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Welcome to the Nanbo Group Accident & Health Plan!
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The Nanbo Group Accident and Health Plan is provided by the Tokio Marine & Fire Insurance Co., Ltd. The Plan reflects current Guam health insurance trends, and answers both you and your family’s health needs, as well as your employer’s need for a healthy staff. It has new provisions that address new requirements brought about by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the Health Insurance Portability and Accountability Act of 1996 (HIPPA), the Women’s Health and Cancer Rights Act of 1998 and the Newborn Act of 1996, in the areas of private business and for protection of both you and your survivors.
The new Nanbo plan keeps freedom to choose your own physician or medical/dental provider. The referral requirement for visits to a Doctor of Chiropractics, Acupuncture and off-island services has been eliminated.
The old health policy is being phased out and replaced by a new policy which has better and more precise wording. This new plan shows an honest attempt to convert much of the medical jargon into layman’s terms. The purpose of this brochure is to fill in the gap in explaining to you, the member, what is and what is not covered in the new plan.
Important Notice: There are exclusions (items the plan does not cover). Please read through the exclusions lists.
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HIGHLIGHTS
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• Unlimited lifetime plan benefit.
• No referral requirements from physician for off-island services.
• No referral requirements from physician for chiropractic care.
• No referral requirements from physician for acupuncture and finger pressure.
• Hemodialysis and Continuous Ambulatory Peritoneal Dialysis (CAPD) covered up to maximum of $5,000 per member per policy year.
• Free coverage for newborn child from date of birth (if the natural mother is covered under the plan) for up to 30 days or expiration of policy, whichever comes first.
• Annual Physical Examination covered up to maximum of $200 per policy year.
• Periodontics covered up to maximum of $500 per policy period.
• Prescription drugs: Generic names –plan pays 90% of UCR
Brand names –plan pays 80% of UCR
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 Employer. This is the COMPANY you work for. The employer negotiated with Nanbo to provide you with this plan benefit to keep you and your family healthy so that you can work well. The employer is the direct link between Nanbo and you. The employer may be represented by your company’s personnel department or the president or owner of your company. The company is the intermediary between Nanbo and you, the subscriber. The company pays your premiums.
Subscriber. This means you, the employee. To be eligible you must be a full-time employee working more than 30 hours per week. As such, all health claim records under your family will be kept under your subscriber number.
Family Member. This is limited to your legal spouse and children, including legally adopted children. When your child reaches 19 years of age, he/she can be eligible up to his/her 23rd birthday, if he/she continues to be totally dependent on you and is a full- time student. A full time student attending school off-island should submit proof of schooling (registration) from the learning institution. The 60 days out of the area residency requirement does not apply. Health Benefits apply as though they were here in Guam. Married children are not eligible to be members. A dependent of your child (dependent of dependents) cannot be eligible as a member.
Member. This means you, the subscriber and your family members. Your family members can be members while you are included in the plan but subject to COBRA. You or your spouse can remain members when you reach 65 provided you apply for and maintain your coverage under Part A and Part B of the Medicare Act; otherwise you may remain a member only up to age 69.
 Injury. Accidental bodily harm caused by external force which manifests itself while the policy is in effect. It includes all complications and recurrence which occur during the life of the policy.
Sickness. An illness or disease which manifests itself while the policy is in force. It includes all complications and recurrence which occur during the life of the policy.
Emergency. A sudden and unexpected onset of a severe medical condition which, if not treated immediately, would be life threatening or result in permanent disability.
Pre-existing Condition. The existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a one year period preceding the effective date of coverage, unless member is qualified under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This includes chronic illness that existed prior to being included in the Plan, such as heart murmur, high blood pressure, diabetes, tuberculosis and kidney failure. Pregnancy at the effective date of coverage is considered a pre-existing condition.
Doctor. A Doctor of Medicine (M.D.) or Doctor of Dentistry or Dental Surgery (D.D.S.), or Osteopathic Physician and Surgeon (D.O.), or Doctor of Chiropractics (D.C.) licensed to practice in Guam or in the country, state or possession where the doctor practices.
