Law Summary
Purpose
- Establishes guidelines for just, reasonable, and expedited adjudication of reimbursement claims for hospitalization expenses of active PNP personnel.
- Focuses on claims arising from service-connected illnesses or injuries.
Objectives
- Promote health awareness and preventive medicine among PNP personnel.
- Set financial limits on payment of benefits to safeguard PNP financial resources.
Rationale
- Medical care in PNP facilities is free but subject to budgetary constraints.
- Reimbursement is an additional privilege, not a right, and is contingent on available funds.
- Limits reimbursement to six months from the expense date.
- Maximum confinement period is 365 days, post which fitness for active service is evaluated.
- Total Permanent Physical Disability (TPPD) is ground for retirement/separation.
Definition of Terms
- Active PNP Personnel: Uniformed and Non-Uniformed PNP members.
- Attendance: Medical services including consultation, treatment, nursing, exams, labs, and medicine dispensing.
- Police Operations Casualty: PNP personnel injured or killed during specified police duties.
- Hospitalization: Admission for medical attendance in PNP or accredited hospitals.
- Emergency: Condition threatening immediate loss of life or limb.
- Injury and Sickness: Defined in relation to work and duty performance.
- TPPD: Irreparable impairments incapacitating the PNP member with specific criteria.
- Maximum Hospitalization Benefits: Up to 1 year of continuous confinement.
- Catastrophic and Intensive Care: Defined based on severity and treatment complexity.
Scope and Coverage
- Covers hospitalization expenses of all active PNP personnel in PNP hospitals or accredited facilities.
- Emergency cases covered fully for battle casualties subject to fund availability.
- Conditions for admission include lack of nearby PNP facility or incapacity of PNP medical facility to manage case.
Benefits and Allowable Expenses
- Room and board capped at P1,500/day.
- ICU fees as per hospital rates limited to crisis period.
- Professional fees based on Relative Unit Value (RUV) guidelines with specific ceilings for medical, surgical, and anesthesiologist fees.
- Maximum allowances for medicines (P35,000), medical supplies (P35,000), ambulance (P1,000), and laboratory work-ups (P30,000).
Claim Settlement Requirements
- Proof of service connection for injury or illness based on nature, duties, circumstances, and physical condition records.
- Certification that illness/injury is free from misconduct, abuse, or pre-existing condition.
Entitlements
- Full reimbursement for battle casualties subject to fund availability.
- Maximum reimbursement for non-battle cases:
- Ordinary medical cases: P60,000
- Surgical cases: P100,000
- Intensive and catastrophic cases: P350,000
- Detailed procedure for availing benefits differs for emergency and non-emergency cases including need for Letter of Authorization (LOA).
Payment System
- Accredited hospitals submit accounts to PNP Health Service.
- Verification and adjudication by specialized boards before processing payment.
Grounds for Denial of Claims
- Expenses related to uncomplicated pregnancy and delivery.
- Refusal to transfer/retro-evacuate to PNP Medical Facilities without justification.
- Claims arising from intoxication, misconduct, abuse, or self-infliction.
- Failure to avail Social Service or PhilHealth assistance or when expenses exceed prescribed ceilings.
- Claims with forged or false documents.
- Expenses incurred from third-party negligence or intent should be sought from the liable party instead.
- Partial reimbursement when HMO/private insurance is involved.
Creation and Function of Adjudication Boards
- National Headquarters (NHQ) and Police Regional Offices (PRO) have separate ERHE Adjudication Boards.
- NHQ Board oversees claims exceeding specified monetary thresholds and processes claims from NHQ personnel.
- PRO Board adjudicates regional claims and forwards excess claims to NHQ.
- Both Boards have defined membership from various PNP departments and functions to expedite claim decisions.
Approving Authorities
- Chief PNP approves claims P1M and above.
- TDCA approves claims over P500,000 up to P1M.
- TDPRM approves claims of P500,000 and below.
Procedures for Filing and Processing Claims
- Claims filed at RHE Section or Regional Health Services depending on personnel assignment.
- Must be filed during confinement or within 60 days after discharge.
- Require supporting documents including LOA, medical certificates, confinement certification, and official receipts.
- Adjudication Boards verify authenticity, cause and nature of illness/injury, and adherence to regulations.
- Boards must submit report within four working days.
- Post-approval, disbursement vouchers are processed for payment in compliance with accounting rules.
Effect of Disapproval
- Rejected claims are for the account of the personnel or heirs.
Funding
- TDPRM is responsible for programming funds for reimbursement under this Circular.
Administrative Provisions
- Fraud, collusion, falsification, or misrepresentation in claims results in criminal and administrative sanctions.
- All conflicting previous PNP memoranda and circulars are repealed.
Effectivity
- Circular effective 15 days after filing at University of the Philippines Law Center as per EO 292 (Revised Administrative Code of 1987).