GR 163123; (April, 2005) (Digest)
G.R. No. 163123 . April 15, 2005.
PHILIPPINE HEALTH INSURANCE CORPORATION, Petitioner, vs. CHINESE GENERAL HOSPITAL AND MEDICAL CENTER, Respondent.
FACTS
Respondent Chinese General Hospital and Medical Center (CGH), an accredited health care provider under the old Philippine Medical Care Commission (PMCC) system, filed Medicare claims with the Social Security System (SSS) for services rendered from 1989 to 1992. The passage of Republic Act No. 7875 (the National Health Insurance Act of 1995) transferred the functions and assets of the PMCC to the newly created Philippine Health Insurance Corporation (PhilHealth). Consequently, CGH’s pending claims fell under PhilHealth’s administration.
PhilHealth denied the majority of CGH’s claims, citing Section 52 of its Implementing Rules and Regulations, which mandates that all claims must be filed within sixty (60) calendar days from the patient’s date of discharge. PhilHealth argued that CGH filed its claims beyond this reglementary period. CGH’s subsequent claims for services rendered from 1998 to 1999 were also denied on the same ground of late filing. PhilHealth maintained this denial with finality in its decision dated June 6, 2000.
ISSUE
Whether PhilHealth correctly denied the claims of CGH for being filed beyond the 60-day period prescribed under its implementing rules.
RULING
No. The Supreme Court affirmed the Court of Appeals’ decision ordering PhilHealth to pay CGH’s claims. The Court ruled that PhilHealth cannot apply its new 60-day filing period retroactively to claims that accrued under the old PMCC regime. The claims for 1989-1992 were filed with the SSS, the proper administering agency at that time, and their processing was merely overtaken by the legislative creation of PhilHealth. Applying the new deadline to these pre-existing claims would be unjust and impair vested rights.
Furthermore, the Court emphasized that the exhaustion of administrative remedies doctrine was not applicable. PhilHealth itself, through its President, had indicated that the denial was final, leaving CGH with no further administrative recourse. The Court also highlighted the law’s social justice objective, noting that denying valid claims for technicalities undermines the National Health Insurance Program’s purpose of making health services available and affordable. PhilHealth’s rigid application of procedural rules contravened the substantive policy of the law.