Hospital. Any licensed inpatient care institution primarily engaged in providing facilities for surgery, diagnosis and treatment of injured or ill person by and under the supervision of a doctor and has registered nurses on duty. It does not include rest homes, skilled nursing facilities or places for the treatment of drug addiction or alcoholism.
Nurse. A Registered Graduate Professional Nurse (R.N.), Licensed Practical Nurse (L.P.N.) or Licensed Vocational Nurse (L.V.N.).
Skilled Nursing Facility. An inpatient care institution where a patient is admitted when hospitalization is no longer necessary but daily skilled nursing services are needed. The plan covers up to 30 days when medically necessary.
Medically Necessary. Means the need to eliminate an illness, or the need to prevent it from progressing into a mass condition (i.e. a pneumonia). A wart removal could be medically necessary if, in the doctor’s opinion, that particular wart type could proliferate into a malignant condition. Circumcision and cosmetic surgeries are not considered medically necessary.
Over the Counter Drugs (OTC). Drugs that do not require a prescription from the doctor. The plan does not cover OTC drugs.
Prescription Drugs. Drugs that can be obtained from a licensed pharmacy through a licensed doctor’s prescription. These are drugs listed in the United States Pharmacopia, National Formulary and can only be supplied, used or prescribed by your doctor.
 Residency Requirement. To remain a member under this plan, one must maintain principal residence on Guam and must not reside outside the Territory of Guam for more than 60 days per calendar year.
Membership Card. A card Group Health Insurance Card that shows your name, date of birth, your subscriber or member number. Nanbo issues this to your employer for delivery and it reflects coverage afforded to you by your employer. It also shows when your coverage starts and when it will expire. It is Nanbo's property and must be returned to your EMPLOYER when you resign or when the policy is cancelled or becomes void. It is not transferable.
Usual, Customary, and Reasonable Fee (UCR). The usual fee is what the doctor regularly charges to all his patients for a specific type of service. Some doctors would usually charge a Limited Visit Fee for colds instead of a Brief Visit Fee if in the same visit you also complained about other problems.
A fee is customary when it is in the range of usual fees charged by doctors of similar training and experience for the same service within the same specific and limited geographic area determined by Nanbo. The Limited Visit Fee by a family doctor or primary doctor on Guam, for example, ranges from $16.00 to $25.60. However, if your primary doctor makes a referral for you to go to a heart specialist, a consultation fee by that specialist will cost more than what a regular family doctor charges. A Limited Visit Fee for a consultation will range from $40.00 to $64.00 on Guam. Hence, a Limited Visit Fee charged by a family doctor on Guam is customary if it is between $16.00 and $25.60. A Limited Visit Fee charged by a specialist for a medical consultation on Guam is customary if it is between $40.00 and $64.00.
A fee is reasonable when it meets the above two criteria or, in Nanbo’s opinion, is justifiable considering the specifics of the case in question.
The Usual, Customary, and Reasonable (UCR) expenses or their various equivalent forms (other health carriers call them “Eligible Charges” or “Fair, Customary, Usual rate for the service”) are now accepted as the basis for payment by the health insurance industry. To date, the UCR method provides a system of payment to providers with as much fairness to all physicians as possible. It is widely accepted by health providers simply because it gives them a systematic method of billing patients, and health carriers keep records at the same time. It also readily lends itself to computerization, which is a must for any medical practitioner.
Co-Payment. Term referring to your share of the cost of your treatment. This is the amount that exceeds the benefits provided by the plan as shown in Part 1 (Medical Benefits) and Part 2 (Dental Benefits). You must pay this cost, out of pocket, to your doctor or hospital.
Off-Island. Location outside Guam and the Commonwealth of Northern Marianas (CNMI). Off-island treatments do not require referral by Guam doctors; however, Nanbo Guam should be notified before leaving island, except in cases of emergency. For services available in Guam, Nanbo will cover only up to on-island costs.
Coordination of Benefits. Applies only when you have other health insurance plans besides the Nanbo plan. In case of dual coverage, the Nanbo plan will not pay as primary carrier.
