AMENDED RULES ON EMPLOYEES' COMPENSATION

ANNEX "C"
 

Medical Benefits

A.  Medical Services — (a) An employee who sustains an injury or contracts sickness shall be entitled to:

1.  Ward services during confinement in an accredited hospital;

2.  the subsequent domiciliary care by an accredited physician; and

3.  medicines.

(b)  Ambulatory services in an accredited hospital shall be allowed only in case of injury.

B.  Ward Services — (a) They cover all of the services an in-patient would ordinarily receive in a hospital such as:

1.  Bed in a ward (6 beds in a room);

2.  All meals, including special diets;

3.  Regular nursing services;

4.  Medicines furnished by the hospital;

5.  Laboratory services such as blood and urine tests;chan robles virtual law library

6.  Radiology service such as X-rays;

7.  Medical supplies such as splints and casts;

8.  Use of appliances and equipment furnished by the hospital such as wheelchair, crutches and braces;

9.  Anesthetic services;

10.  Operating room charges;

11.  Surgery; and

12.  Doctor's services.

(b)  Ward services do not include:

(1)  The extra charge for more comfortable accommodations such as private and semi-private rooms;

(2)  Personal comfort or convenience such as charges for the use of a telephone, radio, or television;

(3)  Private duty nurses;

(c)  If a patient receives more expensive than ward services, payment by the System shall be made only for the ward services. However, private or semi-private room accommodations when medically necessary because the contagious disease or his condition requires him to be isolated, or there is no available ward bed and the emergency nature of the injury or disease requires him to be immediately accommodated, shall be paid by the Systems after satisfying itself as to the reasonableness thereof, and at no cost whatsoever to the patient. The continued accommodation of the patient in a private or semi-private room when a ward bed is available and the emergency or contagion no longer exists shall be paid by the System as ward services.

(d)  Only necessary and relevant services shall be paid by the System. Laboratory and/or radiology services and medicines shall be kept to a level considered by the physician reasonably necessary and relevant to the particular illness or injury.

C.  Hospital confinement — (a) The benefit for each day of confinement in an accredited hospital shall be only for ward services.

(b)  The benefit in case of injury shall not exceed the actual cost of ward services in an accredited hospital.

(c)  The benefit in case of sickness shall not exceed the actual cost of ward services in an accredited hospital equipped with facilities necessary for the treatment of the diseases.

(d)  Confinement shall be counted in units of a full day, with the day of admission counted as a full day but not the day of discharge.

D.  Domiciliary care — The benefit for the subsequent domiciliary care by an accredited physician shall not exceed P60 for the first visit and P50 for each subsequent visits.

E.  Ambulatory services — (a) The benefit for ambulatory care in an accredited hospital, either by (1) a physician in his hospital/clinic, or (2) training resident in emergency shall not exceed P60 a day, exclusive of drugs and medicines.

(b)  A patient who is treated for a specific minor surgical procedure or other treatment that keeps him in the hospital only for a few hours (less than 24) shall be considered an ambulatory patient regardless of the hour of admission, whether or not he used a bed, or whether or not he remained in the hospital past midnight.

F.  Surgical Expense Benefit — (a) A qualified employee who has undergone a surgical procedure in an accredited hospital shall be entitled to a surgical expense benefit, which shall consist of:

1.  A surgeon's fee according to the ECC Relative Value Study (ECC Res. No. 94 dated April 14, 1976, as amended by Res. No. 247 dated April 13, 1977, Res. No. 1554 dated June 26, 1980, and Res. No. 2113 dated July 15, 1982 and Res. No. 2656 dated March 15, 1984).

2.  An anesthesiologist's fee ordinarily not exceeding twenty five percent (25%) of the surgeon's fee.chan robles virtual law library

(b)  The surgeon's fee shall be paid to the surgeon who performed the operation, and the anesthesiologist's fee to the anesthesiologist, subject to the following conditions:

1.  Only one surgeon shall be paid for each operation;

2.  Only one anesthesiologist, if any shall be paid for each operation; and

3.  Local anesthesia, other than regional nerve block anesthesia, shall not be compensable.

(c)  The operating room fee shall be paid by the System only for surgical procedures done in the operating-diagnostic-therapeutic room complex of the accredited hospital.chan robles virtual law library