The Philippine Health Insurance Corporation (PhilHealth) has moved to clarify its benefit policies for stroke patients while confirming that it will reimburse a family after a hospital allegedly failed to apply coverage to a patient who died within 24 hours of admission.
PhilHealth Senior Vice President for Health Finance Policy Sector and spokesperson Israel Francis Pargas said the state insurer is now reviewing its evaluation and payment systems to address possible inconsistencies in how hospitals interpret coverage rules for critical cases.
The clarification came after a viral post involving a stroke patient who passed away less than a day after confinement, with hospital bills reportedly reaching around P200,000 and no PhilHealth deduction applied due to the belief that coverage requires a minimum 24-hour stay.
Pargas said PhilHealth has existing policies that specifically cover stroke cases, including patients who die shortly after admission.
“Hindi ko naman po sinasabing mali, pero gusto po natin ma-evaluate kung ano ‘yung nangyari. Pero doon po sa ating polisiya, meron po nakasulat, especially nga para sa stroke,” he said.
He added that although the hospital may have overlooked applicable provisions, the family remains entitled to benefits through a direct filing or reimbursement process upon submission and evaluation of required documents.
“Kung ano man ‘yung benepisyo ay doon na po sa member o doon sa mga naiwan natin maibibigay… hindi na po deducted but rather reimbursed,” he said.
PhilHealth said that since the bill had already been settled, the claim will proceed through reimbursement rather than hospital deduction.
The agency also addressed reports of large hospital deposit requirements for similar cases, noting that neurological procedures such as brain hemorrhage operations are highly complex and costly.
Pargas said current PhilHealth case rates include coverage of about P76,000 for ischemic stroke and P80,000 for hemorrhagic stroke, while surgical procedures involving brain hemorrhage removal may fall under benefit packages ranging from P73,000 to P108,000.
He said PhilHealth is also reviewing a proposal from the Society of Neurosurgery to increase benefit packages for critical brain procedures.
For cases involving confinement of less than 24 hours, Pargas said patients may still qualify for layered benefits depending on services rendered, including resuscitation, transfer, and partial care packages subject to evaluation.
“Kung halimbawa naman po ay in less than 24 hours at titingnan natin kung ano yung serbisyo,” he said.
He added that the final benefit amount will depend on the assessment of submitted medical records.
“Kapag na-evaluate, pwede po natin kayo ma-inform kung ano talaga yung magkano mismo yung benepisyo na pwede nila makuha,” he said.
PhilHealth’s National Capital Region office has already coordinated with the bereaved family and hospital administrators to verify records and expedite reimbursement processing.
The agency said it is also pursuing policy reviews and tighter coordination with hospitals to ensure consistent implementation of benefits and to prevent issues such as improper upfront billing or misinterpretation of coverage rules.
Photo courtesy of PIDS
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