LESSON 6 AND 7: NATIONAL

HEALTH INSURANCE
PROGRAMS AND HEALTH
INSURANCE COMPANIES IN THE
PHILIPPINES

Prepared By: Joseph Anthony M. Nietes,

LPT
 NATIONAL HEALTH INSURANCE
Under national health insurance programs, governments provide
compulsory health insurance to all or parts of the population.
The term ‘national health insurance’ connotes the compulsory
provision of health insurance to broad sectors of the population, there
is no generally accepted definition for the portion of the population to
be covered or for the exact benefits to be provided. These are matters
of political negotiation and political choice.
 R.A.7875
AN ACT INSTITUTING A NATIONAL HEALTH INSURANCE
PROGRAM FOR ALL FILIPINOS AND ESTABLISHING THE PHILIPPINE
HEALTH INSURANCE CORPORATION FOR THE PURPOSE.
 R.A.7875
Section 11, Article XIII of the 1987 Constitution of the Republic of the
Philippines declares that the State shall adopt an integrated and
comprehensive approach to health development which shall
endeavor to make essential goods, health and other social
services available to all the people at affordable cost. Priority
for the needs of the underprivileged, sick, elderly, disabled,
women, and children shall be recognized. Likewise, it shall be
the policy of the State to provide free medical care to paupers.
 R.A.7875
Section 3. General Objectives. - This Act seeks to:
a. provide all citizens of the Philippines with the mechanism to gain financial
access to health services;
b. create the National Health Insurance Program, hereinafter referred to as the
Program, to serve as the means to help the people pay for health care services;
c. prioritize and accelerate the provision of health services to all Filipinos,
especially that segment of the population who cannot afford such services; and
d. establish the Philippine Health Insurance Corporation, hereinafter referred to
as the Corporation, that will administer the Program at central and local levels.
 R.A.7875
Article III. THE NATIONAL HEALTH INSURANCE PROGRAM
Section 5. Establishment and Purpose.
Created the National Health Insurance Program which shall provide health
insurance coverage and ensure affordable, acceptable, available and accessible
health care services for all citizens of the Philippines, in accordance with the
policies and specific provisions of RA 7875.
This social insurance program shall sense as the means for the healthy to
help pay for the care of the sick and for those who can afford medical care to
subsidize those who cannot.
It shall initially consist of Programs I and II of Medicare and be expanded
progressively to constitute one universal health insurance program for the
entire population.
 R.A.7875
Article III. THE NATIONAL HEALTH INSURANCE PROGRAM
Section 6. Coverage
All citizens of the Philippines shall be covered by the National Health
Insurance Program.
In accordance with the principles of universality and compulsory coverage
enunciated in Section 2 (b) and 2 (l) hereof, implementation of the Program
shall, furthermore, be gradual and phased in over a period of not more
than fifteen (15) years: Provided, That the Program shall not be made
compulsory in certain provinces and cities until the Corporation shall be able to
ensure that members in such localities shall have reasonable access to adequate
and acceptable health care services.
 R.A.7875
Article III. THE NATIONAL HEALTH INSURANCE PROGRAM
Section 7. Enrollment
The Program shall enroll beneficiaries in order for them to be placed under
coverage that entitles them to avail of benefits with the assistance of the
financial arrangements provided by the Program.
The process of enrollment shall include:
• the identification of beneficiaries
• issuance of appropriate documentation specifying eligibility to benefits
• indicating how membership was obtained or is being maintained
 R.A.7875
Article III. THE NATIONAL HEALTH INSURANCE PROGRAM
Section 7. Enrollment
The enrollment shall proceed in accordance with these specific policies:
a. all persons currently eligible for benefits under Medicare Program 1, including
SSS and GSIS members, retirees, pensioners and their dependents, shall
immediately and automatically be made members of the National Health
Insurance Program;
b. all persons eligible for benefits through health insurance plans established by
local governments as part of Program II of Medicare or in accordance with the
provisions of this Act, including indigent members, shall also be enrolled in the
Program;
 R.A.7875
Article III. THE NATIONAL HEALTH INSURANCE PROGRAM
Section 7. Enrollment
The enrollment shall proceed in accordance with these specific policies:
c. all persons eligible for benefits as members of local health insurance plans established by the
Corporation in accordance with the implementing rules and regulations of this Act shall also be
deemed to have enrolled in the Program. Enrollment of persons who have no current health insurance
coverage shall be given priority by the corporation; and
d. all persons eligible for benefits as members of other government initiated health insurance
programs, community-based health care organizations, cooperatives, or private non-profit health
insurance plans shall be enrolled in the Program upon accreditation by the Corporation which shall
devise and provide incentives to ensure that such accredited organizations will benefit from their
participation in the program.
 R.A.7875
Article III. THE NATIONAL HEALTH INSURANCE PROGRAM
Section 10. Benefit Package
Subject to the limitations specified and as may be determined by the Corporation, the following categories of
personal health services granted to the member or his dependents as medically necessary or appropriate shall
include:

a. Inpatient hospital care:

1. room and board;
2. services of health care professionals;
3. diagnostic, laboratory, and other medical examination services;
4. use of surgical or medical equipment and facilities;
5. prescription drugs and biologicals; subject to the limitations stated in Section 37 of this Act;
6. inpatient education packages;
 R.A.7875
Article III. THE NATIONAL HEALTH INSURANCE PROGRAM
Section 10. Benefit Package
b. Outpatient care:

1. services of health care professionals;

2. diagnostic, laboratory, and other medical examination services;

3. personal preventive services; and

4. prescription drugs and biologicals, subject to the limitations described in Section 37 of this R.A. 7875;

c. Emergency and transfer services:

d. Such other health care services that the Corporation shall determine to be appropriate and cost-effective:
Provided, that the Program, during its initial phase of implementation, which shall not be more than five (5) years
 ARTICLE X. PENALTIES

A fine of not less than Ten thousand pesos (P10,000) nor more than
Fifty thousand pesos (P50,000) in case the violation is committed
by the hospital management or provider.
In addition, its accreditation shall be suspended or revoked from
three (3) months to the whole term of accreditation: Provided,
however, that recidivists may not anymore be accredited as a
participant of the Program;
 ARTICLE X. PENALTIES

A fine of not less than Five hundred pesos (P500) nor more than
Five thousand pesos (P5,000) and imprisonment of not less than six
(6) months nor more than one (1) year in case the violation is
committed by the member.
 ARTICLE X. PENALTIES

Where the violations consist of failure or refusal to deduct contributions from

the employee's compensation or to remit the same to the Corporation, the
penalty shall be a fine of not less than Five hundred pesos (P500) but not
more than One thousand pesos (P1,000) multiplied by the total number of
employees employed by the firm and imprisonment of not less than six (6)
months but not more than one (1) year: Provided, further, That in the case of
self-employed members, failure to remit one's own contribution shall be
penalized with a fine of not less than Five hundred pesos (P500) but not
more than One thousand pesos (P1,000).
 R.A.6111

AN ACT ESTABLISHING THE PHILIPPINE MEDICAL CARE PLAN AND

CREATING THE PHILIPPINE MEDICAL CARE COMMISSION, PRESCRIBING
ITS DUTIES, POWERS AND FUNCTIONS, AND APPROPRIATING FUNDS
 R.A.6111

It is hereby declared to be the policy of the Republic of the Philippines to

gradually provide total medical service for our people by adopting and
implementing a comprehensive and coordinated medical care program
based on accepted concepts of health care, namely:
(a) There shall be total coverage of medical services according to the needs
of patients;
(b) There shall be coordination and cooperation in the use of all medical
facilities of both the government and the private sector; and
(c) The freedom of choice of physicians and hospitals and the family doctor-
patient relationship shall be preserved.
 R.A.6111

Section 3. Purposes and Objectives. The main purposes and

objectives of this Act are:
(a) Extension of medical care to all residents in an evolutionary way within
our economic means and capability as a nation;
(b) Providing the people of the country a practical means of helping
themselves pay for adequate medical care; and
(c) To establish a Medical Care Commission.
 R.A.6111

