Philhealth Benefits



This is a summary of the philhealth benefits and coverage given by Philhealth to its members and beneficiaries.  Although updates may be checked further at the website of: http://www.philhealth.gov.ph/

The said office enjoins all Filipinos to be a member. As such, the readers are encourage to learn more of the services offered by the company and the contribution to maintain it. 




Inpatient coverage:










Outpatient coverage:

    Day surgeries, dialysis and cancer treatment
    procedures such as chemotheraphy and radiotheraphy in accredited hospitals and free-standing clinics.

Special benefit packages:

  • Enhanced Outpatient Benefit Package
  • Coverage for up to the fourth normal delivery!
  • Newborn Care Package
  • TB treatment through DOTS
  • SARS and Avian Influenza Package
  • Influenza A (H1N1) Package

Exclusions/non-compensables

Coverage for normal spontaneous deliveries
PhilHealth provides compensation for uncomplicated normal spontaneous delivery or NSD of the first four births done either in hospital or non-hospital settings.
For deliveries in hospital facilities - subsidy shall be broken down as follows:
Services
Coverage
Hospital charges
Professional fees
Php 2,500
Php 2,000

Total

Php 4,500
For deliveries in non-hospital facilities a comprehensive package consisting of maternal and childcare services are offered under the Maternity Care Package.

Details of coverage:

Amount of coverage
Php 4,500
Services included
Prenatal to postnatal care including family planning services
Providers
Duly accredited birthing homes, maternity and lying-in clinics etc.
Eligibility
Confinement within validity period as stated in the Member Data Record
Exclusions
  • NSD of the fifth and subsequent births
  • Maternal age of less than 19 years
  • First pregnancy of patients aged 35 years and older
  • Multiple pregnancies
  • Ovarian abnormalities (ovarian cyst)
  • Uterine abnormalities (myoma uteri)
  • Placental abnormalities (placenta previa)
  • Abnormal fetal presentations (breech)
  • History of three or more miscarriages/abortions
  • History of one stillbirth
  • History of major obstetric and/or gynecologic operation (cesarian section, uterine myomectomy).
  • History of medical conditions such as hypertension, pre-eclampsia, eclampsia, heart disease, diabetes, thyroid disorder, morbid obesity, moderate to severe asthma, epilepsy, renal disease, bleeding disorders.
  • Other risk factors that may arise during present pregnancy (e.g. premature contractions and vaginal bleeding) that warrants a referral for further management.
Other conditions
Pregnancies resulting to abortion are not covered by the limitation of coverage of vaginal deliveries of the first four births.

Enhanced Outpatient Benefit Package

Enjoy a comprehensive package of benefits designed to ensure the health of our new heroes and their families.
A. Consultation
B. Diagnostic services
  • Complete blood count (CBC)
  • Routine urinalysis
  • Fecalysis
  • Fasting blood sugar
  • Blood typing
  • Hemoglobin/Hematocrit
  • Electrocardiogram (ECG)
  • Anti-streptolysin O (ASO-Titer)
  • Hepatitis B Screening Test
  • Treponema pallidum hemaglutination assay (TPHA)
  • Potassium hydroxide (KOH)
  • Erythrocyte sedimentation rate (ESR)
  • Pregnancy test
  • X-ray (Skull, Chest, Lower and Upper Extremities)
  • Sputum Microscopy
  • Pap Smear
C. Visual acuity examination
D. Psychological evaluation and debriefing
E. Promotive/preventive health services:
  • Visual acetic acid screening for cervical cancer
  • Periodic digital rectal examination
  • Periodic clinical breast examination (CBE)
  • Counseling for cessation on smoking
  • Lifestyle modification (regular blood pressure measurement and nutritional or dietary counseling)
  • Counseling for reproductive health particularly breastfeeding
  • Nutritional or dietary counseling
F. Auditory evaluation
G. Treatment of the following diseases based on PhilHealth-adopted clinical practice guidelines:
  • Urinary tract infection (UTI)
  • Upper respiratory tract infection (URTI)
  • Acute gastroenteritis (AGE)








Availment procedures

Here are two simple steps for you and your families to avail of the enhanced outpatient benefit package:
  1. Present clear copy of Member Data Record or MDR to the receiving clerk of the hospital.

    • If qualified dependent is not listed in the MDR - submit valid ID and proof of dependency
    • If MDR is not available - present also valid official receipt of premium payment

  2. After verification, you may now proceed to the doctor for consultation!
Note:
Availment of this package shall not be deducted from your 45-days allowance for room and board and from the separate 45-days allowance of your dependents.

