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Republic of the Philippines )

Zamboanga City ) S.S.


COMPLAINT-AFFIDAVIT

Complainant, the Philippine Health Insurance Corporation (PHIC), as


represented by ATTY. LIZA ANN A. GAGARACRUZ-CAPIN, Attorney IV of
Philippine Health Insurance Corporation Regional Office IX (PRO-IX),
respectfully alleges that:

1. The complainant, PHILIPPINE HEALTH INSURANCE


CORPORATION (PHIC), is a duly organized government owned and
controlled corporation (GOCC) created by virtue of Republic Act No. 7875,
as amended with its Regional Office IX address at BGIDC Corporate Center,
Gov. Lim Avenue, Zamboanga City, where it may be served with summons
and other legal processes;

2. Respondent EASTERN SUN MEDICAL AND DIAGNOSTIC CENTER


(ESMDC) is an accredited health care provider with postal address at
Campaner Street, Manaol, Siocon, Zamboanga del Norte, where it may be
served with summons, copy of this complaint and other legal processes;

3. The instant complaint is filed against the Respondent hospital for


violation of Section 154 of the Revised Implementing Rules and
Regulations (RIRR) of R.A. No. 7875, as amended otherwise known as the
National Health Insurance Act of 2013, which states:

Section 154. Misrepresentation by Furnishing False or


Incorrect Information - Any health care institution shall be
liable for fraudulent practice when, for the purpose of
participation in the Program or claiming payment therefrom, it
furnishes false or incorrect information concerning any matter
required by R.A. 7875 as amended and this Rules. XXX

4. Herein Complainant, through its PhilHealth Regional Monitoring


Committee (PRMC), resolved to file charges against herein respondent for
violation of Section 154 of the Revised Implementing Rules and
Regulations of the National Health Insurance Act of 2013.

A copy of PhilHealth Regional Monitoring Committee (PRMC) Resolution


No. 56, s-2015 is attached herein as Annex "A”;

5. The attending circumstances are as follows:

a. On 3 March 2014, herein Respondent filed a claim for the


confinement of dependent-patient Maria Antonette Orboda Pantilanan
from February 26 to 27, 2014 due to Pneumonia Moderate Risk. For
purposes of filing a claim with PhilHealth, it was made to appear in the
submitted Claim Forms 1, 2 and 3 that the attending physician for the said
patient was Dr. Fidel V. Pondevida, Jr., a PhilHealth accredited physician.
However, as can be seen in the Medical Evaluation and the Clinical Charts,
namely: i.) Validation Report; ii.) Clinical History and Physical Examination;
iii.) Doctor's Order/Nurse's Compliance Sheet; iv.) Discharge Summary; and
v.) Admission and Discharge Record, the physician who actually attended
the patient was Dr. Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "B-1 to B-9”,
respectively;

b. On 28 March 2014, herein Respondent filed a claim for the


confinement of dependent-patient Fatima Berkisa Mohammad Alvarez
from March 22 to 24, 2014 due to Pneumonia Moderate Risk. For purposes
of filing a claim with PhilHealth, it was made to appear in the submitted
Claim Forms 1, 2 and 3 that the attending physician for the said patient was
Dr. Fidel V. Pondevida, Jr., a PhilHealth accredited physician. However, as
can be seen in the Medical Evaluation and the Clinical Charts, namely: i.)
Validation Report; ii.) Clinical History and Physical Examination; iii.)
Doctor's Order/Nurse's Compliance Sheet; iv.) Discharge Summary; and v.)
Admission and Discharge Record, the physician who actually attended the
patient was Dr. Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "C-1 to C-9”,
respectively;

c. On 10 March 2014, herein Respondent filed a claim for the


confinement of dependent-patient Darwin Ganta-o Lumangial from
February 28 to March 2, 2014 due to Pneumonia Moderate Risk. For
purposes of filing a claim with PhilHealth, it was made to appear in the
submitted Claim Forms 1, 2 and 3 that the attending physician for the said
patient was Dr. Fidel V. Pondevida, Jr., a PhilHealth accredited physician.
However, as can be seen in the Medical Evaluation and the Clinical Charts,
namely: i.) Validation Report; ii.) Clinical History and Physical Examination;
iii.) Doctor's Order/Nurse's Compliance Sheet; iv.) Discharge Summary; and
v.) Admission and Discharge Record, the physician who actually attended
the patient was Dr. Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "D-1 to D-9”,
respectively;

