Lll Plan notes letter from mapfre ars Sent june15 ,2023 Reference: Pre-Existing Conditions. Rosa Nunez Sanchez
Distinguished: After a cordial greeting, we kindly inform you that we will not cover claims related to: - Any medical-hospital treatment for arterial hypertension, as well as its sequelae and/or complications - Any medical-hospital treatment related to diabetes mellitus as well as its sequelae and/or complications - Any medical-hospital treatment for hypercholesterolemia, as well as its sequelae and/or complications Because these are pre-existing conditions to this health contract, according to the statements presented on the insurance form. We appreciate your attention to this and we reiterate to your orders for any additional clarification. Very truly yours,
All plans do not cover pre existing conditions including pregnancy.
WAITING PERIODS Some tests Maternity Scheduled Surgeries Catastrophic illnesses 6 months
For doctors visits you pay normally between 800 to 1500 pesos in cash to the doctor and the insurance pays the rest
Available for 6 or 12 month terms only
Outpatient medicine is available for 5000 pesos per year 215 pesos per month 10,000 pesos per year 330 peso per month
All plans do not cover the cost or delivery of blood for transfusions
If you pay cash to the lab ,doctor or hospital it is very difficult to get a refund. It is much better to contact us while at the clinic if there is a problem with accepting the insurance , than paying cash and trying to get your money back. If you do pay cash, and want a refund you need to go to the nearest insurance (Humano or Mapfre) office and make a claim for the refund. Information required for a refund are stamped original receipts you paid , dates of your visit ,date of admitting and date of discharge, , name of doctor and specialty , type and reason for the treatment , name/contact info . of clinic , information on your health card. Additional information may be required as well . Mapfre Prestige 11950 peso per month limit per case 2 million
HOSPITALIZATION COVERAGE Room (unlimited days) 100% Medications in hospital 100% Special Expenses (x-rays, laboratories, expendable material, surgery room use)
100% Fees for Surgery and Anesthesia 100% Visits in Internment 100% Intensive care unit 100% Expenses for Psychiatry 100%SERVICES COVERAGE
Consultations (difference according to specialist) Unlimited Psychological and/or Psychiatric Consultations 30 per calendar year per person. Group Plans: Covered at 90%. Physical Therapies 50 per calendar year per person Laboratories and X-Rays 100% Special proofs 100% Vaccines (covered up to 10 years old) 90% Ambulatory Medicine Maximum per year per person RD$15,000. 80% coverage emergencies 100% Reimbursements outside the Provider Network** 90% Catastrophic illnesses, per year contracted per person RD$3,000,000 Maximum per Case per Affiliated Person RD$2,000,000 ADDITIONAL SERVICES INCLUDED Air ambulance – Alert Plus Plan you pay extra I think Ground Ambulance included Medical Assistance Abroad US$10,000 Before Boarding (AILA VIP lounge access) Dental Plan Plus Ophthalmological Plan – Advanced Funeral Services: RD$150,000 Life insurance for the owner: RD$100,000 WAITING PERIODS Maternity 6 Months Scheduled surgeries 6 months Catastrophic Illnesses 6 Months DETAILS OF THE EXTENSIVE COVERAGES AND SERVICES THAT APPLY TO OUR MEMBERS Orthopedic Boots Laparoscopic surgery Orthopedic Necks Anesthesia for outpatient procedures wristbands Hysterosalpingeography Wheelchair Diagnostic tests not covered by the PDSS, excluding experimental tests, genetic tests or tests not authorized by the scientific association Kneepads Enteral and parenteral nutrition anklets Sleep apnea hospital bed rental Diagnostic tests for blood allergies Private nursing service Osteosynthesis material, not covered by the PDSS Prosthesis Covered organ transplants: Heart, heart and kidney, combined heart and lung, pancreas, liver, or bone marrow (all include donor expense) Blood transfusions, including the cost of blood and its derivatives, platelets by alpheresis Accidental dental services, we cover replacement for loss of natural teeth High cost diseases Medications in hospitalization not covered by the PDSS
