Philippine Health Insurance Corp vs Chinese General Hospital and Medical Center

GR 163123

Facts:
CGH (Chinese General Hospital) filed its Medicare claims with Philhealth (amounting to 14M). However,
Philhealth denied the claims because they were filed beyond 60 days after the discharge of the patient.
This is in accordance with the implementing rules and regulations of RA 7875, Section 52 of which
provides:

SECTION 52. Fee for Service Guidelines on Claims Payment. – xxx b. All claims for payment of services
rendered shall be filed within sixty (60) calendar days from the date of discharge of the patient.
Otherwise, the claim shall be barred from payment except if the delay in the filing of thee claim is due to
natural calamities and other fortuitous events. If the claim is sent through mail, the date of the mailing
as stamped by the post office of origin shall be considered as the date of the filing.

Issue: WON CGH is entitled to received payment from Philhealth YES

Held:
Philhealth should reimburse CGH due to several factors:
1. There are several requirements that need to be accomplished before a claim is filed with
Philhealth, which often necessitate securing documents from other government offices;
2. Most patients are unable to immediately accomplish, file and submit the required documents

Under these circumstances, it is unreasonable to expect CGH to comply 100% of the time with the
prescribed 60-day rule of Philhealth. Also, unreasonably strict implementation of the 60-day rule,
without regard to the causes of delay beyond CGH’s control, will be counter-productive to the long-term
effectiveness of the health program. The Court will not hesitate to allow a liberal implementation of the
rules and regulations of an admin agency in cases where their rigid enforcement will result in a
deprivation of legal rights.

Also, RA 7875 shows that the law itself does not provide for any specific period within which to file
claims. It was only the IRR which established the 60-day cut off for the filing of claims. Technicalities
should not defeat the realization of the state policy to provide Philhealth members with medical care.