Phil Health Insurance Corporation vs. Chinese General Hospital and Medical Center Facts 1.

Chinese Gen (CGH) had been an accredited health care provider under the Phil Medical Care Commission, or Medicare. For services it rendered, it filed its Medicare claims (reimbursement for the period 1989 to 1992) with the SSS which, along with GSIS, administered the Health Insurance fund of the PMCC. It amounted to some P8.1million. 2. However, its application for payment was overtaken by the passage of RA 7875 which abolished the old PMCC and merged all its functions and assets with the Philippine Health Insurance Corporation (PhilHealth). 3. Philhealth promulgated the rules implementing RA 7857. Section 52 of the such rules provide that all claims for payment of services rendered shall be filed within 60 calendar days from the date of discharge of the patient. And beyond such time, further claims shall be barred. 4. Instead of giving due course to CGH's claims totalling P8.1million, Philhealth only paid CGH P1.3million. CGH then re-filed the remaining P7million with PhilHealth but it was denied for having been filed beyond the time limit. 5. CGH , upon advise of the Philhealth's CEO, brought its complaint to the office of the President but no avail. Hence, it filed a petition for review with the CA and its petition was granted. Issue: 1. W/N CGH's remaining claims should be granted despite having been filed beyond the 60 day period? Yes 2 W/N CGH failed to exhaust all administrative remedies before resorting to judicial intervention? No Ratio 1. Strict implementation of the rule is unreasonable. It is unreasonable to expect that the accredited health care providers will be able to comply 100% with the 60day time limit, given the circumstances. The reality is that most patients are unable to immediately submit the required documents. 2. It falls under one of the exceptions under the doctrine of exhaustion of administrative remedies

Under the doctrine of exhaustion of administrative remedies, an administrative decision must first be appealed
to the administrative superiors at the highest level before it may be elevated to a court of justice for review. This doctrine, however, is a relative one and its flexibility is conditioned on the peculiar circumstances of a case. Among the established exceptions are: when the question raised is purely legal; when the administrative body is in estoppel; when the act complained of is patently illegal; when there is urgent need for judicial intervention; when the claim involved is small; when irreparable damage will be suffered;

when there is no other plain, speedy and adequate remedy;

when strong public interest is involved; when the subject of the controversy is private land;

in quo warranto proceedings. although they were not made parties to the instant case, the rights of millions of Filipinos who are members of
PHILHEALTH and who obviously rely on it for their health care, are considered, nonetheless, parties to the present case. Also, it was the Philhealth CEO himself, Dr Zalamea, who advised them to go straight to the Office of the President (instead of filing the complaint first with Philhealth, which is the rule) Hence, Philhealth is estopped from raising the doctrine of exhaustion of administrative remedies as a defense.