d. On 10 March 2014, herein Respondent filed a claim for the


confinement of dependent-patient Heart Arsino Silvestre from March 1 to
4, 2014 due to Pneumonia Moderate Risk. For purposes of filing a claim
with PhilHealth, it was made to appear in the submitted Claim Forms 1, 2
and 3 that the attending physician for the said patient was Dr. Fidel V.
Pondevida, Jr., a PhilHealth accredited physician. However, as can be seen
in the Medical Evaluation and the Clinical Charts, namely: i.) Validation
Report; ii.) Clinical History and Physical Examination; iii.) Doctor's
Order/Nurse's Compliance Sheet; iv.) Discharge Summary; and v.)
Admission and Discharge Record, the physician who actually attended the
patient was Dr. Catherine Q. Sanaani, a non-accredited physician.
Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "E-1 to E-9”,
respectively;

e. On 21 April 2014, herein Respondent filed a claim for the confinement


of dependent-patient Muhairin Almain Baki from April 11 to 13, 2014 due
to Dental Disorders. For purposes of filing a claim with PhilHealth, it was
made to appear in the submitted Claim Forms 1, 2 and 3 that the attending
physician for the said patient was Dr. Fidel V. Pondevida, Jr., a PhilHealth
accredited physician. However, as can be seen in the Medical Evaluation
and the Clinical Charts, namely: i.) Validation Report; ii.) Clinical History
and Physical Examination; iii.) Doctor's Order/Nurse's Compliance Sheet;
iv.) Discharge Summary; and v.) Admission and Discharge Record, the
physician who actually attended the patient was Dr. Catherine Q. Sanaani, a
non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "F-1 to F-9”,
respectively;

f. On 21 April 2014, herein Respondent filed a claim for the confinement


of dependent-patient Claiserd Noot Herbero from April 11 to 13, 2014 due
to Acute Gastroenteritis. For purposes of filing a claim with PhilHealth, it
was made to appear in the submitted Claim Forms 1, 2 and 3 that the
attending physician for the said patient was Dr. Fidel V. Pondevida, Jr., a
PhilHealth accredited physician. However, as can be seen in the Medical
Evaluation and the Clinical Charts, namely: i.) Validation Report; ii.) Clinical
History and Physical Examination; iii.) Doctor's Order/Nurse's Compliance
Sheet; iv.) Discharge Summary; and v.) Admission and Discharge Record,
the physician who actually attended the patient was Dr. Catherine Q.
Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "G-1 to G-9”,
respectively;

g. On 21 April 2014, herein Respondent filed a claim for the confinement


of dependent-patient Roselyn Reogelon Galindo from April 11 to 13, 2014
due to Urinary Tract Infraction. For purposes of filing a claim with
PhilHealth, it was made to appear in the submitted Claim Forms 1, 2 and 3
that the attending physician for the said patient was Dr. Fidel V. Pondevida,
Jr., a PhilHealth accredited physician. However, as can be seen in the
Medical Evaluation and the Clinical Charts, namely: i.) Validation Report;
ii.) Clinical History and Physical Examination; iii.) Doctor's Order/Nurse's
Compliance Sheet; iv.) Discharge Summary; and v.) Admission and
Discharge Record, the physician who actually attended the patient was Dr.
Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "H-1 to H-9”,
respectively;
h. On 21 April 2014, herein Respondent filed a claim for the confinement
of dependent-patient Angela Pulgo Duhaylungsod from April 11 to 13,
2014 due to Pneumonia Moderate Risk. For purposes of filing a claim with
PhilHealth, it was made to appear in the submitted Claim Forms 1, 2 and 3
that the attending physician for the said patient was Dr. Fidel V. Pondevida,
Jr., a PhilHealth accredited physician. However, as can be seen in the
Medical Evaluation and the Clinical Charts, namely: i.) Validation Report;
ii.) Clinical History and Physical Examination; iii.) Doctor's Order/Nurse's
Compliance Sheet; iv.) Discharge Summary; and v.) Admission and
Discharge Record, the physician who actually attended the patient was Dr.
Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "I-1 to I-9”,
respectively;

