National Health Insurance Act of 2013

Section 39

A system of grievance is hereby established, wherein members, dependents, or health care providers of the Program who believe they have been aggrieved by any decision of the implementors of the Program, may seek redress of the grievance in accordance with the provisions of this Article.

Section 40

The following acts shall constitute valid grounds for grievance action: a) any violation of the rights of patients; b) a willful neglect of duties of Program implementors that results in the loss or non-enjoyment of benefits by members or their dependents; c) unjustifiable delay in actions on claims; d) delay in the processing of claims that extends beyond the period agreed upon; and e) any other act or neglect that tends to undermine or defeat the purposes of this Act.

Section 41

A member, a dependent, or a health care provider may file a complaint for grievance based on any of the above grounds, in accordance with the following procedures: (a) A complaint for grievance must be filed with the Corporation which shall refer such complaint to the Grievance and Appeal Review Committee. The Grievance and Appeal Review Committee shall rule on the complaint through a notice of resolution within sixty (60) calendar days from receipt thereof. (b) Appeals from the decision of the Grievance and Appeal Review Committee must be filed with the Board within thirty (30) calendar days from receipt of the notice of resolution. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013]) c) The Offices shall have no jurisdiction over any issue involving the suspension or revocation of accreditation, the imposition of fines, or the imposition of charges on members or their dependents in case of revocation of their entitlement. d) All decisions by the Board as to entitlement to benefits of members or to payments of health care providers shall be considered final and executory.

Section 42

The Board shall create a Grievance and Appeal Review Committee, composed of five (5) members, hereinafter referred to as the Committee, which, subject to the procedures enumerated above, shall receive and recommend appropriate action on complaints from members and health care providers relative to this Act and its implementing rules and regulations. The Committee shall have as one of its members a representative of any of the accredited health care providers as endorsed by the DOH. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013])

Section 43

Upon the filing of the complaint, the Grievance and Appeal Review Committee, from a consideration of the allegations thereof, may dismiss the case outright due to lack of verification, failure to state the cause of action, or any other valid ground for the dismissal of the complaint after consultation with the Board; or require the respondent to file a verified answer within five (5) days from service of summons. Should the defendant fail to answer the complaint within the reglementary five-day period herein provided, the Committee, motu proprio or upon motion of the complainant, shall render judgments as may be warranted by the facts alleged in the complainant and limited to what is prayed for therein. After an answer is filed and the issues are joined, the Committee shall require the parties to submit, within ten (10) days from receipt of the order, the affidavits of witnesses and other evidence on the factual issues defined therein, together with a brief statement of their positions setting forth the law and the facts relied upon by them. In the event the Committee finds, upon consideration of the pleadings, the affidavits and other evidence, and position statements submitted by the parties, that a judgment may be rendered thereon without need of a formal hearing, it may proceed to render judgment not later than ten (10) days from the submission of the position statements of the parties. In cases where the Committee deems it necessary to hold a hearing to clarify specific factual matters before rendering judgment, it shall set the case for hearing for the purpose. At such hearing, witnesses whose affidavits were previously submitted may be asked clarificatory questions by the proponent and by the Committee and may be cross-examined by the adverse party. The order setting the case of hearing shall specify the witnesses who will be called to testify, and the matters on which their examination will deal. The hearing shall be terminated within fifteen (15) days, and the case decided by the Committee within fifteen (15) days from such termination. The decision of the Committee shall become final and executory fifteen (15) days after notice thereof: Provided, however, That it is appealable to the Board by filing the appellant's memorandum of appeal within fifteen (15) days from receipt of the copy of the judgment appealed from. The appellees shall be given fifteen (15) days from notice to file the appellee's memorandum after which the Board shall decide the appeal within thirty (30) days from the submittal of the said pleadings. The decision of the Board shall also become final and executory fifteen (15) days after notice thereof: Provided, however, That it is reviewable by the Supreme Court on purely questions of law in accordance with the Rules of Court. The Committee and the Board, in the exercise of their quasi-judicial function, as specified in Section 17 hereof, can administer oaths, certify to official acts and issue subpoena to compel the attendance and testimony of witnesses, and subpoena duces tecum or ad testificandum to enjoin the production of books, papers and other records and to testify therein on any question arising out of this Act. Any case of contumacy shall be dealt with in accordance with the provisions of the Revised Administrative Code and the Rules of Court. The Board or the Committee, as the case may be, shall prescribe the necessary administrative sanctions such as fines, warnings, suspension or revocation of the right to participate in the Program. In all its proceedings, the Committee and the Board shall not be bound by the technical rules of evidence: Provided, however, That the Rules of Court shall apply with suppletory effect.