Some Requirements
• You or the doctor you have assigned benefits to, must file your claim within ninety (90) days after you have received the services provided by that doctor or hospital. A twenty-five percent (25%) reduction in benefits will be applied for late filing. Any claim filed after six (6) months from date of service will not be paid by this plan and shall be your sole responsibility.
• The referral requirement for all off-island treatment is not mandatory, but Nanbo Guam needs to be notified of the off-island treatment before leaving the island.
• Prior written justification is required from the attending obstetrician explaining any medically necessary abortion.
This plan requires five (5) or more subscribed employees.
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GENERAL EXCLUSIONS
(What The Entire Plan Does Not Cover)
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a. Any injury which is intentionally inflicted by any person who may be eligible to receive benefits under this plan.
b. Any attempt of suicide or any intentional self-inflicted injury.
c. Any act or breach of criminal law.
d. Injury or sickness suffered during the execution of sentence, detention or imprisonment of member.
e. Participation in contests, races, exhibitions (including training for these activities) or test driving by means of aircraft, motor boat, automobile or motorcycle.
f. Military services provided by governmental agencies or institutions.
g. Eligible services provided by governmental agencies or institutions.
h. Injury or sickness for which benefits are payable under any Workers’ Compensation Law, Occupational Disease Act, or any Workers’ Compensation case.
i. War, riot, civil war, civil commotion, military act of foreign nations, revolution, insurrection, armed rebellion or other similar social disturbances.
j. Radioactive, explosive, other hazardous native of nuclear fuel materials, or any nuclear radiation or radioactive contamination.
k. Environmental pollution or contamination such as ground, air or water, but this exclusion does not apply if such pollution is caused by sudden and accidental means.
l. Medical or Dental Claims for which member is entitled to compensation under any other plan or policy. In any dual coverage, this plan shall not be considered as the primary plan.
These general exclusions apply to all Medical, Dental and Accidental Death and Disablement parts of the plan.
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MEDICAL BENEFIT SCHEDULE
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| Benefits |
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What The Plan Covers |
Annual Plan Maximum
Lifetime Maximum Coverage |
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Gold Plan: $100,000/member
Silver Plan: $50,000/member
Unlimited |
Hospital Inpatient Care
•Rooms and Board (Intensive Care, treatment rooms, observation rooms and semi-private rooms only)
•Hospital services such as pharmacy, laboratory, pathology, radiology, radiation, surgery and anesthesia, maternity and newborn care services and dialysis including professional fees
•Inpatient Physical Therapy, Respiratory/Pulmonary Therapy and Pain Management
•General Nursing Care
•Blood Administration |
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80% of UCR Expenses |
| Hospital Skilled Nursing Facility |
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80% of UCR Expenses
30 days maximum per member per policy |
| Hospital Services for Drug and Alcohol Abuse |
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50% of UCR Expenses
Maximum of 24 hours (inpatient only) |
Outpatient Care
Primary and Specialist Office Visit |
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80% of UCR Expenses |
Emergency Room Care
When emergency room visit is made in a non-emergency situation, Nanbo shall pay the UCR fee as if services were provided in an ordinary clinic. |
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80% of UCR Expenses |
| Outpatient Surgery |
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80% of UCR Expenses |
| Physical Therapy |
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80% of UCR Expenses
Plan covers the first 20 visits only per member per policy year |
Chiropractic and Acupuncture/Finger Pressure
No referral requred |
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50% of UCR Expenses up to Plan maximum of $250 |
| Mental Health Care |
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80% of UCR Expenses
Plan covers the first 20 visits only per member per policy year |
| Annual Eye Refraction |
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80% of UCR Expenses
Maximum of $25 |
| Eye Care: Medical treatment of Eye Disorders |
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80% of UCR Expenses |
Annual Physical Examination
• Including doctor's fee, laboratory and other diagnostic expenses |
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80% of UCR Expenses
Maximum of $200 exclusive of copayment |
Routine Immunizations
• Includes Diphtheria Pertussis-Tetanus (DPT), Cholera, Polio, Measles-Mumps-Rubella (MMR), Influenza, Hepatitis, Hemophilus, Influenza type B (HIB), PPD (TB Screening), Chickenpox and Tetanus-Diphtheria (booster) |
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80% of UCR Expenses |
Home Health Care Services