i. On 21 April 2014, herein Respondent filed a claim for the confinement


of member-patient Julpa Jalani Samson from April 14 to 16, 2014 due to
Peptic Ulcer Disease without Hemorrhage. For purposes of filing a claim
with PhilHealth, it was made to appear in the submitted Claim Forms 1, 2
and 3 that the attending physician for the said patient was Dr. Fidel V.
Pondevida, Jr., a PhilHealth accredited physician. However, as can be seen
in the Medical Evaluation and the Clinical Charts, namely: i.) Validation
Report; ii.) Clinical History and Physical Examination; iii.) Doctor's
Order/Nurse's Compliance Sheet; iv.) Discharge Summary; and v.)
Admission and Discharge Record, the physician who actually attended the
patient was Dr. Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "J-1 to J-9”,
respectively;

j. On 21 April 2014, herein Respondent filed a claim for the confinement


of dependent-patient Rahima Sumalpong Jalani from April 14 to 16,
2014 due to Otitis Media. For purposes of filing a claim with PhilHealth, it
was made to appear in the submitted Claim Forms 1, 2 and 3 that the
attending physician for the said patient was Dr. Fidel V. Pondevida, Jr., a
PhilHealth accredited physician. However, as can be seen in the Medical
Evaluation and the Clinical Charts, namely: i.) Validation Report; ii.) Clinical
History and Physical Examination; iii.) Doctor's Order/Nurse's Compliance
Sheet; iv.) Discharge Summary; and v.) Admission and Discharge Record,
the physician who actually attended the patient was Dr. Catherine Q.
Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "K-1 to K-9”,
respectively;

k. On 21 April 2014, herein Respondent filed a claim for the confinement


of member-patient Naima Lailing Bandon from April 14 to 16, 2014 due
to Pneumonia Moderate Risk. For purposes of filing a claim with PhilHealth,
it was made to appear in the submitted Claim Forms 1, 2 and 3 that the
attending physician for the said patient was Dr. Fidel V. Pondevida, Jr., a
PhilHealth accredited physician. However, as can be seen in the Medical
Evaluation and the Clinical Charts, namely: i.) Validation Report; ii.) Clinical
History and Physical Examination; iii.) Doctor's Order/Nurse's Compliance
Sheet; iv.) Discharge Summary; and v.) Admission and Discharge Record,
the physician who actually attended the patient was Dr. Catherine Q.
Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "L-1 to L-9”,
respectively;

l. On 21 April 2014, herein Respondent filed a claim for the confinement


of member-patient Abdulhakim Annuari Samod from April 12 to 13,
2014 due to Peptic Ulcer Disease without Hemorrhage. For purposes of
filing a claim with PhilHealth, it was made to appear in the submitted Claim
Forms 1, 2 and 3 that the attending physician for the said patient was Dr.
Fidel V. Pondevida, Jr., a PhilHealth accredited physician. However, as can
be seen in the Medical Evaluation and the Clinical Charts, namely: i.)
Validation Report; ii.) Clinical History and Physical Examination; iii.)
Doctor's Order/Nurse's Compliance Sheet; iv.) Discharge Summary; and v.)
Admission and Discharge Record, the physician who actually attended the
patient was Dr. Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "M-1 to M-9”,
respectively;

m. On 25 April 2014, herein Respondent filed a claim for the


confinement of dependent-patient Maher Bangguih Ondog from April
17 to 19, 2014 due to Pneumonia Moderate Risk. For purposes of filing a
claim with PhilHealth, it was made to appear in the submitted Claim Forms
1, 2 and 3 that the attending physician for the said patient was Dr. Fidel V.
Pondevida, Jr., a PhilHealth accredited physician. However, as can be seen
in the Medical Evaluation and the Clinical Charts, namely: i.) Validation
Report; ii.) Clinical History and Physical Examination; iii.) Doctor's
Order/Nurse's Compliance Sheet; iv.) Discharge Summary; and v.)
Admission and Discharge Record, the physician who actually attended the
patient was Dr. Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "N-1 to N-9”,
respectively;