TB treatment through DOTS

Treatment of new cases of pulmonary and extra-pulmonary tuberculosis in children and adults are covered through the Directly Observed Treatment Shortcourse or DOTS, the shortest and most effective internationally accepted treatment protocol for TB.

Details of coverage:

Amount of coverage
Php 4,000
Services included
Diagnostic work-up, consultation services and anti-TB drugs required in an outpatient set-up.
Providers
Duly accredited TB-DOTS Centers (available in the Philippines only)
Eligibility
New cases only, i.e., patient has never had treatment for TB or who has taken anti-TB drugs for less than one month.
Enrolment with TB-DOTS center falls within the validity period as stated in the Member Data Record.
Exclusions
Failure cases - a patient who, on previous treatment, is sputum smear positive at five months or later during the course of treatment.
Relapse case - a patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB.
Return after default (RAD) cases - a patient who returns to treatment with positive bacteriology (smear of culture) following interruption of treatment

SARS and Avian Influenza (Influenza Pandemic or Bird Flu) Package

Details of coverage:

Amount of coverage
For members and their qualified dependents - Php 50,000 per case.
For health care workers or HCW (forefront and high risk) - Php 100,000 per case.
Services included


  • Professional fees (Php 2,500 - pay to doctor)
  • Hospital charges (Php 42,500 - pay to hospital)
  • Official receipts amounting to Php 12,000 (Php 5,000 - pay to member)
Providers
Patients must be admitted only in accredited DOH-designated SARS or AI/IP hospitals.
Confinements abroad shall be paid compensated provided a certification from the attending physician is submitted.
Eligibility
Must be certified by the DOH as SARS or avian influenza/influenza pandemic patient.
Confinement within the validity period as stated in the Member Data Record.
Exclusions
SARS suspect cases.
Cases of acute respiratory illness where an alternative diagnosis can fully explain such illness.
Other conditions
Rule on single period of confinement and 45-days allowance for room and board per year applies.
Other conditions (for afflicted HCWs)


  • Must also be active PhilHealth members.
  • Contracted the disease while caring for a SARS or AI/IP patient (person to person transmission).
  • Renders service in DOH-designated hospital.
  • DOH attests that HCW contracted the disease while on official duty.


Special benefit packages

Influenza A (H1N1) Package

PhilHealth Coverage for Confirmed Cases of
Novel Influenza A (H1N1) in Humans

To mitigate the direct medical cost for the treatment of complicated human cases of novel Influenza A (H1N1) with complication or co-morbidities requiring hospitalization. The following shall be effective in all local and overseas confinements with admission dates starting May 1, 2009.

Details of coverage:

Amount of coverage
Maximum of Php 75,000 for non-health worker-members.
Maximum of Php 150,000 for health worker-members.
Services included
Members/ dependents
Room and board allowance of 1,500/day but up to 10,000 only
Drugs and medicines; X-ray, lab and others (including supplies and personal protective equipment and transfer services); and operating room fees – 50,000
Professional fees of 1,000/day but up to 15,000 only
HCWsRoom and board allowance of 1,500/day but up to 20,000 only
Drugs and medicines; X-ray, lab and others (including supplies and personal protective equipment and transfer services); operating room and other medically necessary care – 100,000
Professional fees of 1,000/day but up to 30,000 only
Providers
Hospitals designated by DOH as referral centers (national, sub-national and satellite) for Influenza A (H1N1) and other emerging and re-emerging diseases with the exception of confinements abroad.
Admissions in private hospitals may be covered if confirmatory tests were coordinated with or confirmed by the RITM, DOH-CHD or other DOH certified laboratories
Eligibility
Limited to members and health qualified workers with novel swine-origin influenza A (H1N1) virus infection confirmed by the Department of Health (DOH)
For qualified health care workers (HCWs):
  • Rendered service in a DOH-designated hospital for Influenza A (H1N1) and
  • Contracted the disease while performing their duties and or caring for an influenza A (H1N1) patient as certified or attested by DOH
  • Qualified dependents of HCWs who also contracted the disease shall be provided a maximum coverage of Php 75,000.
Premium payment of at least three months within the last six months prior to the month of confinement
Exclusions
Probable and case under observation*
Admissions in non-DOH designated hospitals*
Influenza-like illnesses (ILI)*
Other seasonal outbreaks of influenza by established flu virus (e.g., H1N2, H5N1)*
SARS**
Avian flu**
Other conditions
Reimbursement (to members) for drugs, medicines and supplies or laboratory procedures bought or performed in other facilities shall be based on the following:
  • Facility cannot provide necessary items and services covered by the benefit.
  • These items and services are used during confinement.
  • Official receipts and/or other purchase documents are submitted.
  • Reimbursement depends on actual cost of receipts submitted but not more than the difference between maximum benefit and reimbursement to facility.
  • Facility acknowledges that cost of benefits and services provided is less than the maximum benefit
Confinements abroad shall also be covered provided that a certification from their Ministry of Health (or its equivalent) confirming that case is due to A (H1N1) is submitted.
Availment of the package shall be charged against the 45-days annual limit and is covered by the rule on single period of confinement (only one Influenza A (H1N1) Package shall be paid within 90 days).
*Covered by regular hospitalization benefit
**Covered by SARS package
***Covered by Avian Flu package


