1. REFERENCES:

a.  Circular No. 2006-16 dated August 15, 2006, œReimbursement of Hospital Expenses of PNP Uniformed Personnel in the Active Service ,
b.  Circular No. 2002-11dated August 3, 2002, œGuidelines in the Accounting of PNP Uniformed Personnel who are confined/treated at PNP Health Facilities and other hospitals ,
c.  Circular No. 2000-10 NHQ PNP dated July 11, 2000, œSeparation from the police service a Active PNP Uniformed Personnel due to Physical Disability .
d.  NAPOLCOM Memorandum Circular No. 2000-005 dated June 8, 2000, œRules and regulations governing the investigation and adjudication of benefit claims of uniformed members of the Philippine National Police (PNP) ;
e.  Standing Operating Procedure No. 15 GHQ PNP dated July 22, 1992, œDecentralization in the processing and payment of retirement and other benefit claims 
f.  Section 70, RA 6975, œHealth and Welfare it shall be the concern of the Department to provide leadership and assistance in developing health and welfare program for its personnel .
g.  Sec 73  RA 6975 as amended by Sec 35 of RA 8551.
h.  Sec 29 and 30 of RA 8551, œAttrition by other means  and œRetirement under the preceding sections œ respectively;
i.  National Health Insurance Act of 1995 (RA 7875)
j.  Circular Nr 1, GHQ, AFP dated January 20, 2004, ˜Medical/Dental attendance and maximum hospitalization a AFP Health Facilities ;
k.  Section 2.3 CSC Memorandum Circular No. 12 S 1994 dated March 10, 1994, Physical and Mental Unfitness

2. PURPOSE:

This Circular prescribes specific guidelines and procedures for the just, reasonable and speedy adjudication of claims for reimbursement of hospitalization expenses of active PNP personnel arising from service-connected illnesses and/or injuries.

3. OBJECTIVES:

This Circular aims to:

a.  Instill health awareness among PNP personnel as part of the preventive medicine aspect thereby minimizing the occurrence of illnesses which may lead to costly hospitalization; and
b.  Instill limitations in payment of benefit claims thereby preventing the dissipation of financial resources.

4. RATIONALE:

The Reimbursement of Hospitalization Expenses scheme is anchored on the following fundamental principles:

a.  Medical attendance rendered to PNP personnel while confined at PNP General Hospital/PNP Medical Facilities is free of charge. Through his designated staff, D HS shall see to it that requirements of PNP personnel confined/admitted as provided for, to be limited only by budgetary and fiscal restriction.
b.  The reimbursement of Hospitalization Expenses (RHE) scheme for PNP personnel in the active service as promulgated in this Circular is an adjunct health care delivery structure to the Health Service logistic support system and the benefit derived thereof is construed as an additional privilege and not a right which therefore has to be exercised in the best lights and always subject to the availability of funds;
c.  The maximum reimbursable hospital expenses is six (6) months reckoned from the time it is incurred regardless of whether or not the personnel concerned has been separated from the service or whether the injury or sickness has been cured or not, while the maximum number of days a personnel may be confined is three hundred six (365) after which he/she shall be thoroughly evaluated for fitness to remain in the active service. Any impairment of the body or mind which renders the patient incapable of performing substantially the duties of a personnel and which is expected to be long, continued and of indefinite duration are grounds for recommendation for retirement and/or separation from the active service through Total Permanent Physical Disability (TPPD)

5. DEFNITION OF TERMS:

Terms used in this Circular shall mean or refer to as:

a.  Active PNP Personnel - shall mean the Uniformed and Non-Uniformed Personnel of the PNP.
b.  Attendance - Medical service rendered to a patient including professional service (consultation and physical examination), treatment, nursing care, radiologic examination, laboratory work-ups and other procedures and dispensing of medicines and medical supplies.
c.  Police Operations Casualty - refers to any PNP personnel who is either killed, wounded or sustained injury by reason of anti-criminality, counter-insurgency, counter-terrorism, and police community operations. These duties shall include but not limited to the following:

1.  Enforcement of all laws, ordinance and legal orders of duly constituted authorities;
2.  Prevention, control and investigation of crimes;
3.  Ensuring public safety and internal security;
4.  Protection of lives, liberties and properties of the public;
5.  Arrest of criminal offenders, bringing them to justice/courts and assisting in their prosecution;
6.  Conduct search and seizure operations in accordance with law and
7.  Conduct of rescue operations to save lives and properties during natural or man made calamities.