• Services limited to wound care and medication administration only |
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80% of UCR Expenses
Maximum of 15 visits per policy year (pre-authorized) |
Special Materials and Appliances (Rental Only)
• Llimited to walkers, standard wheelchair, standard hospital bed, oxygen concentrator and oxygen refill |
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80% of UCR Expenses
Maximum of 30 days (pre-authorized)
Member pays deposit required |
| Diagnostic Laboratory and X-rays |
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80% of UCR Expenses |
| Well Baby Care |
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80% of UCR Expenses
Maximum of 5 visits for children less than 2 years of age |
| Ambulance |
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80% of UCR Expenses |
| Nuclear Medicine |
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80% of UCR Expenses |
| Chemotherapy and Radiation Therapy |
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80% of UCR Expenses |
Maternity Care Services
• Includes prenatal, postpartum delivery care and nursing care of the newborn |
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80% of UCR Expenses |
Newborn Services
• Limited to newborn whose natural mother is covered under the plan and enrolled within 30 days from the date of birth
• If mother is non-member, plan does not cover; however, if enrolled by the subscribing father, effective date of coverage will be on the discharge date subject to enrollment within 30 days
• Newborn Act of 1996: Nanbo allows mother and baby to stay in the hospital up to 48 hours after normal vaginal delivery and up to 96 hours after Caesarean Section |
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80% of UCR Expenses |
| Acquired Immune Deficiency Syndrome (AIDS) |
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80% of UCR Expenses
Maximum of $10,000 coverage per policy year |
Hemodialysis and Continuous Ambulatory Peritoneal Dialysis (CAPD)
• Plan covers inpatient and outpatient dialysis including medications |
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80% of UCR Expenses
Maximum of $5,000 coverage per policy year |
Reconstructive Surgery
Women's Health and Cancer Right Act of 1998 after Mastectomy. Nanbo covers reconstruction surger on the affected breast, surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas |
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80% of UCR Expenses |
Prescription Drugs
• Off-island medication reimbursement will only be honored if accompanied by an updated prescription and original receipts |
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Maximum of 30 days supply per prescription |
| Generic Name Drugs |
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90% of UCR Expenses |
| Brand Name Drugs |
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80% of UCR Expenses |
| Birth Control Medications |
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50% of UCR Expenses |
Congenital Birth Defect
• Limited to persons born under the plan |
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80% of UCR Expenses
Maximum of $10,000 coverage per policy year |
Off-Island Services
• For services available in Guam, plan will cover only up to on-island costs
• Maximum of 60 days off-island |
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80% of UCR Expenses except for Philippines services where Plan pays 90% of UCR |
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EXCLUSIONS: WHAT MEDICAL BENEFITS DO NOT COVER
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• Abortion (voluntary termination of pregnancy/not medically necessary)
• Air fare, transportation fee and hotel expenses
• Alcohol and drug rehabilitation
• Allergy testing, supplies and treatment
• Amyotrophic Lateral Sclerosis (ALS), Parkinson’s Dementia (PD), Tuberculosis (TB), Hansen’s Disease (leprosy) and related conditions
• Blood and blood products
• Cardiac rehabilitation
• Charges that exceed the usual customary and reasonable fee
• Chronic psychiatric disorders and drugs for treatment of mental illness
• Circumcision
• Cosmetic surgery
• Elective sterilization procedures such as tubal ligation, vasectomy, contraceptive devices including intrauterine device (IUD) and the like
• Experimental medical, surgical or other health care procedures
• Eyeglasses, contact lenses and examination for contact lenses
• Hearing aid and hearing aid examinations
• Hospice care, custodial care, convalescent care, rest cures and private duty nurses
• Immunizations for the purpose of international travel, employment or educational purposes
• Implants like cochlear implants, intraocular lens implants, except cardiac pacemakers
• Impotence, sexual dysfunctions or inadequacies, medications and related services
• Injury sustained as a result of participation in, as whether a driver or passenger, drag racing, off-roading or speed testing
• Injury sustained directly or indirectly by the member under the influence of alcohol or controlled substances
• Inpatient mental health care
• Long-term physical therapy and rehabilitation
• Maternity care for common law spouse or dependent child
• Occupational and speech therapy
• Organ and tissue transplant procedures, related services, conditions and complications arising thereto
• Orthopedic and external devices