Section 9. The Philippine Medical Care Plan. The Philippine Medical Care plan
shall consist of two basic programs, namely:
(a) Program I For the members of the SSS and GSIS; and
(b) Program II For those not covered in program I.
Beneficiaries under Program I shall be entitled to medical care benefits specifically provided
for in subsequent sections of this Act.
The Commission shall, within three years after the effectivity of this Act, formulate an
integrated program for the proper implementation of program II as envisioned in this Act.
Likewise, it shall, within the same period, recommend to Congress who shall be entitled to
Medical Care benefits under Program II and the amount of contributions they shall make.
 R.A.6111

Section 11. Compulsory Coverage.

Coverage under this Act shall be compulsory and automatic upon all
employees entitled under Section 35 of this Act: Provided, That in the case
of an employee who is both covered by the SSS and GSIS, only his
employment with the latter shall be considered for purposes of his coverage.
 HEALTH INSURANCE COMPANIES IN THE
PHILIPPINES
1. SUN LIFE PHILIPPINES
Sun Life Financial Inc. is a financial services company in the
world that was founded in Canada by Matthew Hamilton Gault
in 1865.
Nowadays, Sun Life was one of the largest financial services
companies together as being the oldest in the world.
 HEALTH INSURANCE COMPANIES IN THE
PHILIPPINES
• Offers SUN Fit and Well, SUN Senior Care, SUN Cancer Care, SUN LifeAssure, SUN Healthier
Life, Sun First Aid, and Sun Maiden, and Sun Maiden Plus
• SUN Fit and Well is a life and health insurance that endows life insurance benefits and
covers you from 100 critical illnesses until the age of 100.
• SUN Senior Care provides you 150% financial benefit that is equal to the plan’s face
amount if you were diagnosed with any of the 17 advance-age critical illnesses conditions
they covered.
• SUN Cancer Care provides cash benefits for the covered early and late stage of cancer
conditions, aside from this, they will also give a one-time cash benefit if you will undergo
surgery due to a covered benign tumor.
 HEALTH INSURANCE COMPANIES IN THE
PHILIPPINES
• SUN LifeAssure assures your family protection against any of the critical conditions.
• SUN Healthier Life provides protection and financial help for you to recover in any
stage of critical illnesses.
• Sun First Aid provides financial benefits not only for hospitalization or surgery but
also for uncertain events like accidents, disability, etc.
• Sun Maiden and Sun Maiden Plus are specifically designed f for women. It provides
life insurance coverage and female critical illness benefit plus the maternity benefits
(only for Sun Maiden Plus) that will assist the up to three children delivered and in case
of any complications during pregnancy.
 HEALTH INSURANCE COMPANIES IN THE
PHILIPPINES
2. AXA PHILIPPINES INC.
Axa S.A or AXA is a French multinational insurance firm in Paris since 1816 (204
years ago). AXA is not an acronym but it was picked to be the name of the
company because it is easy to pronounce by people who speak in any language.
AXA now offers a complete range of products for all its customers' insurance
and financial protection needs, including savings and investments, health plans,
and income protection as well as general insurance: fire, motor/car, marine
cargo, personal accident, bonds, casualty, and engineering insurance products.
AXA PHILIPPINES INC.
• Offers Critical Illness Coverage (Health Start, Health MaX, Health eXentials) and Global
Health Access

• Health Start is an insurance plan that covers support for critical health conditions of
the family especially the child, life insurance coverage, and even return of premium at
the age of 75 with less any benefit or support paid.

• Health eXentials doesn’t require any medical examinations. The good thing here is
you can have full control of spending as you deem it fit, wherein guaranteed cash
packages or benefits comes into three options; Starter, Advance, and the Deluxe.

