Legal basis and referenced authorities
- Section 70, Republic Act No. 6975 anchors health and welfare leadership and assistance for PNP personnel.
- Section 73, Republic Act No. 6975, as amended by Section 35 of Republic Act No. 8551, is referenced for relevant health and welfare provisions.
- Sections 29 and 30 of Republic Act No. 8551 are referenced in relation to attrition by other means and retirement under preceding sections.
- The National Health Insurance Act of 1995 (Republic Act No. 7875) is referenced in the reimbursement context.
- The Circular references prior PNP memoranda/circulars on: hospitalization expense reimbursement (Circular No. 2006-16 dated August 15, 2006), accounting for confinement/ treatment (Circular No. 2002-11 dated August 3, 2002), and separation due to physical disability (Circular No. 2000-10 dated July 11, 2000).
- NAPOLCOM Memorandum Circular No. 2000-005 dated June 8, 2000 is referenced for rules on investigation and adjudication of benefit claims of uniformed PNP members.
- The Circular references Standing Operating Procedure No. 15 GHQ PNP dated July 22, 1992 on decentralization of processing and payment of retirement and other benefit claims.
- The Circular references Circular Nr 1, GHQ, AFP dated January 20, 2004 on medical/dental attendance and maximum hospitalization at AFP health facilities.
- CSC Memorandum Circular No. 12, s. 1994 dated March 10, 1994 on Physical and Mental Unfitness is referenced.
Purpose, objectives, and key principles
- The Circular prescribes specific guidelines and procedures for just, reasonable, and speedy adjudication of claims for reimbursement of hospitalization expenses for active PNP personnel arising from service-connected illnesses and/or injuries.
- The Circular aims to instill health awareness among PNP personnel as a preventive medicine measure to minimize costly hospitalization.
- The Circular aims to instill limitations in payment of benefit claims to prevent dissipation of financial resources.
- Medical attendance rendered to PNP personnel while confined at PNP General Hospital/PNP Medical Facilities is free of charge, subject to budgetary and fiscal restriction.
- The Reimbursement of Hospitalization Expenses (RHE) scheme is an adjunct health care delivery structure and the benefit derived is an additional privilege and not a right; it is subject to availability of funds.
- The maximum reimbursable hospital expenses cover six (6) months reckoned from when the expenses are incurred, regardless of separation and regardless of whether the injury or sickness is cured.
- The maximum number of days a personnel may be confined is three hundred six (365) days, after which the personnel shall be thoroughly evaluated for fitness to remain in the active service.
- Long, continued, and indefinite impairment that incapacitates a personnel to perform substantially the duties of a police officer is a ground for recommendation for retirement and/or separation through Total Permanent Physical Disability (TPPD).
Definitions governing reimbursement
- Active PNP Personnel means Uniformed and Non-Uniformed Personnel of the PNP.
- Attendance means medical service including professional service (consultation and physical examination), treatment, nursing care, radiologic examination, laboratory work-ups, and dispensing medicines and medical supplies.
- Police Operations Casualty refers to a PNP personnel who is killed, wounded, or sustained injury by reason of anti-criminality, counter-insurgency, counter-terrorism, and police community operations, including duties such as enforcement of laws/orders, prevention/control/investigation of crimes, ensuring public safety/internal security, protection of lives/liberties/properties, arrest and prosecution assistance, search and seizure operations, and rescue operations during calamities.
- Hospitalization means medical attendance after admission in any PNP Medical Facility (including PNP General Hospital), government and/or private health care institution.
- Emergency means a medical or surgical condition that threatens the immediate loss of life or limb when not attended to.
- Injury means harmful change in the human organism from any incident sustained at work, while at the workplace or elsewhere while executing an order from the employer, or sustained by reason of performance of duty.
- Sickness means an illness accepted as an occupational disease or any illness caused or aggravated by employment, subject to proof that the risk of contracting the same is increased by working conditions.
- Total Permanent Physical Disability (TPPD) means impairment of mind or body that renders the disabled PNP personnel incapable of performing substantially the duties of a police officer and expected to be long, continued, and of indefinite duration.
- Maximum Hospitalization Benefits ends when progress appears stabilized and additional hospitalization will not directly contribute to substantial recovery, but hospitalization benefit under the Circular shall not exceed one (1) year of continuous confinement in one or more hospitals.
