Law Summary
Previous Interim Arrangements for Handling Complaints Against HMOs
- IC Circular Letter No. 2015-59 authorized the Association of Health Maintenance Organizations of the Philippines (AHMOPI) to mediate complaints endorsed by the IC during the transition period.
- AHMOPI was recognized as the sole HMO association conducting mediation at that time.
Emergence of Two HMO Associations and Need for Revised Guidelines
- The Philippine Association of Health Maintenance Organization Companies, Inc. (PAHMOC) was incorporated on July 10, 2017.
- There are now two HMO associations: AHMOPI and PAHMOC.
- Due to dual existence, new guidelines were needed for handling complaints and mediation irrespective of HMO membership.
Scope and Endorsement of Complaints Filed Against HMOs
- All complaints received by the IC, including district offices, must be endorsed as follows:
- Complaints involving AHMOPI member HMOs to AHMOPI's grievance machinery.
- Complaints involving PAHMOC member HMOs to PAHMOC's grievance machinery.
- Complaints against non-member HMOs are handled directly by the IC through its Public Assistance and Mediation Division.
Authorization and Responsibilities of AHMOPI and PAHMOC
- Both associations are authorized to conduct mediation proceedings on complaints endorsed by the IC.
- They are mandated to conclude mediation within thirty (30) days from receipt of the complaint.
Reporting and Resolution Procedures Post-Mediation
- Upon settlement, the mediator (endorsee) must submit a report and necessary documents to the IC within five (5) days from settlement.
- If mediation fails, the mediator must forward the complaint and all related records to the IC within five (5) days after termination of the mediation conference.
Role of the Insurance Commission in Failed Mediation Cases
- The IC, through its Public Assistance and Mediation Division, will conduct mediation conferences for cases where mediation by AHMOPI or PAHMOC has failed.
- Further proceedings will follow existing rules and regulations of the IC.
Effectivity and Compliance
- This circular took effect immediately upon issuance.
- All officers and personnel concerned are instructed for strict compliance with these guidelines.