PREMIUM 4420 peso peso per month ea Limit per case 1,000,000 Room (unlimited days)RD$5,000 per day Medicines in hospitalization100% Special Expenses (x-rays, laboratories, expendable material, use of the surgery room)100% Fees for Surgery and Anesthesia100% Visits in Internment100% Intensive care unit100% Expenses for PsychiatryLike any other disabilityLike any other disabilityERNINormal delivery and Cesarean section100% Reception and Newborn Room100% Children with Birth ProblemsWithin Medical Expenses Greater than 80%Within Medical Expenses Greater than 80%
OUTPATIENT SERVICES
Consultations (difference according to specialist)Unlimited
Psychological and/or Psychiatric ConsultationsCoverage per calendar year RD$20,000/ Coverage per calendar year Physical Therapies30 per calendar year per person Laboratories and X-RaysNo limit to 85% Special proofsNo limit to 85% Vaccines (covered up to 10 years old)80% emergenciesAccident 100% / Illness 80%
MAJOR MEDICAL EXPENSES Offers extensive services, also includes coverage for catastrophic illnesses and children with problems at birth
MAXIMUM PER CALENDAR YEAR PER PERSON RD$300,000
Catastrophic Illnesses per contracted year per person Total RD$1,300,000 | RD$1,000,000 Catastrophic + RD$300,000 GMMTotal RD$1,050,000 | MAXIMUM PER CASE PER AFFILIATED PERSON No limits within the base coverage of the plan
Ground Ambulance Funeral services: RD$50,000Life insurance for the owner:
WAITING PERIODS MaternityScheduled SurgeriesCatastrophic illnesses6 months EXTENSIVE SERVICES THAT APPLY WITHIN MAJOR MEDICAL EXPENSESOrthopedic Boots Orthopedic Necks wristbands Wheelchair Kneepads anklets hospital bed rental Private nursing service Prosthesis Osteosynthesis material, not covered by the Basic Plan Covered organ transplants: Heart, heart and kidney, combined heart and lung, pancreas, liver, or bone marrow (all include donor expense) Accidental dental services. We cover replacement for loss of natural teeth Blood transfusions, including the cost of blood and its derivatives, platelets by alpheresis High cost diseases Medications in hospitalization not covered by the Basic Plan Laparoscopic surgery Anesthesia for outpatient procedures Hysterosalpingeography Diagnostic tests not covered by the Basic Plan, excluding experimental tests, genetic tests or tests not authorized by the scientific association Enteral and parenteral nutrition Sleep apnea Diagnostic tests for blood allergies Additional services available
All procedures will be performed according to our Tables of Medical Fees (THM)**Vaccine reimbursements will be made according to the percentage established in the contracted plan *GMM: Major Medical Expenses
ESPECIAL 4099 peso per person per month Maximum per Case per Affiliated PersonRD$800,000RD Room (unlimited days)RD$4,500 per day Medicines in hospitalization100% Special Expenses (x-rays, laboratories, expendable material, use of the surgery room)100% Fees for Surgery and Anesthesia100% Visits in Internment100% Intensive care unit100% Expenses for PsychiatryLike any other disabilityLike any other disability RN Normal delivery and Cesarean section100% Reception and Newborn Room100% Children with Birth ProblemsWithin Medical Expenses Greater than 80%Within Medical Expenses Greater than 80%
OUTPATIENT SERVICES SERVICESSPECIAL Consultations (difference according to specialist) Psychological and/or Psychiatric ConsultationsCoverage per calendar year RD$20,000/ RD$1,000 per consultation Physical Therapies30 per calendar year per person Laboratories and X-RaysNo limit to 85% Special proofsNo limit to 85% Vaccines (covered up to 10 years old)80% emergenciesAccident 100% / Illness 80% . In Medical FeesApplies to all lines. In Medical Fees MAJOR MEDICAL EXPENSES Offers extensive services, also includes coverage for catastrophic illnesses and children with problems at birth
MAXIMUM PER CALENDAR YEAR PER PERSON $250,000 Catastrophic Illnesses per contracted year per person Total RD$1,050,000 | RD$800,000 Catastrophic + RD$250,000 GMM MAXIMUM PER CASE PER AFFILIATED PERSON No limits within the coverage of the plan