• Other health and accident insurance coverage and third party liability settlements
• Over the counter (OTC) drugs for which a prescription from a doctor is not required under the Federal Law
• Personal comfort items such as telephone, television and guest trays
• Physical examination for employment, licensing, sports, educational or insurance purposes unless obtained in the context of annual examination
• Replacement of joints and limbs and related services
• Reversal of voluntary sterilization, diagnosis and treatment of infertility and services related to conception by artificial means
• Self-inflicted or self-induced injuries resulting in suicide and suicide attempts
• Services and treatments provided for under Local, State or Federal Government agency (i.e. MIP and others)
• Temporomandibular joint disorder (TMJ) and related diseases
• Transsexual surgery and related services
• Treatment of or for mental retardation and mental deficiency
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DENTAL BENEFIT SCHEDULE
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| Benefits |
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What The Plan Covers |
Diagnostic Treatment
• Comprehensive oral exam and full mouth x-ray per policy year
• 2 films for bite wing x-ray per policy year
• 16 films for full mouth x-ray per policy year |
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80% of UCR Expenses |
Restorative Dentistry
• Covers routine fillings, silver or composite
• Class V and VI bonding restorations
• Laminations to correct tetracycline stains
• Temporary fillings with zinc oxide eugenols
• Crown buildup with pins and occlusal equilibration of high spots
Note: Posterior composite fillings are not covered |
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80% of UCR Expenses |
Oral Surgery
• Simple and surgical extractions
• Impactions
• Frenectomy (soft tissue surgery)
• Apicoectomy (root amputation)
• Immobilization of fractured, avulsed or luxated tooth
• Pericoronal tissue excision |
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50% of UCR Expenses |
Endodontics
• Pulpotomy on deciduous teeth
• Root canal treatment
• Emergency root canal drainage
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50% of UCR Expenses
Maximum of $500 per policy year |
Periodontics
• Consultation, evaluation and treatment of soft tissue and bones supporting the teeth
• Subgingival Currettage
• Root Planning
• Periodontal surgeries such as crown lengthening and soft tissue graft |
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50% of UCR Expenses
Maximum of $500 per policy year |
Sedation and General Anesthesia
• Covered only when it is medically necessary |
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50% of UCR Expenses |
Fixed and Removable Prosthetics on Guam only
• Gold Crown (semi-precious), porcelain over metal
• Bridges (or abutment)
• Repair of broken dentures
• Reline
Note: Off-island procedures for crowns or bridges, or repair of dentures are not covered |
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50% of UCR Expenses
Maximum of $400 per policy year |
| Dental Prescription Drugs |
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80% of UCR Expenses |
Preventive Care Services on Guam Only
• Routine cleaning (oral prophylaxis) limited to twice a year |
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80% of UCR Expenses |
Off-Island Dental Reimbursement
• All dental reimbursements should be accompanied by dental records and original receipts and a contact number of the dentist |
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50% of Guam's UCR Expenses |
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EXCLUSIONS: WHAT DENTAL BENEFITS DO NOT COVER
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• All costs and services related to implants of any kind and treatment of traumatic injuries
• All hospital costs and services charged by dentist for hospital treatment
• Dental work for cosmetic purposes
• Charges that exceed the usual customary and reasonable fee
• Experimental dental procedures
• Full mouth rehabilitation, periodontal splints, restoration of tooth surface lost from attrition and restoration of misalignment of teeth
• Off-island procedures for crowns or bridges, or repair of dentures
• Orthodontic and related services
• Platinum procedures
• Posterior composite fillings
• Procedure or procedures (including crowns, bridges, dentures or root canals) started prior to the day of becoming an eligible member
• Replacement of lost or stolen dentures, bridges or other dental appliances
• Single, partial and full dentures
• Temporomandibular (jaw) joint disorders and related diseases
• Treatment and/or removal of oral tumors
• Benefits and services not specified as covered
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PART 3: ACCIDENTAL DEATH AND DISABLEMENT BENEFITS
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The Plan will pay up to $10,000 per member per year. |
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BENEFITS - What the Plan Covers
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a. If you sustain bodily injury through any sudden and/or accidental happening of external origin during the policy period, the plan will pay compensation as set forth in the Table of Accidental Death and Disablement Compensation (see page 17).
