QuestionsQuestions (INSURANCE MEMORANDUM CIRCULAR NO. 2017-01)
The rules are adopted pursuant to Section 4 of Executive Order No. 192, Series of 2015, which transferred the regulation and supervision of all Health Maintenance Organizations (HMOs) to the Insurance Commission.
They must be liberally construed to achieve the objectives of just, expeditious, and inexpensive resolution and settlement of disputes.
In the absence of an applicable provision in the HMO rules, the pertinent provisions of the Rules of Court may be applied by analogy or in a suppletory character and effect, whenever practicable and convenient and to promote expeditious dispensation of justice.
A member (whether natural or juridical) may file a complaint against an HMO doing business in the Philippines.
Disputes arising from the contractual relations between HMOs and affiliated hospitals, medical clinics, and physicians are excluded; the rules apply only to complaints filed by a member against an HMO.
Except as to actual damages, attorney’s fees, and costs (including filing fees and litigation expenses), no other form of damages shall be recoverable.
The complaint must be verified under oath by the complainant with a certificate of non-forum shopping, include a certificate to file action, and be accompanied by payment of docket fees (for commencement).
It is a certification issued by the Public Assistance and Mediation Division stating that the parties underwent mediation and failed to reach an amicable settlement (or that mediation had already been conducted and terminated, as reflected in the endorsement requirement).
The Hearing Officer must endorse the complaint to the Public Assistance and Mediation Division for the conduct of mediation, if none has been had, or for the issuance of a certificate to file action, if mediation had already been conducted and terminated.
Within ten (10) days from receipt of the summons.
No. No Motion for Extension of Time to file an answer shall be allowed.
The Commission, motu proprio or on motion of the complainant, shall render judgment as may be warranted by the facts alleged in the complaint and limited to what is prayed for therein; the Commission may also reduce interest and attorney’s fees if excessive or unconscionable.
The rules prohibit, among others, motions to dismiss except on specific grounds (lack of jurisdiction over the subject matter, res judicata, prescription, extinguishment by payment, and forum shopping). Other prohibited motions include extensions, bill of particulars, new trial, petition for relief from judgment, and motion for reconsideration of a Hearing Officer’s order.
It is held not later than thirty (30) days after the last answer is filed. It aims to explore amicable settlement, determine real parties in interest, simplify issues, define admissions or stipulations, mark documents and affidavits as evidence, and handle preliminary matters.
The case shall be dismissed without prejudice.
Within five (5) calendar days after termination, parties submit simultaneously their verified position papers with supporting documents and doctor’s affidavit on a date set within fifteen (15) calendar days from termination. A reply may be filed within fifteen (15) days from receipt of the adverse party’s position paper.