- Catastrophic illness or injury includes specified conditions such as cancer with metastasis and/or requiring chemotherapy or radiation therapy, meningitis, encephalitis, cirrhosis of the liver (child C), myocardial infarction, cerebrovascular attack, rheumatism heat disease grade III, renal failure, dialysis or transplant, massive hemorrhage/shock, and surgical or multiple surgical procedures with total Relative Unit Value (RUV) of 20 and above per PhilHealth definition, including specified major procedures.
- Intensive Care refers to confinement requiring intensive care unit services and specified serious illnesses/injuries, including cases requiring surgical procedure or multiple procedures with total RUV of 8 but not exceeding 19.99 per PhilHealth RUV Manual.
- Ordinary Condition refers to illnesses or injuries other than those enumerated under the above intensive/catastrophic categories.
Coverage and eligibility for reimbursement
- The Circular covers hospitalization expenses of all active PNP personnel confined in PNP General Hospital and/or PNP Medical Facilities, or admitted in PNP accredited government and/or private hospitals due to illness/injury.
- The Circular covers active PNP personnel admitted as emergency cases in private and/or government hospitals when:
- Admission occurs during police operations/battle casualty circumstances, with reimbursement in full subject to availability of funds and usual accounting/auditing requirements.
- There is no PNP hospital within a reasonable distance, in which case the injured/sick personnel is admitted to another hospital and transferred to PNP General Hospital as soon as the period of crisis is over.
- Emergency admission in other hospitals is allowed when the injury is service connected and the patient is immediately evacuated to PNP General Hospital/PNP Medical facilities as soon as condition permits (no imminent danger to life).
- Emergency admission in other hospitals is allowed when a PNP Medical Facility exists and the management is beyond PNP Medical Facility capability, with immediate evacuation to the PNP Medical Facility as soon as the condition permits (transfer is medically advisable; no imminent danger to life).
- The Circular covers active PNP personnel confined/admitted for non-urgent conditions in hospitals other than PNP General Hospital/PNP Medical Facility when the Chief of PNP General Hospital/PNP Medical Facility gives proper authorization.
- The Circular sets that reimbursement is applicable to benefit claims for hospitalization expenses for active PNP personnel arising from service-connected illnesses and/or injuries, and adjudication determines eligibility through service connection.
Reimbursable items, ceilings, and cost limits
- Room and Board is reimbursable at PHP 1,500.00/day.
- Admission to Intensive Care Units is subject to the prevailing rate of the hospital and is limited until the patient’s crisis is over.
- Medical Case professional fees are limited to:
- PHP 350.00/day for ordinary cases, and
- PHP 750.00/day for intensive or catastrophic cases.
- Surgical Case professional fees are based on prevailing RUV and are capped by category:
- Minor: not to exceed PHP 10,000.00
- Intermediate: PHP 10,000.00 to PHP 20,000.00
- Major: PHP 20,000.00 to PHP 60,000.00
- Anesthesiologist fee is 30% of the main surgeon’s fee.
- Medicines are capped at PHP 35,000.00.
- Medical supplies are capped at PHP 35,000.00.
- Ambulance fee is capped at PHP 1,000.00.
- Laboratory work-ups are capped at PHP 30,000.00.
- For non-battle casualties, maximum reimbursable amounts are:
- Ordinary non-urgent medical case: not to exceed PHP 60,000.00
- Surgical cases: not to exceed PHP 100,000.00
- Intensive and catastrophic cases: not to exceed PHP 350,000.00
- For battle casualties, hospitalization expenses are reimbursed in full once stable and evacuated for definitive treatment, subject to availability of funds and usual accounting/auditing of funds.
Claim requirements, filing timelines, and processing
- Claims require evidence that death/sickness/injury occurred or was contracted/sustained in line of duty, and service connection must be determined considering:
- Nature and extent of the sickness/injury
- Position held and duties, including duration of daily duty, regularity and frequency of exposure to elements, and other general duty conditions
- Facts and circumstances surrounding incurrence of disease/sickness/injury
- Physical condition upon entrance into service and at separation, based on reports of physical examination, clinical records, certificate of discharge, and other official records
- Before final approval, each claim must be supported by a definite finding by the proper Department Head that the sickness/injury:
- Was not the proximate result of abuse of authority, misconduct, willful failure, gross negligence, indiscriminate use of drug, or alcoholic liquor, or vicious or immoral act/habit
- Was not contracted prior to entry into service or after separation
- Was not incurred or contracted during absence without authority from the assigned place of duty
- Claims must be limited to a maximum of two (2) claims in a single period of confinement.
