Article 86Labor and Agrarian Laws and Social Legislation, p. 86

LABOR LAWS AND SOCIAL LEGISLATION SPECIAL LAWS AND IMPLEMENTING RULES AND REGULATIONS

ARTICLE IX Grievance and Appeal

SECTION 39. Grievance System . — A system of grievance

is hereby established, wherein members, dependents, or

health care providers of the Program who believe they

have

been

aggrieved

by

any

decision

of

the

implementors of the Program, may seek redress of the

grievance in accordance with the provisions of this Article.

SECTION 40. Grounds for Grievances . — The following

acts shall constitute valid grounds for grievance action:

a) any violation of the rights of patients;

b) a willful neglect of duties of Program implementors

that results in the loss or non-enjoyment of benefits by

members or their dependents;

c) unjustifiable delay in actions on claims;

d) delay in the processing of claims that extends beyond

the period agreed upon; and

e) any other act or neglect that tends to undermine or

defeat the purposes of this Act.

SECTION 41. Grievance and Appeal Procedures . — A

member, a dependent, or a health care provider may file

a complaint for grievance based on any of the above

grounds, in accordance with the following procedures:

(a) A complaint for grievance must be filed with the

Corporation which shall refer such complaint to the

Grievance and Appeal Review Committee. The Grievance

and

Appeal

Review

Committee

shall

rule

on

the

complaint through a notice of resolution within sixty (60)

calendar days from receipt thereof.

(b) Appeals from the decision of the Grievance and

Appeal Review Committee must be filed with the Board

within thirty (30) calendar days from receipt of the notice

of resolution.

(National Health Insurance Act of 2013, Republic Act No.

10606, [June 19, 2013])

c) The Offices shall have no jurisdiction over any issue

involving the suspension or revocation of accreditation,

the imposition of fines, or the imposition of charges on

members or their dependents in case of revocation of

their entitlement.

d) All decisions by the Board as to entitlement to benefits

of members or to payments of health care providers shall

be considered final and executory.

SECTION 42. Grievance and Appeal Review Committee .

— The Board shall create a Grievance and Appeal Review

Committee, composed of five (5) members, hereinafter

referred to as the Committee, which, subject to the

procedures

enumerated

above,

shall

receive

and

recommend

appropriate

action

on

complaints

from

members and health care providers relative to this Act

and its implementing rules and regulations.

The Committee shall have as one of its members a

representative

of

any

of

the accredited health care

providers as endorsed by the DOH.

(National Health Insurance Act of 2013, Republic Act No.

10606, [June 19, 2013])

SECTION 43. Hearing Procedures of the Committee . —

Upon the filing of the complaint, the Grievance and

Appeal Review Committee, from a consideration of the

allegations thereof, may dismiss the case outright due to

lack of verification, failure to state the cause of action, or

any other valid ground for the dismissal of the complaint

after

consultation

with

the

Board;

or

require

the

respondent to file a verified answer within five (5) days

from service of summons.

Should the defendant fail to answer the complaint within

the reglementary five-day period herein provided, the

Committee,

motu

proprio

or

upon

motion

of

the

complainant,

shall

render

judgments

as

may

be

warranted by the facts alleged in the complainant and

limited to what is prayed for therein.

After an answer is filed and the issues are joined, the

Committee shall require the parties to submit, within ten

(10) days from receipt of the order, the affidavits of

witnesses

and other evidence on the factual issues

defined therein, together with a brief statement of their

positions setting forth the law and the facts relied upon

by

them.

In

the

event

the Committee finds, upon

consideration of the pleadings, the affidavits and other

evidence, and position statements submitted by the

parties,

that

a judgment may be rendered thereon

without need of a formal hearing, it may proceed to

render judgment not later than ten (10) days from the

submission of the position statements of the parties.

In cases where the Committee deems it necessary to hold

a

hearing

to

clarify

specific

factual

matters

before

rendering judgment, it shall set the case for hearing for

the purpose. At such hearing, witnesses whose affidavits

were previously submitted may be asked clarificatory

questions by the proponent and by the Committee and

may be cross-examined by the adverse party. The order

setting the case of hearing shall specify the witnesses

who will be called to testify, and the matters on which

their

examination

will

deal.

The

hearing

shall

be

terminated within fifteen (15) days, and the case decided

by the Committee within fifteen (15) days from such

termination.

The decision of the Committee shall become final and

executory fifteen (15) days after notice thereof: Provided,

however , That it is appealable to the Board by filing the

appellant's memorandum of appeal within fifteen (15)

days from receipt of the copy of the judgment appealed

from. The appellees shall be given fifteen (15) days from

notice to file the appellee's memorandum after which the

Board shall decide the appeal within thirty (30) days from

the submittal of the said pleadings.

The decision of the Board shall also become final and

executory fifteen (15) days after notice thereof: Provided,

however , That it is reviewable by the Supreme Court on

purely questions of law in accordance with the Rules of

Court.

The Committee and the Board, in the exercise of their

quasi-judicial function, as specified in Section 17 hereof,

can administer oaths, certify to official acts and issue

subpoena to compel the attendance and testimony of

witnesses,

and

subpoena

duces

tecum

or

ad

testificandum to enjoin the production of books, papers

and other records and to testify therein on any question

arising out of this Act. Any case of contumacy shall be

dealt with in accordance with the provisions of the

Revised Administrative Code and the Rules of Court. The

Board or the Committee, as the case may be, shall

prescribe the necessary administrative sanctions such as

fines, warnings, suspension or revocation of the right to

participate in the Program.

In all its proceedings, the Committee and the Board shall

not be bound by the technical rules of evidence: Provided,

however ,

That

the

Rules

of

Court

shall

apply with

suppletory effect.

ARTICLE X Penalties

SECTION 44. Penal Provisions . — Any violation of the

provisions of this Act, after due notice and hearing, shall

suffer the following penalties:

(a) Violation by an Accredited Health Care Provider — Any

accredited health care provider who commits a violation,

abuse, unethical practice or fraudulent act which tends

to undermine or defeat the objectives of the Program

shall be punished with a fine of not less than Fifty

thousand pesos (P50,000.00) but not more than One

hundred thousand pesos (P100,000.00) or suspension of

accreditation from three (3) months to the whole term of

accreditation,

or

both,

at

the

discretion

of

the

Corporation: Provided, That recidivists may no longer be

accredited as a participant of the Program;

(b) Violations of a Member — Any member who commits

any violation of this Act independently or in connivance

© Compiled By RGL

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