d.  Hospitalization - The rendering of medical attendance after admission in any PNP Medical Facility (to include PNP General Hospital), government and/or private health care institution.
e.  Emergency - medical or surgical condition that threaten the immediate loss of life or limb when not attended to.
f.  Injury - Any harmful change in the human organism from any incident sustained at work, while at the work place or elsewhere while executing an order from the employer, or sustained by reason of the performance of duty.
g.  Sickness - An illness accepted as an occupational disease or any illness caused or aggravated by employment, subject to proof that the risk of contracting the same is increased by working conditions.
h.  Total Permanent Physical Disability (TPPD) - Any impairment of the mind or body which renders the disabled PNP personnel incapable of performing substantially the duties of a police officer and which is expected to be long, continued and of indefinite duration. Provided that irreparable loss (Functional or Physical) of the power of speech, or sense of hearing, or loss of one or both hands or feet, or loss of one eye or both eyes, or loss of limbs at or above the ankle or wrist, paralysis of one or both limbs, or brain injury resulting in incurable imbecility or insanity shall be considered permanent total disability.

In all cases, the disability shall be deemed permanent if it has persisted for a period exceeding two (2) years without fixed healing period, and renders the PNP personnel incapable of performing his duties. Provided, further, that in case the disability is found to be permanent beyond doubt upon medical examination of said personnel, the waiting period of two (2) years may be waived.

i.  Maximum Hospitalization Benefits - Period of hospitalization ends when the patients ™ progress appears to have stabilized and it can be anticipated that additional hospitalization will not directly contribute to any further substantial recovery.  However, as used in this Circular, such hospitalization benefit shall not exceed one (1) year of continuous confinement in one or more hospitals.
j.  Catastrophic - illness or injuries such as but not limited to cancer cases with metastasis and/or requiring chemotheraphy or radiation theraphy, meningitis, encephalitis, cirrhosis of the liver (child C, myocardial infarction, cerebrovascular attack, rheumatism heat disease grade III, renal failure, other conditions requiring dialysis or transplant, other conditions with massive hemorrhage, shock of any cause; surgical procedure or multiple surgical procedures done in one sitting with a total Relative Unit Value (RUV) of 20 (per PhilHealth definition) and above such as but not limited to coronary angioplasty, coronary bypass, open heart surgery of neurosurgery.
K.  Intensive Care - refers to confinements requiring services in an   intensive care unit such as respiratory and monitoring support, cardiac/hemodynamic monitoring and maintenance; other similar serious illnesses or injuries such as but not limited to cancer, pneumonia, moderately or far advanced pulmonary tuberculosis including its complications, cardiovascular attack, disease of the heart, chronic obstructive pulmonary disease, liver disease, typhoid fever, fever grade III, H-Fever, kidney disease, septicemia, diarrhea with severe dehydration, hepatitis B, dengue hemorrhagic, or severe injuries; including surgical procedure or multiple procedures done in one sitting with a total RUV of 8 but not exceeding 19.99 (source PHILHEALTH RUV Manual).
i.  Ordinary Condition - refers to illnesses or injuries than those included in the above enumeration.

6.  GUIDELINES:

a. Scope/Coverage

1. Benefits derived hereof shall include the hospitalization expenses of:

a. All active PNP personnel confined in PNP General Hospital and/or PNP Medical Facilities, or PNP accredited government and/or private hospitals due to illness/injury;
b. All active PNP personnel admitted as emergency case in private and/or government hospitals under the following circumstances:

1. On police operations or battle casualty reimbursement of hospitalization expenses shall be in full. A condition must be included therein, that, the reimbursement is subject to availability of funds and usual accounting and auditing requirements:
2. In case there is no PNP hospital within a reasonable distance, the injured or sick PNP personnel on emergency cases shall be admitted in other hospitals provided that the concerned personnel shall be transferred to a PNP General Hospital as soon as the period of crisis is over.
3. For emergency admission in other hospitals provided the injury is service connected and provided further that the patient is immediately evacuated to PNP General Hospital/PNP Medical facilities as soon as the condition permits (no imminent danger to the life of the patient);
4. For emergency admission into other hospitals where there is a PNP Medical Facility (to include PNP General Hospital) provided that  the management of the patient is not within the capability of the PNP Medical Facility and provided further that the patient is immediately evacuated to the PNP Medical Facility as soon as the condition permits (transfer is medically advisable as there is no imminent danger to life of the patient).

c. All active PNP personnel confined/admitted for non-urgent conditions which are not manageable at PNP General Hospital/PNP Medical Facility, provided that the Chief of PNP General Hospital/PNP Medical Facility gives proper authorization.