Funeral services: RD$50,000 Life insurance for the owner: RD$100,000 WAITING PERIODS Maternity. some tests CAT scans , EMR ,Scheduled Surgeries ,Catastrophic illnesses6 months EXTENSIVE SERVICES THAT APPLY WITHIN MAJOR MEDICAL EXPENSES Orthopedic Boots Orthopedic Necks wristbands Wheelchair Kneepads anklets hospital bed rental Private nursing service Prosthesis Osteosynthesis material, not covered by the Basic Plan Covered organ transplants: Heart, heart and kidney, combined heart and lung, pancreas, liver, or bone marrow (all include donor expense) Accidental dental services. We cover replacement for loss of natural teeth Blood transfusions, including the cost of blood and its derivatives, platelets by alpheresis High cost diseases Medications in hospitalization not covered by the Basic Plan Laparoscopic surgery Anesthesia for outpatient procedures Hysterosalpingeography Diagnostic tests not covered by the Basic Plan, excluding experimental tests, genetic tests or tests not authorized by the scientific association Enteral and parenteral nutrition Sleep apnea Diagnostic tests for blood allergies Additional services available
Reduced Mobility Transfer
All procedures will be performed according to our Tables of Medical Fees (THM) **Vaccine reimbursements will be made according to the percentage established in the contracted plan *GMM: Major Medical Expenses
Plus Plan 3850 peso per person per month Maximum per Case per Affiliated PersonRD$600,000RD0
HOSPITALIZATION Room (unlimited days)RD$4,000 per day Medications in hospital100% Special Expenses (x-rays, laboratories, expendable material, use of the surgery room)100% Fees for Surgery and Anesthesia100% Visits in Internment100% Intensive care unit100%MATERNITY Normal delivery and Cesarean section100% Reception and Newborn Room100% Children with Birth ProblemsUp to the Limit per Case of the MotherUp to the Limit per Case of the MotherUp to the Limit per Case of the Mother
SERVICESPLUSHIGHERPRIMARY Consultations (difference according to specialist)UnlimitedUnlimitedUnlimited
Psychological and/or Psychiatric ConsultationsCoverage per calendar year RD$20,000/RD$1,000
Physical Therapies30 per calendar year per person
Laboratories and X-RaysNo limit at 85%No limit
Special proofsNo limit at 85%No limit
Vaccines (covered up to 10 years old)80%
EmergenciesAccident 100% / Illness 80% Tables apply in emergencies and consultations according to our Medical Fees Tables Catastrophic illnessesRD$700,000 Maximum per Case per Affiliated PersonRD$600,000RD0 OPTIONAL SERVICES INCLUDED
Customers can request other options and/or limits on the different lines of the plan. All procedures will be performed according to our Tables of Medical Fees (THM). Funeral services: RD$50,000 Ground AmbulanceOphthalmological Plan – Basic Life insurance for the owner: RD$100,000 Ophthalmological Plan – Basic
WAITING PERIODS Maternity. some tests ,CAT scans , EMR ,and others ,Scheduled Surgeries ,Catastrophic illnesses6 months
*Vaccine reimbursements will be made according to the percentage established in the contracted plan All procedures will be performed according to our Tables of Medical Fees (THM) All plans are subject to the conditions stipulated in our contracts Added values apply to members who have the Basic Plan plus Corporate Plan in force All procedures will be performed according to our Tables of Medical Fees (
. Superior 3100 peso per person per month Maximum per Case per Affiliated Person RD$400,000 Room (unlimited days)RD$3,500 per day Medications in hospital 100% Special Expenses (x-rays, laboratories, expendable material, use of the surgery room) 100% Fees for Surgery and Anesthesia 100% Visits in Internment 100% Intensive care unit 100% MATERNITY Normal delivery and Cesarean section 100% Reception and Newborn Room 100% Children with Birth Problems Up to the Limit per Case of the Mother PREFERENCE protect your health Structured for the family/person who seeks to cover their basic health needs, with a wide network of providers selected for their well-being. Plan designed to add value to PDSS services. HOSPITALIZATIONCOVERAGE Room (unlimited days) RD$2,500 per day Medications in hospital 100% up to RD$2,000 per day Special Expenses (x-rays, laboratories, expendable material, use of the surgery room) 80% Fees for Surgery and Anesthesia 80% Visits in Internment 80% Intensive care unit 100% up to RD$2,000 per day