Exclusions

The following are not being compensated yet except when, after actuarial studies, PhilHealth recommends their inclusion subject to approval of its Board of Directors:
  • Fifth and subsequent normal obstetrical deliveries
  • Non-prescription drugs and devices
  • Alcohol abuse or dependency treatment
  • Cosmetic surgery
  • Optometric services
  • Other cost-ineffective procedures as defined by PhilHealth

Availment conditions and procedures

Availment conditions

The following must first be met to avail of your PhilHealth benefits:
  • Availment must be within the validity period as stated in your Member data record or MDR or in the payment receipt.
  • The 45 days allowance for room and board of the member and the separate 45 days allowance shared among the dependents have not been consumed yet.

Benefit availment procedures

For outright/automatic deduction of benefits:

  • Submit to the billing section the following prior to discharge from the hospital:
    • Duly accomplished PhilHealth Claim Form 1 (original)
    • Clear copy of MDR.
      • If MDR is not available, submit official receipt of applicable premium payment
      • If qualified dependent is not listed in the MDR - submit applicable proof of dependency
  • Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit.
  • Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill.

For direct filing/reimbursement:

Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge:
  • PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians)
  • Official receipts or hospital and doctor's waiver
  • Operative record for surgical procedures performed

For confinements abroad:

Submit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates.
  • PhilHealth Claim Form 1
  • MDR or supporting documents
  • Proof of applicable premium payments
  • Original official receipt or detailed statement of account (written in English)
  • Medical certificate (written in English) indicating the final diagnosis, confinement period and services rendered.

Post availment reminders:

After the automatic deduction or reimbursement of your benefits, PhilHealth will send you (to the address you have indicated in your claim form) a benefit payment notice or BPN. The BPN is a report of actual payments made by PhilHealth relative to your confinement/availment.
Should there be discrepancies or if you have other concerns pertaining to your benefit availments, you may contact PhilHealth or your health care providers and bring the BPN as reference document.

Qualified Dependents

The following also enjoy PhilHealth coverage without additional premiums for each qualified dependent:
  • Legal spouse (non-member or membership is inactive)
  • Child/ren - legitimate, legitimated, acknowledged and illegitimate (as appearing in birth certificate) adopted or step below 21 years of age, unmarried and unemployed. Also covered are child/ren 21 years old or above but suffering from congenital disability, either physical or mental, or any disability acquired that renders them totally dependent on the member for support.
  • Parents (non-members or membership is inactive) who are 60 years old, including stepparents (biological parents already deceased) and adoptive parents (with adoption papers).
All of your qualified dependents shall be entitled to a separate coverage for up to 45 days per calendar year. However, their 45 days allowance will be shared among them.
Important:
Your dependents need to be declared and/or updated with PhilHealth to include them in your Member Data Record or MDR, your official membership profile with PhilHealth. Your updated MDR will make your benefit availments easier and convenient.

43 comments:

  1. i am scheduled for a cataract extraction this month. at present i am unemployed since february this year. but i i have paid my contributions from sept to december this year(6 months) as voluntary member. can i claim some monetary assistance from philhealth after my operation. how much can i receive? thank you i hope you can answer my questions>

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  2. Unfortunately PhilHealth is very strict when it comes to cataract surgery. They're strict about the nine months contribution. And there's required pre-approval, HMO-style. If you go ahead with the surgery without this pre-approval, Philhealth will not reimburse you. Sorry. - from Dr. Marge Lat-Luna, PGH

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  3. My suggestion for that patient is to go to a government hospital where there are DOH-medical assistance funds, like in PGH. She will be evaluated by the Medical Social Service, which is required by the MOA between PGH and DOH.

