Case Digest: PHILIPPINE HEALTH INSURANCE CORPORATION, petitioner, vs. CHINESE GENERAL HOSPITAL AND MEDICAL CENTER, respondent.

[G.R. No. 1631 3. A!"i# 1$, %%$& Po'e'te: Co"o'a, (. Nat)"e: A petition for review on certiorari under Rule 45 of the Rules of Court assailing the March 29, 2004 decision[1 of the Court of Appeals which ordered the !hilhealth to give due course to petitioner"s, Chinese #eneral $ospital and Medical Center, clai%s for the period fro% 19&9 to 1992, a%ounting to !14,291,5'&()1( *ACTS: *n +e,ruar- 14, 1995, Repu,lic Act .o( )&)5, otherwise /nown as 0An Act 1nstituting a .ational $ealth 1nsurance !rogra% for all +ilipinos and 2sta,lishing the !hilippine $ealth 1nsurance Corporation +or the !urpose,3 was approved and signed into law( !rior to the enact%ent of R(A( )&)5( Chinese #eneral $ospital 4C#$5 had ,een an accredited health care provider under the !hilippine Medical Care Co%%ission 4!MCC5, %ore popularl/nown as Medicare( As such, petitioner filed its Medicare clai%s with the 6ocial 6ecurit- 6-ste% 46665, which, together with the #overn%ent 6ervice 1nsurance 6-ste% 4#6165, ad%inistered the $ealth 1nsurance +und of the !MMC( 7hus, petitioner filed its clai% fro% 19&9 to 1992 with the 666, a%ounting to 21#$7 M1881*. *.2 $9.:R2: 7;* 7$*96A.: 62<2. $9.:R2: 21#$7=>7;* and 10?100 4!&,102,)&2(105( 1ts application for the pa-%ent of its clai% with the 666 was overta/en ,- the passage of R(A( )&)5, which in 6ection 51 and 52, provides@ SECTION 51. Merger. Within sixty (60) ays !ro" the #ro"$%gation o! the i"#%e"enting r$%es an reg$%ations& a%% !$nctions an assets o! the 'hi%i##ine Me ica% Care Co""ission sha%% (e "erge )ith those o! the Cor#oration ('*I+*E,+T*) )itho$t nee o! con-eyance& trans!er or assign"ent. The 'MCC sha%% therea!ter cease to exist. The %ia(i%ities o! the 'MCC sha%% (e treate in accor ance )ith existing %a)s an #ertinent r$%es an reg$%ations. xxx SECTION 5.. Trans!er o! *ea%th Ins$rance /$n s o! the SSS an 0SIS. The *ea%th Ins$rance /$n s (eing a "inistere (y the SSS an 0SIS sha%% (e trans!erre to the Cor#oration )ithin sixty (60) ays !ro" the #ro"$%gation o! the i"#%e"enting r$%es an reg$%ations. The SSS an 0SIS sha%%& ho)e-er& contin$e to #er!or" Me icare !$nctions $n er contract )ith the Cor#oration $nti% s$ch ti"e that s$ch !$nctions are ass$"e (y the Cor#oration xxx. 1nstead of giving due course to petitioner"s clai%s totaling to !&,102,)&2(10, onl!1,A'5,55'(A2 was paid to petitioner, representing its clai%s fro% 19&9 to 1992 4sic5( !etitioner again filed its clai%s representing services rendered to its patients fro% 199& to 1999, a%ounting to !),554,A42(9A( +or ,eing allegedl- filed ,e-ond the siBt- 4'05 da- period allowed ,- the i%ple%enting rules and regulations, 6ection 52 thereof, petitioner"s clai%s were denied ,- the Clai%s Review 9nit of !hilhealth in its letter dated Canuar- 14, 200, thus@ 1This #ertains to yo$r three h$n re se-enty three 'hi%hea%th "e icare c%ai"s (232) )hich )ere #ri"ari%y enie (y C%ai"s 'rocessing 4e#art"ent !or %ate !i%ing an !or )hich yo$ "a e an a##ea% to this o!!ice. We regret to in!or" yo$ that a!ter thoro$gh e-a%$ation o! yo$r c%ai"s& 5yo$r6 261 "e icare c%ai"s )ere 4ENIE4& $e to the !act that the c%ai"s )ere !i%e 5 to 16 7 "onths a!ter ischarge. *o)e-er& the re"aining "e icare c%ai"s ha-e (een !or)ar e to C%ai"s 'rocessing 4e#art"ent (C'4) !or #ay"ent.