MATERNITY Normal delivery and Cesarean section 100% Reception and Newborn Room 100% Children with Birth Problems 100% up to RD$50,000 OUTPATIENT SERVICESCOVERAGE Consultations (difference according to specialist) Unlimited Psychological and/or Psychiatric Consultations Coverage per calendar year RD$5,000/ RD$1,000 per consultation Physical Therapies 20 per calendar year per person Laboratories and X-Rays No limit to 70% Special proofs No limit to 70% Vaccines (covered up to 10 years old) 80% According to specific details of vaccines included emergencies 100%
Catastrophic illnesses RD$500,000 Maximum per Case per Affiliated Person RD$200,000 Ground Ambulance Basic Ophthalmological RD$50,000 Life insurance for the owner: RD$100,000 WAITING PERIODS Maternity. some tests ,CAT scans , EMR ,and others ,Scheduled Surgeries ,Catastrophic illnesses6 months
Primario(primary) 2300 pesos per month Limit per case 300,000 pesos Room (unlimited days)RD$3,000 per day Medications in hospital100% up to RD$3,000 per day Special Expenses (x-rays, laboratories, expendable material, use of the surgery room)100% Fees for Surgery and Anesthesia100% Visits in Internment100% Intensive care unit100% / RD$3,000 per day MATERNITYNormal delivery and Cesarean section100% Reception and Newborn Room100% Children with Birth ProblemsUp to the Limit per Case of the Mothe
.HOSPITALIZATIONCOVERAGE Room (unlimited days)RD$2,500 per day Medications in hospital100% up to RD$2,000 per day Special Expenses (x-rays, laboratories, expendable material, use of the surgery room)80% Fees for Surgery and Anesthesia80% Visits in Internment80% Intensive care unit100% up to RD$2,000 per day
MATERNITYNormal delivery and Cesarean section100% Reception and Newborn Room100% Children with Birth Problems100% up to RD$50,000
OUTPATIENT SERVICESCOVERAGE Consultations (difference according to specialist)Unlimited Psychological and/or Psychiatric ConsultationsCoverage per calendar year RD$5,000/ RD$1,000 per consultation Physical Therapies20 per calendar year per person Laboratories and X-RaysNo limit to 70% Special proofsNo limit to 70% Vaccines (covered up to 10 years old)80% According to specific details of vaccines included emergencies100%
Catastrophic illnessesRD$500,000 Maximum per Case per Affiliated PersonRD$200,000 ADDITIONAL SERVICES INCLUDED Ground AmbulanceBasic Funeral services: RD$50,000 Life insurance for the owner: RD$100,000 WAITING PERIODS Maternity. some tests ,CAT scans , EMR ,and others ,Scheduled Surgeries ,Catastrophic illnesses6 months
ADDITIONAL SERVICES AVAILABLE
All procedures will be performed according to our Tables of Medical Fees (THM)
PREFERENCIAL 1200 peso per person per month Maximum per Case per Affiliated PersonRD$200,000
HOSPITALIZATIONCOVERAGE Room (unlimited days)RD$2,500 per day Medications in hospital100% up to RD$2,000 per day Special Expenses (x-rays, laboratories, expendable material, use of the surgery room)80% Fees for Surgery and Anesthesia80% Visits in Internment80% Intensive care unit100% up to RD$2,000 per day Normal delivery and Cesarean section100% Reception and Newborn Room100% Children with Birth Problems100% up to RD$50,000
OUTPATIENT SERVICES SERVICESCOVERAGE Consultations (difference according to specialist)Unlimited Psychological and/or Psychiatric ConsultationsCoverage per calendar year RD$5,000/ RD$1,000 per consultation Physical Therapies20 per calendar year per person Laboratories and X-RaysNo limit to 70% Special proofsNo limit to 70% Vaccines (covered up to 10 years old)80% According to specific details of vaccines included emergencies100%
Catastrophic illnessesRD$500,000 Maximum per Case per Affiliated PersonRD$200,000
Ground Ambulance Funeral services: RD$50,000 Life insurance for the owner: RD$100,000
WAITING PERIODS Maternity. some tests ,CAT scans , EMR ,and others ,Scheduled Surgeries ,Catastrophic illnesses6 months