b. In case of death as a direct result of the injury within 180 days from the date of the accident, the plan will pay the amount insured in full as shown in the Table.
c. When an aircraft or vessel in which you are riding disappears or meets a disaster and if you have not been found within 30 days, it will be presumed that you have suffered loss of life resulting from bodily injury at the date of such disappearance or disaster.
d. If as a direct result of injury you lose a part of your body or suffer from heavy impediment in the functions thereof within 180 days from the date of accident, the plan will pay the disablement indemnity as in the specified Table.
e. For disability or deformity, other than those shown in the Table, Nanbo will determine, regardless of your occupation, age, status, etc., the amount of compensation payable according to the degree of disability or deformity sustained by you and will follow the classification of injury specified in the Table.
f. All sums paid by way of compensation under this coverage part shall not exceed $10,000 during the policy period. |
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EXCLUSIONS: WHAT THE ACCIDENTAL DEATH AND DISABLEMENT BENEFITS DO NOT COVER
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a. Accident while you are out of Guam and the CNMI (i.e. if a plane you are on [whether a domestic or an international airline] crashes outside the service territory, namely Guam and the CNMI).
b. Accident while driving an automobile or a motorcycle without having a valid driver’s license.
c. Accident occurring while you are driving an automobile or a motorcycle under the influence of alcohol or illegal drugs.
d. Accident while you are operating an aircraft.
e. Accident while you are participating in a dangerous sport or game including, but not limited to: 1) mountain climbing; 2) hunting; 3) airship boarding; 4) glider boarding; 5) skydiving; 6) scuba diving; 7) ocean yacht boarding in the open sea; 8) target practice using any gun; 9) other dangerous sports or games similar thereto.
f. Death or disablement from sickness, brain disease or insanity.
g. Pregnancy, childbirth, premature birth or miscarriage of member.
h. Surgical treatment of member (except as may be necessary solely by injury covered by this coverage).
i. Misconduct or malpractice of doctor and/or hospital.
j. Death and disablement covered by Workers’ Compensation.
k. Disablement not specified in Table.
l. Bodily injury or death arising from poisoning, anesthesia, stroke or mental agitation.
“Pre-existing Condition” Limitation:
If at the time of “injury” sustained by “member”, there already existed physical suffering, which “member” suffered before becoming “member”, and, if “member” thereafter sustains another “injury” and such physical suffering causes “injury” to become aggravated, then we will determine and pay the amount that would have been payable had there been no such aggravation.
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Table of Accidental Death and Disablement Coverage
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a. Accidental Death
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100% of insured amount |
b. Permanent and Total Loss of Sight
1. Loss of sight of both eyes
2. Loss of sight in one eye |
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50% of insured amount
25% of insured amount |
c. Permanent and Total Loss of Hearing
1. Loss of hearing in both ears
2. Loss of hearing in one ear |
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50% of insured amount
25% of insured amount |
d. Permanent and Total Loss of Smell
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10% of insured amount |
e. Permanent and Total Loss of Speech
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30% of insured amount |
f. Permanent Facial Disfigurement (scar measuring 2 inches or more)
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5% of insured amount |
| g. Permanent Disability or Deformity of the Spinal Column |
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25% of insured amount |
h. Permanent Loss of One Arm or One Leg
1. Loss of one arm or leg
2. Loss of both arms or legs |
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50% of insured amount
100% of insured amount |
i. Permanent Loss of Hands or Feet (Loss of three or more fingers or toes above knuckle)
1. Loss of one hand or foot
2. Loss of both hands or feet |
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30% of insured amount
60% of insured amount |
j. Permanent Loss of Fingers or Toes
1. Loss of one finger or toe
2. Loss of two fingers or toes |
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10% of insured amount
20% of insured amount |
k. Permanent and Total Physical Disability
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100% of insured amount |
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HOW TO USE THE PLAN WISELY
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1. Taking good care of yourself is the most economical form of care. Eat balanced meals. Reduce intake of junk foods, excessive sugar and salt. Watch your weight. Avoid foods high in fat and cholesterol, especially fried foods. Exercise regularly. Maintain a good posture. In doing so, you will help prevent visits to your chiropractor. Brush and floss your teeth after every meal. Visit your dentist regularly. Don’t smoke. Don’t abuse alcohol or other drugs. Get plenty of rest.
