Case Digest (G.R. No. 163123)
Facts:
Philippine Health Insurance Corporation v. Chinese General Hospital and Medical Center, G.R. No. 163123, April 15, 2005, the Supreme Court Third Division, Corona, J., writing for the Court. Petitioner is Philippine Health Insurance Corporation (PhilHealth); respondent is Chinese General Hospital and Medical Center (CGH).Prior to Republic Act No. 7875, CGH was an accredited provider under the Philippine Medical Care Commission (PMCC) and filed Medicare claims for services rendered from 1989 to 1992 with the Social Security System (SSS) amounting to P8,102,782.10. After RA 7875 (approved February 14, 1995) created the National Health Insurance Program and PhilHealth, the PMCC functions and funds were to be merged into PhilHealth under Sections 51 and 52 of RA 7875 and its Implementing Rules and Regulations (IRR).
PhilHealth promulgated IRR Section 52(b) imposing a 60-calendar-day filing cutoff from date of discharge for claims; it then paid only P1,365,556.32 of CGH’s 1989–1992 claims and denied the balance. CGH later filed additional claims for 1998–1999 (P7,554,342.93) that PhilHealth denied as late; PhilHealth issued Circulars (No. 31‑A, Sept. 15, 1998 and No. 50, Apr. 20, 1999) temporarily extending or relaxing the 60‑day period in recognition of members’ difficulties in securing supporting documents.
PhilHealth denied CGH’s claims with finality (June 6, 2000). CGH sought judicial relief in the Court of Appeals via a petition for review under Rule 43, which granted the petition and ordered PhilHealth to give due course to CGH’s claims, awarding P14,291,568.71 principally on the ground that the 60‑day rule must be applied liberally in view of the NHIP’s public‑interest pu...(Subscriber-Only)
Issues:
- Did respondent fail to exhaust administrative remedies such that judicial recourse was premature?
- May PhilHealth strictly apply the 60‑day filing rule in Section 52(b) of RA 7875’s IRR to bar CGH’s claims, or must the rule be liberally construed/extended in light of policy and PhilHealth circulars?
- Is PhilHealth estopped from asserting procedural defenses (including non‑exhaustion) because of its representatives’ conduct and its own circulars, ...(Subscriber-Only)
Ruling:
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Ratio:
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Doctrine:
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