n. On 21 April 2014, herein Respondent filed a claim for the confinement


of dependent-patient Armia Amilussin Adala from April 12 to 14, 2014
due to Pneumonia Moderate Risk. For purposes of filing a claim with
PhilHealth, it was made to appear in the submitted Claim Forms 1, 2 and 3
that the attending physician for the said patient was Dr. Fidel V. Pondevida,
Jr., a PhilHealth accredited physician. However, as can be seen in the
Medical Evaluation and the Clinical Charts, namely: i.) Validation Report;
ii.) Clinical History and Physical Examination; iii.) Doctor's Order/Nurse's
Compliance Sheet; iv.) Discharge Summary; and v.) Admission and
Discharge Record, the physician who actually attended the patient was Dr.
Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "O-1 to O-9”,
respectively;

o. On 21 May 2014, herein Respondent filed a claim for the confinement


of member-patient Jibba Pascual Alasti from April 12 to 14, 2014 due to
Pneumonia Moderate Risk. For purposes of filing a claim with PhilHealth, it
was made to appear in the submitted Claim Forms 1, 2 and 3 that the
attending physician for the said patient was Dr. Fidel V. Pondevida, Jr., a
PhilHealth accredited physician. However, as can be seen in the Medical
Evaluation and the Clinical Charts, namely: i.) Validation Report; ii.) Clinical
History and Physical Examination; iii.) Doctor's Order/Nurse's Compliance
Sheet; iv.) Discharge Summary; and v.) Admission and Discharge Record,
the physician who actually attended the patient was Dr. Catherine Q.
Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "P-1 to P-9”,
respectively;

p. On 28 February 2014, herein Respondent filed a claim for the


confinement of member-patient Dalmanis Rusain Hassan from
February 22 to 24, 2014 due to Urinary Tract Infraction. For purposes of
filing a claim with PhilHealth, it was made to appear in the submitted Claim
Forms 1, 2 and 3 that the attending physician for the said patient was Dr.
Fidel V. Pondevida, Jr., a PhilHealth accredited physician. However, as can
be seen in the Medical Evaluation and the Clinical Charts, namely: i.)
Validation Report; ii.) Clinical History and Physical Examination; iii.)
Doctor's Order/Nurse's Compliance Sheet; iv.) Discharge Summary; and v.)
Admission and Discharge Record, the physician who actually attended the
patient was Dr. Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "Q-1 to Q-9”,
respectively;

q. On 28 February 2014, herein Respondent filed a claim for the


confinement of member-patient Minjama Manson Abunawas from
February 22 to 24, 2014 due to Urinary Tract Infraction. For purposes of
filing a claim with PhilHealth, it was made to appear in the submitted Claim
Forms 1, 2 and 3 that the attending physician for the said patient was Dr.
Fidel V. Pondevida, Jr., a PhilHealth accredited physician. However, as can
be seen in the Medical Evaluation and the Clinical Charts, namely: i.)
Validation Report; ii.) Clinical History and Physical Examination; iii.)
Doctor's Order/Nurse's Compliance Sheet; iv.) Discharge Summary; and v.)
Admission and Discharge Record, the physician who actually attended the
patient was Dr. Catherine Q. Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "R-1 to R-9”,
respectively;

r. On 25 April 2014, herein Respondent filed a claim for the confinement


of dependent-patient Anisa Pascual Sahi from April 12 to 14, 2014 due
to Pneumonia Moderate Risk. For purposes of filing a claim with PhilHealth,
it was made to appear in the submitted Claim Forms 1, 2 and 3 that the
attending physician for the said patient was Dr. Fidel V. Pondevida, Jr., a
PhilHealth accredited physician. However, as can be seen in the Medical
Evaluation and the Clinical Charts, namely: i.) Validation Report; ii.) Clinical
History and Physical Examination; iii.) Doctor's Order/Nurse's Compliance
Sheet; iv.) Discharge Summary; and v.) Admission and Discharge Record,
the physician who actually attended the patient was Dr. Catherine Q.
Sanaani, a non-accredited physician.