2. Medical Attendance and hospitalization benefits (authorized votes) include the following:

a. Room and Board - shall be P1,500.00/day
b. Admission to Intensive Care Units is subject to the prevailing rate of the hospital and shall be limited until the patient ™s crisis is over;

3. Professional Fees - based on the prevailing RUV

a. Medical Case - maximum of Three Hundred Fifty Pesos (P350.00)/day on ordinary case and Seven hundred Fifty Pesos (P750.00)/day for intensive or catastrophic cases. b.  Surgical Case - based on the prevailing RUV

1. Minor - Not to exceed Ten Thousand Pesos (P10,000.00)
2. Intermediate - Ten Thousand Pesos to Twenty Thousand Pesos (P10,000.00-P20,000.00)
3. Major - Twenty Thousand to Sixty Thousand Pesos (P20,000.00 - P60,000.00)

c. Anesthesiologist Fee - 30% of the main surgeon ™s fee

4. Medicines - Maximum of P35,000.00
5. Medical Supplies - Maximum of 35,000.00
6. Ambulance Fee - Maximum of P1,000.00
7. Laboratory work-ups - maximum of P30,000.00

b. Requirements for the settlement of claims

1.  The claim should be supported by evidence showing that the death, sickness or injury, as the case may be occurred or was contracted or sustained in line of duty and the determination of service connection of the causative sickness or injury shall be done by considering the following:

a. Nature and extent of the sickness or injury incurred or sustained by the personnel concerned.
b. Position held and nature of duties including duration of daily duty, regularity and frequency of exposure to the elements and other general conditions obtained during the performance of duty;
c. Facts and actual circumstances surrounding the incurrence of incipience of disease, sickness or injury; and
d. Physical condition upon entrance into the service and at the time of separation there from, as may be established by reports of physical examination, clinical records, certificate of discharge and other official records, if any.

2.  Before the final approval, each claim shall further be supported by a definite finding by the proper Department Head of the sickness, injury or disease incurred;

a. was not the proximate result of the personnel ™s abuse of authority, misconduct, willful failure, gross negligence, indiscriminate use of drug, or alcoholic liquor or vicious or immoral act or habits;
b. was not contracted prior to his entry into the service or after his separation there from; and
c. was not incurred or contracted during his absence without authority from his assigned place of duty.

c. Entitlement

1. For Police Operations Battle casualties:

Battle casualties would be given emergency treatment in the nearest PNP accredited hospital where the injury occurred and once he becomes stable and there is no longer a threat to his life, such patient shall be immediately evacuated to PNPGH for definitive treatment.  All hospitalization expenses incurred shall be reimbursed in full subject to the availability of funds and usual accounting and auditing of funds.

2. For non-Battle casualties:

a. The maximum amount reimbursable for an ordinary non-urgent medical case, shall not exceed Sixty Thousand Pesos (60,0000.00). For surgical cases, shall not exceed One Hundred Thousand Pesos (100,000.00)
b. the maximum amount reimbursable for Intensive and Catastrophic Cases shall not exceed Three Hundred Fifty Thousand Pesos (P350,000.00).
c. System Flow of availment:

1. For Non Emergency Cases

PNP personnel must secure a Letter of Authorization (LOA) from the PNP Health Service Facility provided that the PNP Health Service Facility is not capable of managing the condition of the PNP Personnel.  The LOA and the personnel ™s PNP ID must be presented to the Accredited Hospitals (Annex B) before undergoing treatment and/or confinement. Upon discharge, the patient must ensure that all necessary documents required for the payment/reimbursement of hospital expenses are properly signed.

2. For Emergency Cases:

PNP personnel must present  their PNP ID to the Accredited Hospitals prior to treatment and/or confinement.  Concerned personnel or his/her dependents should communicate with PNP Health Service within 24 hours to secure LOA. This is to verify if any treatment and/or confinement is chargeable to PNP and does not fall under the grounds for denial of claims. When the emergency situated is over, the patient sign the necessary documents to reimburse the expenses incurred and then transfer to a PNP Health Facility.

d. System of Payment:

Upon discharge of the PNP personnel the PNP Accredited Hospital will send the Statement of Account (SOA) to RHE Section, PNP Health Service indicating therein the deduction such as Philhealth and/or HMO. The Hospital SOA will be forwarded to the Adjudication Board for verification of the authenticity of the charges. Once verified and approved by the Board, the SOA will be forwarded to the Directorate for Comptrollership for processing and payment of the said bill.