- A claim may be filed either during the period of confinement or upon discharge, but in no case later than sixty (60) days from discharge from confinement.
- Claims for personnel assigned in the National Headquarters and National Support Units are filed with the RHE Section, MSD Office of the Director Health Service.
- Claims for personnel assigned in Police Regional Offices including NSUs with regional offices are filed with the RHS.
- Patient supporting documents for filing include:
- Letter of Authorization
- Certificate of Duty Status from Unit Assignment
- Medical Certificate by the Attending Physician
- Hospital supporting documents for filing include:
- Certificate of Confinement from Administrative Officer/Chief of the PNP Medical Facility or Hospital Registrar/Attending Physician of government/private hospital attesting inclusive days of confinement of PNP personnel
- Original invoices and official receipts of medicines, medical supplies, and medical services rendered inclusive of confinement days
- Non-emergency/non-urgent cases require a Letter of Authorization (LOA) from the PNP Health Service Facility when that facility is not capable of managing the condition; the LOA and PNP ID must be presented to the accredited hospitals before treatment/confinement, and all necessary documents for payment/reimbursement must be properly signed upon discharge.
- Emergency cases require presentation of the PNP ID to accredited hospitals prior to treatment/confinement; personnel or dependents must communicate with PNP Health Service within 24 hours to secure LOA to verify whether treatment/confinement is chargeable to PNP.
- For system flow of availment:
- Accredited hospitals issue a Statement of Account (SOA) to the RHE Section, PNP Health Service, reflecting deductions such as Philhealth and/or HMO.
- The SOA is forwarded to the Adjudication Board for verification of the authenticity of charges.
- After board verification and approval, the SOA is forwarded to the Directorate for Comptrollership for processing and payment.
- The Adjudication Board must review, verify, and evaluate all matters pertaining to the claim and may only recommend approval if the sickness/disease/injury is:
- Not self-inflicted and not result of abuse of authority, misconduct, willful disobedience, gross negligence, use of drugs or liquor, or immoral acts/habits
- Not incurred or contracted during absence without authority from assigned place of duty
- The Adjudication Board Report must be submitted within four (4) working days, signed by the Chairman and members, for notation/approval by approving authorities, using a prescribed format including facts, certified/validated supporting documents, computation sheet, and recommendation.
- After board approval, a disbursement voucher must be prepared and forwarded to the Director for Comptrollership/ARDC through the Disbursing Officer, and then processed according to existing accounting and auditing rules until checks are released to claimants.
Expanded RHE adjudication boards and convening
- Expanded RHE Adjudication Boards are created at the National Headquarters (NHQ) level and at the Police Regional Office (PRO) level to adjudicate claims justly, reasonably, and speedily.
- The NHQ ERHE Adjudication Board convenes twice a month or as deemed necessary by the Chairman.
- NHQ ERHE Board composition includes:
- Director, Health Service (Chairman)
- Deputy Director, Health Service (Vice-Chairman)
- Chief, PNP General Hospital (Member)
- Chief, Budget & Fiscal Office, DPRM (Member)
- DI Representative (Member)
- LS Representative (Member)
- Chief, ERHE Section, MSD, HS (Member)
- NHQ ERHE Board functions include:
- Adjudicating hospitalization bills of PNP personnel assigned with NHQ offices and headquarters national support units treated/confined in listed DOH accredited hospitals, submitting recommendations for approval within four (4) working days upon receipt
- Reviewing regional board recommendations and rendering an adjudication report within four (4) working days for final approval of claims exceeding PHP 60,000.00 (medical), PHP 100,000.00 (surgical), and PHP 350,000.00 (intensive/catastrophic)
- Initially determining legal heirs/rightful beneficiaries of deceased personnel
- Processing and recommending approval for claims of PNP personnel hospitalized in DOH accredited hospitals in Metro Manila upon presentation of certification from the regional board that no similar claims were filed, adjudicated, or approved thereat
- The PRO ERHE Adjudication Board convenes twice a month or as deemed necessary by the Chairman.