Copies of the claim forms, the said clinical charts and the medical
evaluation are hereto attached and marked as Annexes "S-1 to S-9”,
respectively;

6. Accreditation with PhilHealth is a condition precedent for a health care


institution or professional to participate in the Program by filing a claim
therefrom.1 Be that as it may, by making it appear that the patient was
attended by a PhilHealth accredited physician, herein respondent furnished
false or incorrect information and such constitutes a violation of Section
154 of the RIRR of R.A. 7875, as amended. In all of the foregoing, such
misrepresentation was further established after a judicious and circumspect
medical evaluation of the claim, where it was confirmed that Dr. Fidel V.
Pondevida, Jr. was the attending physician based on the claim forms
whereas, in truth and in fact, it was a non-accredited physician who actually
attended the patients based on the clinical charts.

7. In addition, Section 169 of the same RIRR clearly categorizes


Misrepresentation by furnishing false or incorrect information as a
fraudulent administrative offense. Fraud has been defined thus, "to include
an inducement through insidious machination. Insidious machination refers
to a deceitful scheme or plot with an evil or devious purpose xxx"2

Following the said definition, the misrepresentation by herein respondent


is tantamount to a deceitful scheme or plot with an evil purpose of
participating in the National Health Insurance Program by filing a claim
therefrom. Therefore, such misrepresentation constitutes a fraudulent
administrative offense;

8. Ultimately, In Western Mindanao Medical Center v. Philippine Health


Insurance Corporation, G.R. 206025, June 3, 2013, the Supreme Court made
1
Section 55 of the RIRR of R.A. 7875, as amended.
2
Cathay Pacific Airways, Ltd. v. Vasquez, G.R. No. 150843, March 14, 2003, 399 SCRA 207,
220.
it clear that any violation of the Revised Implementing Rules and
Regulations of the National Health Insurance Act shall be dealt with
severely, when it affirmed the decision of the Court of Appeals, ordering the
suspension of accreditation of petitioner Health Care Provider, when it was
found guilty of misrepresentation by furnishing false or incorrect
information in violation of Section 154 of the said RIRR. The suspension
eventually caused the cessation of operations of petitioner Health Care
Provider;

9. Applying the said pronouncement in this case, herein Respondent's


deliberate misrepresentation by furnishing false or incorrect information,
being a violation of the Revised Implementing Rules and Regulations of the
National Health Insurance Act must be dealt with severely. Hence,
PhilHealth is entitled to charge Respondent for the imposition of the
appropriate Administrative Penalties and to collect damages arising from
the said administrative offense, without prejudice to other legal reliefs
applicable.

PRAYER

In view of the foregoing, it is respectfully prayed that:

1. The above-named Respondent be charged for eighteen (18) counts of


violation of Section 154, in relation to Sections 55 and 169 of the
RIRR of R.A. 7875, as amended, as applicable, for the acts committed as
specified in this Complaint-Affidavit;

2. After due notice and preliminary investigation, a Resolution be


rendered in favor of the Complainant and against Respondent; and

3. Other reliefs and remedies as may be deemed just and equitable


under the circumstances are likewise prayed.

IN WITNESS WHEREOF, that I have affixed my signature this


_________________________, in the City of Zamboanga, Philippines.

ATTY. LIZA ANN A. GAGARACRUZ-CAPIN


Affiant

VERIFICATION AND CERTIFICATION AGAINST FORUM


SHOPPING

I, LIZA ANN A. GAGARACRUZ-CAPIN, under oath, state that:

1. I am the representative of the complainant in the above complaint;


2. I caused the preparation and authorized the filing of the foregoing
“Complaint Affidavit”;

3. I have read and understood the contents of the “Complaint


Affidavit,” the allegations of which are true and correct to the best of
my own personal knowledge and authentic records;

4. I have not heretofore commenced any action or filed any claim


involving the same issues in any court, tribunal or quasi-judicial agency
and, to the best of my knowledge, no such other action or claim is
pending therein. If there is such other pending action or claim, I will
make a complete statement of the present status thereof. If I should
thereafter learn that the same or similar action or claim has been filed
or is pending, I shall report that fact within five (5) days therefrom to
this Honorable Office.

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


____________________ in _____________________

ATTY. LIZA ANN A. GAGARACRUZ-CAPIN


Affiant

SUBSCRIBED AND SWORN to before me, in __________________________, this


____ day of ___________________, the affiant exhibiting her Tax Identification
No. 269-425-190 issued by the Bureau of Internal Revenue (BIR).

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of ______.

ATTY. MA. EMILY P. ROQUE, CPA


Administering Officer

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