d.  Grounds for Denial of Claims

1. Medical/Hospitalization expenses incurred during uncomplicated pregnancy and delivery (Normal Spontaneous Delivery);
2 . Expenses incurred in private or government hospital by patients who refuse to be transferred/retro-evacuated to PNP General Hospital/PNP Medical Facility without justifiable reasons after the period of crisis is over and when transfer is already feasible;
3. Expenses incurred in private or government hospital by patient when the injury and/ or sickness are occasioned by any of the following:

a. By intoxication or drunkenness or various immoral habits or intemperate use of regulated or prohibited drugs;
b. By willful intention to injure or kill oneself or another;
c. By notorious negligence (AWOL);
d. By unlawful aggression or provocation on the part of the claimant; and
e. If the illness is due to abuse of lifestyle wherein the patient has been repeatedly warned to modify in order to correctly maintain a healthier lifestyle, or has failed to consult a physician for treatment.  Lifestyle of the patient should be investigated and confirmed by the proper authorities. Should abuse be proven, Reimbursement of Hospital Expenses will be denied by the PNP.

1. The following are considered as abuse of lifestyle:

i.  intoxication/drunkenness
ii.  use of prohibited drugs
iii  excessive substance consumption
iv. various immoral habits, leading to STD ™s

2. Specific diseases to be investigated:

i.  Diabetes Mellitus
ii.  Renal Disease
iii. Hypertension
iv. Cancers
v. Liver Diseases: (alcoholic cirrhosis, liver cancer)
vi.  Sexually transmitted diseases

4. When claims fall under any of the following circumstances:

a. failure to avail of Social Service assistance/Philhealth Benefits with regards to the excess on the allowable reimbursable amount as provided for by this Circular;
b. hospitalization expenses are unreasonably beyond the allowable prescribed ceiling;
c. failure to meet/submit the documentary requirements within the sixty (60) day prescriptive period (reckoned from the date of discharge from confinement);
d. drugs prescribed and dispensed and other procedures do not conform or apply to the diagnosis (nature of illness); and
e. claims contain any of the following:

1. supporting documents to the claim are false, incorrect, altered and/or tampered with;
2. receipts submitted cover non-medical items such as bath soaps, toiletries, perfumes, etc;
3. receipts include purchase/hiring of equipment and/or for other services such as hiring of special nurse, nurse aide and/or caregivers etc.; and
4. dates of receipts for purchase of medicines, medical supplies and other medical services rendered do not conform with the inclusive dates of confinement.

4. When claims fall under any of the following circumstances:

5. In case of illness and/or caused by a 3^rd party (1^st party him the patient, 2^nd party the PNP) intent to cause harm or due to negligence, the claimant shall be advised to exhaust all means for claims for hospitalization from the 3^rd party or those liable to answer for his illness and/or injury. The PNP is not liable for damage caused by 3^rd parties.

6. In case the patient has availed himself of the services of HMO (private insurance companies), the PNP will reimburse part of the hospital expenses after the particular HMO has paid for reimbursed the expenses of the patient, provided such expenses do not exceed the limits set by this Circular and that professional fees for doctors and other services fall within the limits of this Circular and that instances of excessive compensation be eliminated.

e.  Creation and Function of the Expanded RHE Adjudication Boards:

To obtain a just, reasonable and speedy adjudication of benefit claims, RHE Adjudication Boards will be created at the National Headquarters (NHQ) level and at the Police Regional Office (PRO) level.
 

1.  NHQ ERHE Adjudication Board shall convene twice a month or as deemed necessary by the Chairman:

A. Composition

Director, Health Service	Chairman
Deputy Director, Health Service	Vice-Chairman
Chief, PNP General Hospital	Member
Chief, Budget & Fiscal Office, DPRM	Member
DI Representative	Member
LS Representative	Member
Chief, ERHE Section , MSD, HS	Member

B. Functions:

1.  Adjudicate hospitalization bills of PNP Personnel assigned with the NHQ PNP Offices and Headquarters National Support Units treated and/or confined in the listed DOH Accredited Hospitals. Within four (4) working days upon receipt thereof submit its recommendations for approval by the designated approving authorities.
2.  Review claims and recommendations forwarded by the Regional ERHE Adjudication Board and within four (4) working days upon receipt thereof, render an adjudication report for final approval of claims exceeding Sixty Thousand Pesos (P60,000.00) for medical cases and One Hundred Thousand (100,000.00) for surgical cases and Three Hundred Fifty Thousand Pesos (P350,000.00) for intensive and catastrophic cases.
3.  Initially determine the legal heirs or rightful beneficiaries of deceased personnel.
4.  Process and recommend approval of claims of PNP Personnel assigned in the different PROs/Units who were hospitalized in DOH accredited hospitals in Metro Manila provided that the concerned personnel presented a certification from the Regional Expanded RHE Adjudication Board that no similar claims were filed, adjudicated and/ or approved thereat.

