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Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION
Protest & Appeals Review Department
PHIC Citystate Centre
709 Shaw Boulevard, Pasig City

IN RE: APPEAL OF THE ORDER OF THE

PHILIPPINE HEALTH INSURANCE CORP.
PRO IX, ZAMBOANGA CITY DENYING
THE MOTION FOR RECONSIDERATION
OF ZAMBOANGA CITY MEDICAL CENTER
IN CASES NO. 1221160190021, 1221160190
022, 1221160190023, 1221160190025,12211
60190012, 1221160190011, 12211601
90009,1208160010048, 1208160010062 for
Patients JEMARK M. ABUSAMAN, JEZIL ME A.
MACADILDIG, ALKADIR A. ARASAD, VIRGIE
M. DELA PEDRA ABDULLAH L. PASCUAL,
ANTONIO C. ENRIQUEZ, ROBERTO U.
FRONDA, FORTUNATO N. GORION and
ABDULLA T. MOHAMMAD, respectively,

ZAMBOANGA CITY MEDICAL HOSPITAL

Herein rep. by: ROMEO A. ONG, M.D. in
His capacity as Medical Center Chief II,
Appellant,

x---------------------------------------------------------x

APPEAL

COMES NOW, ZAMBOANGA CITY MEDICAL CENTER, herein

represented by Dr. ROMEO A. ONG, in his capacity as Medical Center
Chief II and unto this Honorable Office, most respectfully files this Appeal
and further states that:

1.) The Philippine Health Insurance Corporation (Philhealth for

brevity), Philhealth Regional Office, Region IX, Zamboanga City
issued Orders all dated 17 January 2017 denying Appellant Motion
for Reconsideration in the above captioned cases on the ground of
Exhaustion of 45 Compensable Days and Violation of Single
Period of Confinement, the dispositive portions of which read, as
follows:

CASE NO. 1221160190009 (JEMARK M. ABUSAMAN)

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After a thorough evaluation of the subject motion for

reconsideration dated December 10, 2016 of ZAMBOANGA
CITY MEDICAL CENTER the same is hereby DENIED on the
following ground/s:

VIOLATION OF SINGLE PERIOD POLICY

Accordingly, let the enclosed original case records be

returned to ZAMBOANGA CITY MEDICAL CENTER

SO ORDERED

ZAMBOANGA CITY, Philippines, January 17, 2017

SGD.
ROMEO D. ALBERTO
Regional Vice-President PhROIX

CASE NO. 1221160190011 (JEZIL ME A. MACADILDIG)

After a thorough evaluation of the subject motion for

reconsideration dated October 27, 2016 of ZAMBOANGA CITY
MEDICAL CENTER the same is hereby DENIED on the
following ground/s:

VIOLATION OF SINGLE PERIOD POLICY

Accordingly, let the enclosed original case records be

returned to ZAMBOANGA CITY MEDICAL CENTER

SO ORDERED

ZAMBOANGA CITY, Philippines, January 17, 2017

SGD.
ROMEO D. ALBERTO
Regional Vice-President PhROIX

CASE NO. 1221160190012 (ALKADIR A. ARASAD)

After a thorough evaluation of the subject motion for

reconsideration dated October 27, 2016 of ZAMBOANGA CITY
MEDICAL CENTER the same is hereby DENIED on the
following ground/s:

VIOLATION OF SINGLE PERIOD POLICY

Accordingly, let the enclosed original case records be

returned to ZAMBOANGA CITY MEDICAL CENTER
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SO ORDERED

ZAMBOANGA CITY, Philippines, January 17, 2017

SGD.
ROMEO D. ALBERTO
Regional Vice-President PhROIX

CASE NO. 1221160190021 (VIRGIE M. DELA PEDRA)

After a thorough evaluation of the subject motion for

reconsideration dated November 09, 2016 of ZAMBOANGA
CITY MEDICAL CENTER the same is hereby DENIED on the
following ground/s:

EXHAUSTED 45 COMPENSABLE DAYS; VIOLATION

OF SINGLE PERIOD POLICY

Accordingly, let the enclosed original case records be

returned to ZAMBOANGA CITY MEDICAL CENTER

SO ORDERED

ZAMBOANGA CITY, Philippines, January 17, 2017

SGD.
ROMEO D. ALBERTO
Regional Vice-President PhROIX

CASE NO. 1221160190022 (ABDULLA L. PASCUAL)