SECTION 5. (8) 9$%e 5. (8) 9$%e :III o! the I"#%e"enting 9$%es an 9eg$%ations o! 3;35 #ro-i es that a%% c%ai"s !or #ay"ent o! ser-ices ren ere sha%% (e !i%e )ithin sixty (60) ays !ro" the ay o! ischarge o! the #atient. *o)e-er& 'hi%hea%th Circ$%ar No& 21<,& series o! 1==;& state that a%% c%ai"s #en ing )ith 'hi%hea%th as o! Se#te"(er 15& 1==; an c%ai"s )ith ischarge ates !ro" Se#te"(er to 4ece"(er 21& 1==; are gi-en one h$n re t)enty (1.0) ays !ro" the ate o! ischarge to !i%e their c%ai". In as "$ch as )e )o$% %i>e to grant yo$r re?$est !or reconsi eration& the Cor#oration co$% no %onger exten the #erio o! !i%ing xxx. C#$ filed a petition for review under Rule 4A of the Rules of Court( 7he Court of Appeals ordered herein petitioner !hilippine $ealth 1nsurance Corporation 4!hilhealth5 to pa- the clai%s in the a%ount of !14,291,5'&()1, principall- on the ground of li,eral application of the '0>da- rule under 6ection 52 of RA )&)5"s 1%ple%enting Rules and Regulations( 7hus, !hilhealth"s petition for review on certiorari(

ISSUE: ;hether or not !hilhealth is entitled to receive pa-%ent fro% !hilhealth for services rendered fro% 19&9 to 1992( HELD: 7he Court ruled that !hilhealth %ust pa- the clai%s of C#$ and affir%ed the decision of the Court of Appeals( 0A careful reading of RA )&)5 shows that the %a) itse%! oes not #ro-i e !or any s#eci!ic #erio )ithin )hich to !i%e c%ai"s( ;e can safel- presu%e therefore that the period for filing was not #er se the principal concern of the legislature( More i%portant than %ere technicalities is the realiDation of the state polic- to provide !hilhealth %e%,ers with the reEuisite %edical care at the least possi,le cost( 0 0BBB an accredited health care provider li/e C#$ has to contend with an average of a,out a thousand %e%,ers and?or dependents see/ing %edical treat%ent for various illnesses per %onth( 9nder these circu%stances, it is unreasona,le to eBpect respondent C#$ to co%pl- 100F of the ti%e with the prescri,ed '0>da- rule of !hilhealth( :espite the prescri,ed standard procedures, respondent has no assurance of the %e%,ers" pro%pt su,%ission of the reEuired docu%ents( 7his factor is co%pletel- ,e-ond its control( 7here will alwa-s ,e dela- not attri,uta,le to respondent(3 07he unreasona,l- strict i%ple%entation of the '0>da- rule, without regard to the causes of dela- ,e-ond respondent"s control, will ,e counter>productive to the long>ter% effectiveness of the .$1!( 1nstead of placing a pre%iu% on participation in the !rogra%, !hilhealth punishes an accredited health provider li/e C#$ ,- refusing to pa- its clai%s for services alread- rendered( 9nder these circu%stances, no accredited provider will ga%,le on honoring clai%s with dela-ed supporting papers G no %atter how %eritorious G /nowing that rei%,urse%ent fro% !hilhealth will not ,e forthco%ing(3 7he avowed polic- in the creation of a national health progra% is, as provided in 6ection 11, Article H111 of the 19&) Constitution, to adopt an integrated and co%prehensive approach to health develop%ent which shall endeavor to %a/e essential goods, health and other social services a+ai#a,#e to a## !eo!#e at a--o".a,#e /ost( 01t is *ur fir%l- held view that the polic- of the state in creating a national health insurance progra% would ,e ,etter served ,- granting the instant petition( 3