GR 214485; (January, 2021) (Digest)
G.R. No. 214485, January 11, 2021
Philippine Health Insurance Corporation, Petitioner, vs. Urdaneta Sacred Heart Hospital, Respondent.
FACTS
Respondent Urdaneta Sacred Heart Hospital (USHH), an accredited health care institution, filed 374 reimbursement claims with petitioner Philippine Health Insurance Corporation (Philhealth) for cataract treatments from December 2008 to April 2010. Philhealth reimbursed 199 claims, denied 15, and did not act on 160 claims. Philhealth’s Board, via a July 30, 2009 Resolution, denied 60 claims for being non-compensable as the treatments were allegedly conducted during medical missions, which is prohibited under Philhealth Circulars. USHH was informed of the denial three months later. USHH cited a Philhealth Fact-Finding Verification Report dated March 25, 2009, which stated the claims were not part of any medical mission. USHH filed a Complaint before the Regional Trial Court (RTC) for Philhealth’s failure to act on the claims within the mandated 60-day period. During proceedings, Philhealth paid some claims, leaving an outstanding amount of P1,475,988.42. The RTC granted USHH’s claims, noting USHH did not exhaust administrative remedies but ruled strong public interest justified an exception. The Court of Appeals affirmed the RTC decision.
ISSUE
Whether or not the reimbursement claims of USHH should be granted.
RULING
Yes, the reimbursement claims of USHH should be granted. The Supreme Court denied Philhealth’s petition and affirmed the lower courts’ decisions. The Court held that while the doctrine of exhaustion of administrative remedies generally requires that claims first undergo Philhealth’s internal grievance procedures, exceptions apply. This case falls under the exception due to the involvement of strong public interest. The Court found that Philhealth’s own Fact-Finding Verification Report established that the disputed claims were not performed during medical missions, contrary to Philhealth’s denial. Furthermore, Philhealth’s failure to act on the claims within the statutory 60-day period and its delayed communication of the denial prejudiced USHH. Technicalities should not defeat the right to reimbursement, as doing so would deprive health care providers of legal rights and undermine the public interest in the effective implementation of the National Health Insurance Program.