After a thorough evaluation of the subject motion for

reconsideration dated November 09, 2016 of ZAMBOANGA
CITY MEDICAL CENTER the same is hereby DENIED on the
following ground/s:

EXHAUSTED 45 COMPENSABLE DAYS; VIOLATION

OF SINGLE PERIOD POLICY

Accordingly, let the enclosed original case records be

returned to ZAMBOANGA CITY MEDICAL CENTER

SO ORDERED

ZAMBOANGA CITY, Philippines, January 17, 2017

SGD.
ROMEO D. ALBERTO
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Regional Vice-President PhROIX

CASE NO. 1221160190023 (ANTONIO C. ENRIQUEZ)

After a thorough evaluation of the subject motion for

reconsideration dated November 28, 2016 of ZAMBOANGA
CITY MEDICAL CENTER the same is hereby DENIED on the
following ground/s:

EXHAUSTED 45 COMPENSABLE DAYS

Accordingly, let the enclosed original case records be

returned to ZAMBOANGA CITY MEDICAL CENTER

SO ORDERED

ZAMBOANGA CITY, Philippines, January 17, 2017

SGD.
ROMEO D. ALBERTO
Regional Vice-President PhROIX

CASE NO. 1221160190025 (ROBERTO U. FRONDA)

After a thorough evaluation of the subject motion for

reconsideration dated November 28, 2016 of ZAMBOANGA
CITY MEDICAL CENTER the same is hereby DENIED on the
following ground/s:

EXHAUSTED 45 COMPENSABLE DAYS

Accordingly, let the enclosed original case records be

returned to ZAMBOANGA CITY MEDICAL CENTER

SO ORDERED

ZAMBOANGA CITY, Philippines, January 17, 2017

SGD.
ROMEO D. ALBERTO
Regional Vice-President PhROIX

CASE NO. 1208160010048 (FORTUNATO N. GORION)

After a thorough evaluation of the subject motion for

reconsideration dated October 06, 2016 of ZAMBOANGA CITY
MEDICAL CENTER the same is hereby DENIED on the
following ground/s:
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VIOLATION OF SINGLE PERIOD POLICY

Accordingly, let the enclosed original case records be

returned to ZAMBOANGA CITY MEDICAL CENTER

SO ORDERED

ZAMBOANGA CITY, Philippines, January 17, 2017

SGD.
ROMEO D. ALBERTO
Regional Vice-President PhROIX

CASE NO. 1208160010062 (ABDULLA T. MOHAMMAD)

After a thorough evaluation of the subject motion for

reconsideration dated October 10, 2016 of ZAMBOANGA CITY
MEDICAL CENTER the same is hereby DENIED on the
following ground/s:

VIOLATION OF SINGLE PERIOD POLICY

Accordingly, let the enclosed original case records be

returned to ZAMBOANGA CITY MEDICAL CENTER

SO ORDERED

ZAMBOANGA CITY, Philippines, January 17, 2017

SGD.
ROMEO D. ALBERTO
Regional Vice-President PhROIX

2.) The aforementioned Orders were received by the Appellant on

___________________. Section 216 of the Implementing Rules
and Regulations of Republic Act No. 7875 (as amended by
Republic Acts 9241 and 10606) otherwise known as the Revised
Implementing Rules and Regulations of the National Health
Insurance Act of 2013 provides that the decision of PROs may be
appealed by the aggrieved health care provider or member in
writing to the Honorable Office within fifteen (15) days from receipt
of such decision or notice. Thus, Appellant has until
_____________ within which to file and submit this Appeal. It is
submitted that the same is seasonably filed. Machine copies of the
appealed Orders dated 17 January 2017 are hereto attached as
Annexes A to I and forming an integral part of this Appeal;
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3.) Per said Order, the Motion for Reconsideration was denied due to
ground that the case is not compensable considering the HOP
NOT ALLOWED TO PERFORM OPTHALMIC PROCEDURES;
4.) Under Section 9, Rule II of Philhealth Circular No. 03, Series of
2008, the above decision of the Regional Office of Philhealth PRO
IX may be appealed to the Honorable Office based on the
ground/s of any error of fact or law. The said provision is
hereunder cited thusly:
RULE II - FINAL APPEAL WITH THE PARD:
xxx
Section 9. A final appeal may be filed on the ground of any
error of fact or law or both on the part of the PRO or Office
of the Area Head in denying an MR.
5.) Under Section 13, Rule IV of Philhealth Circular No. 03, Series of
2008, the liberal construction of the guidelines is allowed in order
to serve the ends of substantial justice and equity over matters of
form and technicality;

