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WHEREAS, Executive Order No. 192, Series of 2015 (E.O. No. 192, s. 2015) transferred the regulation and supervision of health maintenance organizations (HMOs) from the Department of Health (DOH) to the Insurance Commission (IC);

WHEREAS, pursuant to E.O. No. 192, s. 2015, the IC was given the authority to formulate, adopt and implement such rules, regulations, and other issuances as may  be  necessary   for  the  effective   implementation   of  the  aforementioned executive order;

WHEREAS,  IC  Circular  Letter  (CL)  No.  2015-59  dated  22  December  2015 entitled, “Endorsement of all Complaints filed against HMOs with the Grievance Machinery   of  the  Association   of  Health  Maintenance   Organizations   of  the Philippines (AHMOPI) for Mediation during the Transition Period” was issued;

WHEREAS, IC CL No. 2015-59 authorized AHMOPI, being the only association of  HMOs  at  that  time,  to  conduct  mediation  proceedings  on  all  complaints endorsed by IC against any HMOs;

WHEREAS,   the  Philippine   Association   of  Health  Maintenance   Organization Companies, Inc. (PAHMOC) was duly incorporated on 10 July 2017;

WHEREAS, there are now two (2) HMO associations that exist, the AHMOPI and the PAHMOC;

WHEREAS, in recognition of the existence of the two (2) associations, there is a need to set the guidelines in the handling of complaints and conduct of mediation proceedings against HMOs received by IC, regardless of whether such HMO are members of any HMO organization;

NOW   THEREFORE,   pursuant   to   the   authority   vested   in   the   Insurance Commission under E.O. No. 192, s. 2015, the following are hereby promulgated:

1.     All complaints filed against an HMO received by the Insurance Commission, including its District Offices, shall be:

a.   Endorsed   to   the   AHMOPI’s    grievance   machinery    involving   their members; or
b.   Endorsed to PAHMOC’s grievance machinery involving their members.

2.    Complaints against HMOs, which are non-members, shall be handled by the
Insurance Commission through Public Assistance and Mediation Division;

3.     The AHMOPI and the PAHMOC are hereby authorized to conduct mediation proceedings on all complaints referred/endorsed by this Commission;

4.     The  AHMOPI  and  the  PAHMOC,   are  hereby  enjoined  to  conclude  all mediation  proceedings  within  thirty  (30)  days  from  receipt  of  the endorsement of the complaint from this Commission;

5. Should there be settlement between the parties, the endorsee is directed to file a report, together with the necessary documents, within five (5) days from the  settlement  of  the  complaint/case  addressed  to  the  Insurance Commission;

6. In  the  event  that  the  parties  fail  to  reach  an  amicable  settlement,  the endorsee shall forward the complaint, including all records pertaining thereto, within five (5) days from termination of the mediation conference, to this Commission for appropriate action in accordance with existing rules and regulations; and

7. The IC, through  the PAMD, shall conduct  the mediation  conference  of the cases of failed mediation mentioned in the immediately preceding paragraph forwarded by either AHMOPI or PAHMOC in accordance with existing rules and regulations.

This Circular Letter shall take effect immediately. For strict compliance.