims, charges or damages, legal fees or litigation cost incurred by or caused to the Member by the acts of the doctors or physicians in the course of the delivery of the medical services, whether in-patient, out-patient or emergency. It is hereby understood that the liability of MHSI is limited to the payment of hospital bills, professional fees and all medical expenses directly related to the medical management of the Member.

4. MHSI Electronic Facilities

  1. Processing of the transactions and information of the Member may be performed electronically via information and communications systems developed by MHSI and its Representatives. The availability of the electronic facilities to the Member may depend on the provisions of the Agreement.
  2. MHSI shall not be liable for any loss or damage of whatever nature in connection with the use of the aforementioned facilities in the following instances:
    • Disruption, failure or delay which are due to circumstances beyond the control of MHSI, fortuitous events such as but not limited to prolonged power outages, breakdown in computers and communication facilities, typhoons, public disturbances and calamities, and other similar or related cases;
    • Loss or damage the Member may suffer due to theft or unauthorized use of his Prima  Card, passwords, personal data, or violation of other security measures with or without his participation; and
    • Inaccurate, incomplete or delayed information that Member received due to disruption or failure of any communication facilities.
  3. In the event that the user of the electronic facility is not the Member, the user hereby represents and warrants that he is duly authorized to represent and act on behalf of the Member and he shall hold MHSI and its Representatives free and harmless from any claim, cost, or damage that may arise as a result thereof.  
  4. MHSI shall not be liable for any loss, liability, damage or expense arising out of or in connection with the use of the electronic facilities, unless such loss, liability, damage or expense shall be proven to result directly from the gross and willful misconduct of MHSI or its Representatives. In no event will MHSI be liable for special, indirect, punitive or consequential damages. Under no circumstances will the liability of MHSI exceed, in the aggregate, the fees actually paid pursuant to the Agreement.
  5. MHSI and its Representatives retain all rights in any software, user and system documentation, master and transaction data files, ideas, concepts, know-how, processes, development tools, techniques or any other proprietary material or information related to the electronic facilities.
  6. Disclaimers for Use of Teleconsult Services
    1. The services received from MHSI’s health counselor are not intended to replace a primary care physician relationship. The Member should seek emergency help or follow-up care when recommended by the health counselor or when otherwise needed, and continue to consult with his primary care physician and other health care professionals as recommended. Anticipated benefits may be expected but no results can be guaranteed or assured. The health counselor, in his sole discretion and professional judgment, may determine that Teleconsult services are not appropriate for some or all of the Member’s treatment needs and, accordingly, may elect not to provide Teleconsult services to a Member.
    2. MHSI makes no representations or warranties, express or implied, with respect to the health advice to be provided by the health counselor. It does not warrant the reliability, accuracy, timeliness, usefulness, adequacy, completeness or suitability of the advice provided. Furthermore, it does not guarantee that a video and/or telephone consultation is the appropriate course of treatment for the Member’s particular health care problem. The Member hereby agrees to contact his physician immediately should his condition change or symptoms worsen.
    3. Limitation of Liability: MHSI shall not be liable for any loss, liability, damage or expense arising out of or in connection with the health advice to be provided by the health counselor, unless such loss, liability, damage or expense shall be proven to result directly from the gross and willful misconduct of such person.
    4. Potential Risks: It is hereby understood that the following risks are associated with Teleconsult services:
      • The information provided by Members may be insufficient to enable the health counselor to provide appropriate medical or health care advice;
      • There may be delays in evaluation due to failure of the electronic equipment;
      • The lack of access to all the Member’s medical records may result in adverse drug reactions or allergic reactions or other judgment errors; and
      • There may be symptoms and ailments that may not be completely diagnosed except through actual physical examination or observation of demeanor which may cause misdiagnosis or errors in treatment.

5. Invalidation or Termination of Membership

  1. Invalidation of Membership:
    Failure to disclose any material information about a Member, including but not limited to gender, date of birth, or medical information, whether intentional or unintentional, shall automatically invalidate the coverage of the Member effective from the date of coverage. An information is deemed material if its disclosure would have resulted in the:     

    1. Declination of the application for Membership of the Applicant;
    2. Assessment of a higher Membership Fee;
    3. Inclusion of additional restrictions and exclusions to the benefits of the Member under the Agreement. The Client shall reimburse MHSI for the difference between the cost of any medical services rendered to such Member and the membership fee.
  2. Termination of Membership:
    The rights of the Member shall be extinguished at any of the following dates: 

    1. Expiry date of the Agreement;
    2. When obligations to MHSI are not paid within the grace period;
    3. Effective immediately, when the Member has fraudulent availment or material misrepresentations or misstatements for the purpose of availing MHSI benefits;
    4. Effective immediately, when the Member enters military, naval or air service of any country or international authority;
    5. Effective immediately, when the Member fails to observe the terms and conditions of the Agreement or fails to act with utmost good faith.

6. Miscellaneous Provisions

  1. Waivers. MHSI may waive compliance by the Member of any provision of the Membership Terms provided, however, that such waiver shall not operate as a waiver of or estop the right to invoke compliance therewith. Likewise, no failure to exercise and no delay in exercising any right, remedy, or power hereunder shall operate as a waiver thereof.
  2. Successors and Assigns. The Membership Terms shall be applicable to the benefit of and shall be binding upon the Member and his respective successors and assigns. The Member shall have no right to assign or otherwise transfer, in whole or in part, any of his rights or obligations pursuant to the Membership Terms without obtaining the prior written consent of MHSI.
  3. Attorney’s Fees and Cost of Litigation. In the event of any legal action or other proceeding brought to enforce the Membership Terms, MHSI shall be entitled to reasonable attorney’s fees and other costs incurred during that proceeding in addition to any other relief to which it is entitled. MHSI shall be entitled to collect Two Hundred Thousand Pesos (P200,000.00) as minimum damages, in addition to any other damages which it may be entitled under the Agreement and under the law, and attorney’s fees in the amount of One Hundred Thousand Pesos (P100,000.00) in the event that it shall be constrained to engage the services of counsel to prosecute its claim.
  4. Severability Clause. If a court of competent jurisdiction holds any provision of the Membership Terms unenforceable or invalid, such provision shall be severed and shall not affect the validity or enforceability of the remaining provisions.
  5. Complete Agreement. This Membership Terms and any addenda thereto, including the Agreement and all amendments and supplements thereto, shall constitute the complete agreement and sets forth the entire understanding of the parties as to the subject matter of this Membership Terms and supersede all prior discussions and understandings in respect to the subject of this Membership Terms, whether written or oral.  
  6. Amendments: MHSI may, at any time and for whatever reason, amend, revise or modify the Membership Terms when deemed necessary and it shall inform the Member of such fact by publication, posting, electronic mail or any other means that MHSI deems proper. Any and all amendments, revisions or modifications shall be binding upon the Member.
  7. Settlement of Disputes. The Member agrees to reconcile and amicably settle, on a best effort basis, any dispute and/or differences arising out of, or connected with, this Membership Terms.
  8. Governing Law and Venue. The Membership Terms shall be governed by and construed in accordance with the laws of the Republic of the Philippines. Any legal action or proceedings arising out of or in connection with this transaction contemplated herein shall be brought exclusively in the proper courts of Makati City.

* The Terms and Conditions are subject to change. You may access https://maxihealth.com.ph/member-terms for the latest version of the Member Terms and address any Data Privacy queries related thereto to dpo@mhsi.com.ph.

 

Form Template Control: Human Resources / May 7, 2025 / MHSI-FO-HR-097 / Rev. 00