6.) Hence, in view thereof, we respectfully appeal the decision of the

Regional Office PRO IX based on error of law in the findings of the
said office;

7.) It is hereby submitted that there was an error of the denial of the
claim considering that the Appellant substantially complied with the
requirements in relation to the processing of claim and that
Appellant had rendered its services in favor of the
member/claimant. Moreover, per letter of the Billing & Claims Unit
of the appellant, it stated through MICHELLE C. INSO-LIBAGO
that said unit does not have the capabilities to detect the
exhaustion of 45 compensable days and violation of single period
of confinement due to the following reasons:

a.) That the system (Portal) provided for by the corporation does
not include eligibility to the rule of Single Period of
Confinement (SPC), sample of PhilHealth Benefit Eligibility
Form is attached herein;

b.) The system does not warn us of exhaustion of 45

compensable days; and

c.) Most of the patients/representatives do not divulge

information regarding previous confinements from other
hospitals.

The letter dated 11 May 2016 is hereto attached as

Annex J and forming an integral part hereof.
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8.) The Appellant was able to submit all the documents in connection
with the processing of the claim.

9.) In view of the foregoing, considering that the Appellant

substantially complied with the requirements provided under the
circular in connection therewith and the said Orders of denial were
obviously focused on the ground which is not expressly provided
by the law and/or circular as it was mainly exercise of discretion in
ruling out the matter of the case which in effect, clearly renders
unavailability of the health benefit which eligible members and
their dependents ought to enjoy, it is most respectfully prayed of
this Honorable Office to please reverse the Decisions of the
Philhealth PRO IX, Zamboanga City.

PRAYER

Wherefore, in light of the foregoing, it is most respectfully prayed of

the Honorable Office to please REVERSE the Decisions of the Philhealth
PRO IX, Zamboanga City and in effect thereof to please issue an order
approving the claim of herein appellant for members JEMARK M.
ABUSAMAN, JEZIL ME A.MACADILDIG, ALKADIR A. ARASAD, VIRGIE
M. DELA PEDRA ABDULLAH L. PASCUAL, ANTONIO C. ENRIQUEZ,
ROBERTO U. FRONDA, FORTUNATO N. GORION and ABDULLA T.
MOHAMMAD.

Other reliefs that are just and equitable under the premises are
likewise prayed for.

RESPECTFULLY SUBMITTED. This ___ day of May 2017 at

Zamboanga City for Pasig City, Philippines.

ZAMBOANGA CITY MEDICAL CENTER

Herein represented by:

ROMEO A. ONG, M.D

Medical Center Chief II

VERIFICATION/CERTIFICATION
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Republic of the Philippines)

City of Zamboanga )s.s.
X----------------------------------X

I, ROMEO A. ONG, M.D, of legal age, married, Filipino citizen with

business address located at Dr. A. Evangelista St., Zamboanga City,
Philippines after being sworn in accordance with law hereby depose and
state that:

1. I am the authorized representative/Medical Center Chief II of

ZAMBOANGA CITY MEDICAL CENTER, APPELLANT in the
above-entitled case and I have caused the preparation of the
foregoing Appeal;

2. I have read and understood all the allegations contained therein

and the same are true of my personal knowledge and based on
authentic records;

3. I have not commenced any action or proceeding involving the

same issue in the Supreme Court, Court of Appeals or any division
thereof or any agency or tribunal and that if I should learn that a
similar action or proceeding has been filed or pending before the
Supreme Court, Court of Appeals or any division thereof or any
agency or tribunal, I undertake to inform this Honorable Court
within five (5) days from notice thereof.

IN WITNESS WHEREOF, I have hereunto set my hand on this ___

day of May 2017 in the City of Zamboanga, Philippines.

ROMEO A. ONG, M.D

Affiant
TIN bearing No.136-084-289

SUBSCRIBED AND SWORN to before me this ____ day of May

2017 in Zamboanga City, Philippines. Affiant exhibited to me his valid
government issued identification card, the details were written above.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2017 [[

Copy furnished:
PhilHealth PRO IX, Zamboanga City
EXPLANATION
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The undersigned most respectfully explains that a copy of the

foregoing appeal was filed with the Office of the Protest and Appeals
Review Department, PHIC Citystate Centre, Pasig City via registered mail
with return card due to distance.

ROMEO A. ONG, M.D