2. If you become ill, remember to seek medical attention immediately. However, use the GMH Emergency Room only for those cases which are emergencies. For non-emergency type situations, visit your doctor’s clinic. However, do not hesitate to use the emergency facility when it is medically necessary.
3. Choose the right type of doctor: Family doctor, specialists such as Ear/Nose/Throat (ENT), Surgeons, Cardiac (or heart) specialists, Obstetrician/Gynecologists (for females only) and Pediatricians for children. For colds or flu, see your family doctor. Remember, your co-payment will be lower when you visit your family doctor instead of a specialist, so give your family doctor a chance first. When a second opinion or input of a specialist is needed, your family doctor will refer you to one for consultation. However, keep your family doctor as your primary physician; he will prescribe as the specialist advises him. If your case merits more attention by a specialist, he will take your case on a regular basis wherein he will now be your primary, or attending physician. By simply knowing the differences between types of physicians, you will prevent paying excessive co-payments. It will also prevent future increases in your health insurance premiums.
We have two (2) types of medical emergencies:
• Urgent Medical Problems include fractures, possible poisoning, pain in the abdomen and chest, sudden shortness of breath, heat reaction, objects in eye, ear or nose; serious cuts, serious burns on hands, face; sudden onset of high fever and listlessness in an infant or child.
• Life Threatening Emergencies include multiple injuries from major accidents, chest or abdominal wounds, drowning, continued unconsciousness for more than five minutes, burns on over more than half the body, severe shock, severe chest pain and difficulty in breathing.
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1. For Local Doctor/Laboratory/Clinic/ Pharmacy or Hospital visits: Ask your doctor to itemize your charges on the Nanbo claim form before you pay your co-payment and before you sign the Assignment of Benefits. Keep the third copy of the Claim form that you have signed. Ask the doctor/hospital to file the claim form with Nanbo for you. The plan will only pay UCR expenses, hence any remaining balance will be your responsibility. Try to negotiate with your doctor regarding his charges. It will also help lower your co-payment. Remind your doctor to file your claim within ninety days.
2. Off-island referral claims must be approved by Nanbo beforehand in writing. The Nanbo health claims section will provide you with ample health claim forms to take off-island. Ask the off-island hospital to file claims directly with Nanbo for you. If you must pay cash in emergency off-island cases, make sure to keep all original receipts and document the diagnosis and treatment you received. If possible, get a written attending physician’s report. File a formal claim with Nanbo as soon as you return to Guam. Just mailing or delivering your receipts to us does not constitute a formal claim. You must sign the Nanbo claim forms. A detailed claim with all procedures itemized will speed up the processing of your claim. Keep copies of all your health bills or receipts for your records.
3. Always include your Member Number in all claims. Make sure your mailing address is correct. Include your home and work phone should we need additional information about your claim. Please notify your physician of any change in your address or phone number. Since some people change employers from time to time, your Member Number can change a number of times. To keep track of your record, we may find it necessary to use your Social Security Number instead. Check your Membership ID Card to ensure the correct Social Security Number is shown.
4. As of the production of this Membership brochure, the location of the Nanbo Health Claims Section is on the second floor of the Nanbo building, located along West O’ Brien Drive across from Julale Shopping Center in Hagatna, Guam. Our mailing address is P.O. Box 2980, Hagatna, Guam 96932. You may also obtain Health Claim forms from our Nanbo Tamuning Branch, on the first floor of the GITC building, at the intersection of Marine Drive and Chalan San Antonio, Tamuning.
You must submit your claim with Nanbo within 90 days from the date you received treatments or procedures. Otherwise, your benefits will be reduced by 25% or denied altogether.
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