• Global Health Access gives you world-class medical and health coverage wherever
inside and outside the Philippines with 27/7 support and hassles free and cashless
transactions.
 HEALTH INSURANCE COMPANIES IN THE
PHILIPPINES
3. BPI-PHILAM
The BPI-Philam Life Assurance Corporation or BPI-Philam alliance has started in
1935 and focuses on Asia- Pacific region.
Philam Life understands the real life needs of its customers and provides the right
plans and the right solutions including life protection, health insurance, savings,
education, retirement, investment, group and credit life insurance. It also offers
bancassurance and fund management products and services through its
subsidiaries – BPI Philam Life Assurance Company (BPI-Philam) and Philam Asset
Management Inc. (PAMI).
 HEALTH INSURANCE COMPANIES IN THE
PHILIPPINES
3. BPI-PHILAM
• Offers you 5 choices: Critical Care 100, Critical Max Care, Critical Care Plus, Health Save 10,
and Life Health Protect
• Critical Care 100 is a life and health insurance plan that grants an issue from age zero to 100
protecting you from 100 covered critical illnesses with your family. And if you are such a healthy
human, it could also make your pocket healthy as you can gain rewards and discounts from its
partners.
• Critical Max Care and Critical Care Plus aids financial help in the early stages of a critical illness
and recovering and even accidents. It also includes the Philam Vitality Rewards wherein you can
enjoy an upfront additional coverage of 20% within the policy and any add-ons attached.
 HEALTH INSURANCE COMPANIES IN THE
PHILIPPINES
4. PRU LIFE U.K.
The Pru Life UK is a 1996 branch of the British financial services
giant Prudential plc that has more than 170-year legacy worldwide.
In 2019, Pru Life UK ranked 2nd based on the Insurance
Commission in terms of total premium income and new business
annual premium equivalent.
PRU LIFE U.K.
• Offers PRULink Assurance Account Plus, PRU Life Care Series for Critical Illness,
PRUShield, PRUWellness, and PRU Personal Accident

• PRULink Assurance Account Plus is designed for people who want a comprehensive
life and assured insurance protection that provides critical illness, life, and death
protection by investment components and protection.

• PRU Life Care Series for Critical Illness is annual renewable term products until the age
of 70 that aids cash benefits to cover the expenditures of your treatments for your
critical illness depending on what Life Care you have such as Life Care Plus, Life Care
Advance Plus, and Multiple Life Care Plus.
• PRUShield is an annual renewable term product until the age of 65 that provides daily
hospital income benefit wherein it comes with daily cash benefits up to 365 days in
able to aid your recovery due to an accident, injury, illnesses and you can also get a
death that pays a lump sum amount.
PRU LIFE U.K.
• PRUWellness is also an annual renewable term product until the age of 65 that
provides you a lump and daily cash benefits for your hospitalization.

• PRU Personal Accident is an annually renewable plan that will cover your injury or
even death due to an accident. It has various packages available to suit your age,
lifestyle, income, and occupation.
 HEALTH INSURANCE COMPANIES IN THE
PHILIPPINES
5. MANULIFE PHILIPPINES
It is a financial corporation (formerly known as The Manufacturers Life
Insurance Company) established in Canada in 1887 that provides multinational
insurance services. Moreover, it is the largest insurance company in Canada
and gained 28th place for the largest fund manager in the world.
Manulife Philippines offers affordable health insurance wherein you can choose
your plan based on three options they provided for the clients; Adam, Eve, and
the Healthy Choice.
 HEALTH INSURANCE COMPANIES IN THE
PHILIPPINES
5. MANULIFE PHILIPPINES
• Eve plan is exclusive for women. Just like Adam, it also provides the same kind of aid for
its owner who’s fighting against cancer, financial support for the loved ones, and the
same percentage of face amount to receive once you were diagnosed with any 60 critical
illnesses they covered.
• Health Choice lets the owner enjoy critical illness coverage, hospital benefits,
emergency, and life insurance in one plan. Once you’ve diagnosed with any 60 illnesses
they cover, Manulife will give you financial aid for the treatments you need. Aside from
this, they also help you in your hospitalization by daily cash support up to the year of
confinement.