2.  PRO ERHE Adjudication Board shall convene twice a month or as deemed necessary by the Chairman:

A. Composition:
 

Deputy Reg ™l Director for Administration
    Chairman Chief, Regional Health Service Vice-Chairman C, RPHRDD or his authorized Rep Member C, RDPFC or his authorized Rep Member C, RDIMDI or his authorized Rep Member Chief, Regional Legal Service Member Regional Chief Nurse, Member

B. Functions:

1. Adjudicate within four (4) days hospitalization bills of PNP Personnel assigned in the Police Regional Officers, treated and/or confine in the listed DOH Accredited, upon receipts thereof submit its recommendation for approval of the Regional Director:

i.  All claims in excess of the allowable reimbursable amount for medical and surgical cases respectively shall be forwarded to the NHQ PNP Adjudication Board for review and recommendation prior to approval of higher authorities.
ii.  For Battle casualty claims in excess of One Hundred Thousand Pesos (P100,000.00), the RDs may release the amount of One Hundred Thousand Pesos (P100,000.00) as initial payment and forward the certificate of payment with the necessary supporting documents and recommendations to the NHQ ERHE Adjudication Board for final disposition.

e.  Approving Authorities
 

CPNP
P1M and above TDCA more than P500,000.00 but less than P1M TDPRM P500,000.00 and below

7.  PROCEDURE IN THE FILING AND ROCESSING OF ERHE CLAIMS

a. Where to file claims:

1. Claims for personnel assigned in the National Headquarters and National Support Units - RHE Section, MSD Office of the Director Health Service.

2. Claims for RHE of personnel assigned in the PROs including NSUs with regional offices - RHS.

b. When to file:

Claims maybe filed either during the period of confinement or upon discharge from confinement but in no case to exceed sixty (60) days there from.

c. Supporting Documents:

1. Patient:

a. Letter of Authorization
b. Certificate of Duty Status from Unit Assignment
c. Medical Certificate by the Attending Physician

2. Hospital:

a. Certificate of Confinement from Administrative Officer/Chief of the PNP Medical Facility or Hospital Registrar/Attending Physician of government/private hospital attesting to the inclusive days of confinement of PNP personnel.

b. Original invoices and official receipts of medicines, medical supplies and medical services rendered inclusive of confinement days.

d. Adjudication Proper:

The Board shall review, verify and evaluate all matters pertaining to the claim.  Before recommending approval of ay claims, the Adjudication Board shall ascertain that the sickness, disease or injury was:

1. Not self-inflicted and not a result of the personnel ™s abuse of authority, misconduct, willful disobedience, gross negligence, use of drugs or liquor or immoral acts or habits;
2. Not incurred or contracted during his absence without authority from his assigned place of duty.
3. The number of claims to be filed shall not exceed two (2) in a single period of confinement.
4. Within four (4) working days the Adjudication Board Report, duly signed by its Chairman and members must be submitted for notation/ approval by the approving authorities. The Report following the prescribed format must include the facts of the case, duly certified/validated supporting documents, computation sheet and recommendation.

e. Preparation of Disbursement Voucher:

1. After approval of the Adjudication Board, the disbursement voucher shall then be prepared and forwarded to the Director for Comptrollership/ARDC through the Disbursing Officer.
2. It shall then be processed in accordance to existing accounting and auditing rules until after the checks has been released to the claimants.

8. EFFECT OF DISAPPROVAL OF CLAIM

If the claim is disapproved payment of medical and/or hospitalization services rendered shall be borne by the concerned PNP personnel or his/her heirs.

9. FUNDING

The Director for Personnel and Records Management (TDPRM) shall program the funds to support the reimbursement of Hospitalization expenses under this Circular.

10. ADMINISTRATIVE CLAUSE:

Any PNP personnel or his representative who, for the purpose of securing entitlement to any benefit or payment under this Circular commits fraud, collusion, falsification, misrepresentation or any other kind of anomaly shall be subject to criminal and administrative action deemed appropriate by the investigating body.

11. RESCISSION:

All PNP Memoranda and Circulars contrary or in direct conflict with this Circular are hereby rescinded/nullified upon approval.

12.  EFFECTIVITY:

This Circular will take effect fifteen (15) days from the filing of a copy hereof at the University of the Philippines Law Center in consonance with Section 3 and 4 of Chapter 2, Book, VII of Executive Order No. 292, otherwise known at œThe Revised Administrative Code of 1987 , as amended.


Adopted: 01 April 2011


(SGD.) ATTY. RAUL M. BACALZO, Ph.D.
Police Director General
Chief, PNP