Guidelines for the Handling of Complaints Filed Against Health Maintenance Organizations

The Insurance Commission (IC) has issued Circular Letter (CL) No. 2018-14 which provides the guidelines for handling complaints filed against Health Maintenance Organizations (HMOs). The guidelines provide that:
1.  All complaints filed against an HMO received by the IC, including its district offices, shall be: 
a. Endorsed to the Association of Health Maintenance Organizations of the Philippines' (AHMOPI) grievance machinery involving their members; or
b. Endorsed to the Philippine Association of Health Maintenance Organization Companies, Inc.’s (PAHMOC) grievance machinery involving their members.
2. Complaints against non-member HMOs shall be handled by the IC through its Public Assistance and Mediation Division (PAMD).
3. The AHMOPI and the PAHMOC are authorized to conduct mediation proceedings on all complaints referred/endorsed by the IC.
4. The AHMOPI and PAHMOC, are enjoined to conclude all mediation proceedings within thirty (30) days from receipt of the endorsement of the complaint from the IC.
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 IC.
6. ln 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 the IC for appropriate action in accordance with existing rules and regulations.
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.
The full text of CL No. 2018-14 is available here.