- PRO ERHE Board composition includes:
- Deputy Regional Director for Administration (Chairman)
- Chief, Regional Health Service (Vice-Chairman)
- C, RPHRDD or authorized rep (Member)
- C, RDPFC or authorized rep (Member)
- C, RDIMDI or authorized rep (Member)
- Chief, Regional Legal Service (Member)
- Regional Chief Nurse (Member)
- PRO ERHE Board functions include:
- Adjudicating within four (4) days hospitalization bills of PNP personnel assigned in PROs treated/confined in listed DOH accredited hospitals
- Recommending approval to the Regional Director after receipts, with escalation rules for claims exceeding allowable reimbursable amounts
- For battle casualty claims exceeding PHP 100,000.00, releasing PHP 100,000.00 as initial payment and forwarding certificate of payment with supporting documents and recommendations to NHQ for final disposition.
Approving authorities and thresholds
- CPNP is the approving authority for reimbursements of PHP 1M and above.
- TDCA is the approving authority for more than PHP 500,000.00 but less than PHP 1M.
- TDPRM is the approving authority for PHP 500,000.00 and below.
Grounds for denial of claims
- Claims are denied for hospitalization expenses incurred during uncomplicated pregnancy and delivery (Normal Spontaneous Delivery).
- Claims are denied for expenses incurred in a private or government hospital by a patient who refuses to be transferred/retro-evacuated to PNP General Hospital/PNP Medical Facility without justifiable reasons after the crisis period ends when transfer is already feasible.
- Claims are denied for expenses incurred in a private or government hospital when the injury/sickness is occasioned by:
- Intoxication/drunkenness or immoral habits or intemperate use of regulated or prohibited drugs
- Willful intention to injure or kill oneself or another
- Notorious negligence (AWOL)
- Unlawful aggression or provocation on the part of the claimant
- Illness due to abuse of lifestyle where the patient has been repeatedly warned to modify to maintain a healthier lifestyle or failed to consult a physician for treatment, where lifestyle investigation and confirmation establishes abuse
- The Circular identifies as abuse of lifestyle:
- Intoxication/drunkenness
- Use of prohibited drugs
- Excessive substance consumption
- Various immoral habits leading to STD(s)
- The Circular identifies specific diseases subject to lifestyle abuse investigation and confirmation:
- Diabetes Mellitus
- Renal Disease
- Hypertension
- Cancers
- Liver Diseases: (alcoholic cirrhosis, liver cancer)
- Sexually transmitted diseases
- Claims are denied when:
- The claimant fails to avail of Social Service assistance/Philhealth benefits for the excess beyond the allowable reimbursable amount under the Circular
- Hospitalization expenses are unreasonably beyond the allowable prescribed ceiling
- Documentary requirements are not met/submitted within the sixty (60) day prescriptive period, reckoned from the date of discharge from confinement
- Prescribed and dispensed drugs or other procedures do not conform to the diagnosis (nature of illness)
- Supporting documents are false, incorrect, altered, and/or tampered with
- Receipts include non-medical items such as bath soaps, toiletries, perfumes, etc.
- Receipts include purchase/hiring of equipment or services such as hiring special nurse, nurse aide and/or caregivers
- Receipt dates for purchase of medicines, medical supplies, and other medical services rendered do not conform with inclusive dates of confinement
- The Circular denies PNP liability for damage caused by third parties, and requires claimants in illness/injury caused by a third party (or due to negligence) to exhaust all means for hospitalization claims from the third party or those liable.
- When the patient avails of HMO (private insurance companies) services, the PNP reimburses part of hospital expenses only after the HMO has paid the reimbursed expenses, provided:
- Expenses do not exceed the limits set by the Circular
- Professional fees and other services fall within the limits set by the Circular
- Instances of excessive compensation are eliminated.
Effect of disapproval, funding, and administrative sanctions
- If a claim is disapproved, payment for medical and/or hospitalization services rendered is borne by the concerned PNP personnel or the personnel’s heirs.
- The Director for Personnel and Records Management (TDPRM) must program funds to support reimbursement of hospitalization expenses under the Circular.
- Any PNP personnel or representative who commits fraud, collusion, falsification, misrepresentation, or any other kind of anomaly for purposes of securing entitlement to benefits or payments under the Circular is subject to appropriate criminal and administrative action by the investigating body.
Rescission and separability
- All PNP memoranda and circulars contrary or directly in conflict with the Circular are rescinded/nullified upon approval.
- The Circular provides an effectivity rule, taking effect fifteen (15) days after filing with the University of the Philippines Law Center in accordance with Executive Order No. 292.