Should We Get An HMO As Freelancers?

My fiance was scheduled today for an endoscopy at 10 AM today. He was supposed to use his HMO subscription, which is a Maxicare Gold plan. The diagnosis given by his gastroenterologist was abdominal pain, by which probably caused his recent acid reflux, that’s why he needed to do an endoscopy to confirm. But for Maxicare, it claimed that he was diagnosed with GERD (Gastroesophageal reflux disease), which they said was a pre-existing condition, therefore he could not have his procedure expenses be fully covered by his plan.

We are well aware of the details in the brochure before he paid for the plan. We know what are the pre-existing conditions and dreaded diseases covered or not covered. It was listed on the brochure.

But our question, how could Maxicare assume that his condition was pre-existing? So they give their own diagnosis to the patient now? How could they know better about the condition than the patient himself? Our doctor even talked to the Maxicare agent over the phone and was surprised that the procedure expenses would not be fully covered.

It was really frustrating because my fiance paid for his plan in full. He availed of the individual account since he is a freelancer, Gold Plan with a maximum benefit limit of PHP 100,000.00, and paid its annual fee in full which amounted to PHP 24,668.00.

We thought that he could use his plan for this procedure so we would not need to take out some cash. And besides, that’s the reason why we get an HMO plan in the first place, right? So we could use in times like this.

So we went home without having his endoscopy procedure done. Maxicare would not want to fully cover his expenses. Later in the afternoon, the Health Benefit Agent who sold him the plan called on the phone and explained the same thing. She also said that pre-existing conditions will be fully covered on the second year of your plan (if you renew), only PHP 10,000.00 is available in the first year (and I was like, WHAT? Simply means you cannot actually maximize your plan in the first year. She did not mention this when we inquired in their Makati office). And she also said something which really disappointed us: this particular procedure, the endoscopy, is actually fully covered if it is a corporate account. So there. Corporate Account.

This incident has made us realize the following:

It is all about money. Maxicare only cares about the money you pay. They care more about their Corporate Accounts because obviously, they would pay more. Individual Accounts are then what?

I am also a freelancer. We are both freelancers. Now, is it worthy to get an HMO plan as freelancers? After this incident, I still need to think if we should get a new one next year from a different HMO company. Or should we just rely on our PHILHEALTH? I used to think that having an HMO plan is much better than just having a PHILHEALTH membership, but I doubt this time.

Any freelancers out there who has an HMO plan? Which HMO company offers better coverage based on your experience?

(Just to be fair. I appreciate Maxicare’s customer service for responding to our concerns, though the outcome has not been favorable to us. I guess it just can’t be helped if that is what their company requires)