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  4. Hi,

    I am an OFW who had an executive health check in Asian Hospital. Can you please kindly advise if I can reimburse my payment from Philhealth? May I know the requirements as well. Thanking you in advance.

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    Replies
    1. Executive check-ups in general are not covered by Philhealth especially in private hospitals. For details watch: https://www.youtube.com/watch?v=YFIgF5nkphg

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  5. I have been checked up by the private doctor here in our province.He gave me a referral for laboratory test for: EMG-NCV and RNSS.Can I use my philhealth to this kind of lab.test?And may i know how much is this kind of lb.test?if ever i t will ot pproved

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    Replies
    1. Usually philhealth could be used but sometimes you need to be admitted 24 hrs . And the price range is 4 to 6 thou depending in the institution doing it. - Dr. Lynne Lucena, Neurosurgeon at USI-Mother Seton Hospital, Bicol

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    2. both tests cost 1-1.5k at PGH - Dr. Susette Nacario, neurologist

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  6. Im a philhealth voluntarily member. I married indonesian citizen married in philippines. Im now here in indonesia because my wife will give birth. Can i my wife be a beneficiarry? And my baby too?

    ReplyDelete
    Replies
    1. Yes, you may check the list of dependents with the link and as long as you use a facility here in the Philippines even in accredited health centers:

      http://www.philhealthnet.com/2014/11/philhealth-dependents.html

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  7. Executive check-ups in general are not covered by Philhealth especially in private hospitals. For details watch: https://www.youtube.com/watch?v=YFIgF5nkphg

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  8. Is hemorrhoid operation (laser/surgical) covered by Philhealth for both member and dependent?

    Thanks.

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  9. I am a holder of a lifetime philhealth ID I was operated on Recurrent Mandibular Tumor on the left neck with the following diagnosis:
    -Dermarofibrosarcoma Protruberance
    - Reactive Hyperplasia
    - Chronic Sialadenitis
    If I go to for chemotheraphy can I be cured?
    Is chemotheraphy covered under the philhealth benefits?

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    Replies
    1. i suggest that you discuss the prognosis, possible management and outcome of the disease with your doctor. Philhealth covers chemotherapy

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    2. In case you still need some funding, you may visit my other webpage (this will guide you to assistance through Philippine Charity Sweepstakes Office): http://www.philhealthnet.com/2008/12/part-ii-chemotherapy-dialysis.html

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  10. can i reimburse payment made of my HMO for may laboratories? SKULL XRAY and CBC

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  11. How much coverage for vehicular accident w multiple fracture surgery? 4th day in the hospital

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  12. Just wanted to verify if Philhealth covers "nasolabial cellulitis".

    Thank you in advance.

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    Replies
    1. It is covered by philhealth under "cellulitis of the face". You can visit the list of medical diseases in this reference: http://www.philhealth.gov.ph/circulars/2013/annexes/circ35_2013/Annex1_ListOfMedicalCaseRates.pdf

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  13. My mother will undergo operation, she is a senior and my dependent. Can we use both my philhealt and senior dscount?tnx

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    Replies
    1. you can use philhealth then use the senior citizen's discount for the remaining balance

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  14. please post in every hospital a clear amount of coverage per case/disease so that we have an idea on availing philhealth benefits.

    ReplyDelete
    Replies
    1. hi. I agree with this. I will inform my colleagues working in the agency. As of now, this is their comprehensive list of medical cases: http://www.philhealth.gov.ph/circulars/2013/annexes/circ35_2013/Annex1_ListOfMedicalCaseRates.pdf

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  15. I have a hernia, I want it to be removed. I am a newly registered member to philhealth. Can philhealth help cover the expenses? Thank you.

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    Replies
    1. once you know what type, you can check the list here: Hi! My fellow doctors would like to advise you to go directly to the philhealth office designated to the hospital you are referring. From our understanding, they require 9 months of payment before you are entitled of the benefits. It would be best that conflicting policies be settled by their office and we will respect these policies. We only hope that they could be more clear of their information dissemination though. thanks

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  16. my son was diagnosed of tooth impaction he is beneficiary of my husband philhealth does this kind of condition also covered by philhealth thanks

    ReplyDelete
    Replies
    1. hi, dental care such as tooth extraction is not covered yet with philhealth. The listed medical cases are listed in the website below: I hope this answers your question.
      http://www.philhealth.gov.ph/circulars/2013/annexes/circ35_2013/Annex1_ListOfMedicalCaseRates.pdf

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  17. My husband have an operation last 2 years ago in appendisities but he is new in philhealth he only pay 6 months,but the hospital let us use philhealth they approved it even the the philhealth inside the hospital we pay for the rest of the payment,but after 1 year the hospital send us a letter because we ask to pay the rest of thr payments because philhealth dont want to pay the hospital because they said we need 9 months to use for an operation but when we pay they gave us thier reciept that the philhealth should pay for rest..i think we pay 42 thousand and philhealth covered is 25 thousand..i dont know what will happen in this case but continue paying philhealth until now,i hope i can have an explanation in this case.

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  18. Hi,it is possible that 6 months paid to the philhealth covered a surgery?my husband had surgery last 2 year and he use philhealth,the hospital agree to use it also philhealth in that hospital mmg lucena,we pay the hospital the other is covered by philhealth,but after a year the hospital want us to pay because philhealth dont want to pay the hospital because they said it is not yet covered by philhealth because he new,we need 9 months payments,what we can do in this case..they ask me to pay 25 000 in 6 months because the hospital said its a long time ago but we know its not our fault,i hope i can have an explanation with this case.

    ReplyDelete
    Replies
    1. Hi! My fellow doctors would like to advise you to go directly to the philhealth office designated to the hospital you are referring. From our understanding, they require 9 months of payment before you are entitled of the benefits. It would be best that conflicting policies be settled by their office and we will respect these policies. We only hope that they could be more clear of their information dissemination though. thanks

      Delete
  19. Hi.. I got chickenpox started this monday.. Can I reimburse the consultation and laboratory fees? And also the medications prescribed to me?? The consultation only cost 350 and CBCP cost 330, but the medicines cost us almost 2k.. can o reimburse this to philhealth?? tnx

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    Replies
    1. hi sorry, varicella or chickenpox on an outpatient basis is not covered by philhealth

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  20. i was confined last november and was operated due to gal stones. i have spent almost 10k for all the materials for the OR for the operation. can i still reinburse it with philhealth? how many months do i have to wait? thanks RBF

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  21. Hi RBF, it must be filed within 60 days from the time you were discharged.

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  22. Hi,

    My father-in-law has just recently had a kidney transplant at NKTI, which so far has been a great success. He's been discharged but is facing very large bills of about P12,000/week for the post-surgery medication. I understand he will need to be on some form of immunosuppressants for the rest of his life. Does philhealth cover such post-surgery medication expenses?

    thanks

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    Replies
    1. I'll ask my colleagues from NKTI and get back to you but feel free to visit the hospital's social service for your financial concerns. They will provide recommendations. I wrote an article on getting assistance from PCSO. They can help you for the maintenance. Visit this website: http://www.philhealthnet.com/2008/12/part-ii-chemotherapy-dialysis.html

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    2. ask the treatment protocol from your attending physician

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    3. Post-KT patients need immunosuppressive meds yes, and in the immediate post-op period, these are in high doses, thus expensive. As his body gets used to the graft, the doses and even the number of meds goes down and becomes cheaper in the long run. Eventually it will become significantly less expensive than twice a week dialysis, with a better QoL. PhilHealth, I don't think will cover home meds. Assistance from PCSO/PAGCOR or the respective Congressman or Senator or even Mayor can be done. - Dr. Gene Yusi, NKTI Surgeon

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  23. My father had been hospitalized twice because of Pneumonia. First last Dec. 23 to Jan. 3 and second on Jan. 18-26, 2015. On his second admission, he was not covered by Philhealth because they said that he can not be covered if hospitalized twice with the same diagnosis. Is this true considering that my father is already 83 years old and that old people often get pneumonia.

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  24. My father is 83 yo and hospitalized twice due to pneumonia last Dec. 23, 2014 - Jan. 3, 2015 and on Jan. 18-26, 2015. On his second confinement, he was no longer covered by Philhealth because they said that he was twice with the same diagnosis. Is this true? Considering that my father is old and most often old people get pneumonia.

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  25. As far as I know, there is such a rule. Pag masyadong magkalapit Ang dates of confinement, it is assumed that Hindi talaga gumaling ang patient, and the second confinement is a continuation of the same diagnosis for the first confinement. That's why dyan lugi ang PGH. Usually sa PGH na pumupunta for the second confinement. And since nagamit na Nya yung PhilHealth sa first confinement, Hindi na Pwede mag claim ang PGH. - Dr. Marge Luna , PGH Liason Officer

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