a 2 ON wiemeceaiee NATIONAL HEADQUARTERS, PHILIPPINE NATIONAL POLICE OFFICE OF THE CHIEF, PNP Camp BGen Rafael T Crame, Quezon City MEMORANDUM CIRCULAR NO.: REVISED RULES GOVERNING THE REIMBURSEMENT OF SERVICE- CONNECTED HOSPITALIZATION EXPENSES AND OTHER HOSPITAL BENEFITS OF PNP PERSONNEL IN THE ACTIVE SERVICE 1, REFERENCES: a Republic Act (RA) No. 11032 entitled: “An Act Promoting Ease of Doing Business and Efficient Delivery of Government Services, amending for the Purpose Republic Act No. 9485, otherwise known as the Anti-Red Tape Act of 2007, and for other purposes”: RA No. 10606 entitled: “National Health insurance Act of 2013", amending RA No. 7875 and RA No. 9241; RA No. 11036 otherwise known as “Mental Health Act of 2017"; RA No, 4136 entitled: “An Act to Compile the Laws Relative to Land Transportation and Traffic Rules, to create a Land Transportation Commission and For Other Purposes”: RA No. 6713, otherwise known as “An Act Establishing a Code of ‘Conduct and Ethical Standards for Public Officials and Employees”; RA No. 9710 otherwise known as “Magna Carta of Women"; Civil Service Commission Memorandum Circular (MC) No. 12 Series of 1994 Section 2.3 dated March 10, 1994, with subject: “Physical and Mental Unfitness"; and PNP MC No. 2011-011 dated April 1, 2011 otherwise known as: “Expanded Reimbursement of Hospitalization Expenses of PNP Personnel in the Active Service.” 2. RATIONALE: This Memorandum Circular (MC) prescribes the revised specific guidelines and proced jures to be undertaken by concerned offices/units for the just, reasonable, and prompt adjudication of claims for reimbursement of hospitalization expenses of active Philippine National Police (PNP) personnel arising from service-connected illnesses and injuries. This MC also prescribes the additional benefits for female PNP personnel. 3. SITUATION: ‘The PNP General Hospital (PNPGH) is the only PNP Level I! hospital that caters to the hospitalization needs of PNP personnel and their dependents. However, the medical facilities in Police Regional Offices (PROs) have limited capabilities Page 1 of 16PNP MC No. 2011-011 dated April 1, 2011 otherwise known as: “Expanded Reimbursement of Hospitalization Expenses of PNP Personnel in the Active Service needs updating to address the following identified issues and concems: ‘a. PNP personnel in areas without PNP-accredited hospitals cannot avail reimbursement for non-emergency cases, b. Clear guidelines on injuries that arise from mental health issues such as depression ¢ Guidelines on reimbursement in case of pregnancy, and d. Unreasonable delay in the release/long processing of claims for reimbursement. To create equal opportunity and to improve its processing procedures in order to hasten the release of claims, there is a need to review the PNP's existing guidelines and create more responsive policies that will help ease the burden of PNP personnel applying for claims. 4. PURPOSE: This MC aims to uplift the morale and welfare of active PNP personnel who were hospitalized due to diseaseiiliness/injury/pregnancy during his/her active duty by expanding the Reimbursement of Hospitalization Expenses (RHE) coverage simplifying reimbursement requirements, and streamlining the processes of RHE claims to speed up adjudication. 5. DEFINITION OF TERMS a. Active PNP personnel — shall mean the Uniformed and Non-Uniformed Personnel of the PNP from the day of oath-taking excluding those on absence without official leave (AWOL), automatic leave of absence without pay due to detention and those who are suffering from administrative disabilities including but not limited to suspensions restrictions to specified limits, withholding of privileges and other similar disabilities b. Attendance - medical service rendered to a patient including professional service (consultation and physical examination), treatment nursing care, radiologic examination, laboratory workups and other procedures and dispensing of medicines and medical supplies provided when confined/admitted at hospital. Compensable condition under RHE c. Catastrophic Case - disease or injury acquired during active PNP service that involves highly specialized life-support care of an actively ill or severely traumatized patient and/or severe illness and or malignancy requiring prolonged hospitalization or recovery or may incapacitate personnel from working d. Emergency - sudden onset of a medicalisurgical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) Page 2 of 16such that the absence of immediate medical/surgical attention could reasonably be expected to result in placing the patient's health in serious jeopardy and serious impairment to bodily functions Intensive Care — refers to confinement requiring services in an Intensive Care Unit (ICU) such as respiratory and monitoring support cardiac/hemodynamic monitoring and maintenance and other similar cases Line of Duty — Disease, injury or illness that was caused while in the performance of official duty or occasioned by a fortuitous event, force majeure, or any other act of a third party without fault or negligence attributable to the personnel. Provided, that, where the disease, injury or illness was due to the personnel’'s own act, the latter must not be selt: inflicted or caused by his/her gross negligence, alcoholism, rug addiction, or abuse of authority. Provided, further, that the phrase “ine of duty” shall include going to and coming from his/her office or while on leave or on administrative mission. Provided, finally, that any doubt as to whether or not the disease, injury or illness of the personnel is in the line of duty or by reason of his/her office or position shall be decided in his/her favor Maximum Hospitalization Benefits - period of hospitalization ends when the patient's 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 MC, such hospitalization benefit shall not exceed one year of continuous confinement in one or more hospitals. Medical Case — diseaseiiliness acquired during active PNP service that does not necessitate any surgical procedure and does not involve highly specialized life support care. Medical Devices - for the purpose of this MC is defined as devices that usually sustain or support life, are implanted to prevent a potential unreasonable risk of illness or injury Police Operations Casualty ~ refers to any PNP personnel who is either killed (KIPO), wounded (WIPO), or injured 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. Page 3 of 165) Arrest of criminal offenders, bringing them to justice/courts and assisting in their prosecution; 6) Conduct of 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. k. Surgical Case ~ disease/injury acquired during active PNP service that necessitates a patient to undergo a surgical procedure or series of surgeries to include obstetric and gynecologic surgical procedures (emergency or elective). Trauma to any parts of the body shall be considered under this category 6. GUIDELINES: a General Guidelines: 1) Application for RHE must be filed by the PNP personnel or in case of incapacity, his/her duly authorized representative and must be submitted to RHE Section, Health Service (HS)/Regional Health Service (RHS); 2) RHE must be filed within ninety working days reckoned from the time of discharge; 3) All PNP personnel assigned at NHQ may file their RHE claims at RHE Section of the PNPGH 4) PNP personnel assigned at PROs and in Regional Support Units (RSUs) may file their claims at RHE Section of their respective RHS. 5) Folders with incomplete documentary requirements will be received by the Secretariat, and the claimant shall be given 30 days to comply from date of notice unless a longer period is justified as determined by the Board; 6) PhilHealth and other Health Maintenance Organizations (HMOs) coverage shall be deducted in the statement of account prior to RHE claim; 7) The period covered for maximum reimbursable hospital expenses is six months reckoned from the time it is incurred regardless of whether oF not the personnel concerned has been separated from the service or whether the injury or sickness has been cured or not; 8) Any personne! who are physically or mentally incapacitated for 365 days due to frequent confinement for medical/surgical treatment andlor recoveryirecuperation shall be evaluated for fitness to remain in PNP service. Any physical and/or mental impairment, which Page 4 of 16renders the patient incapable of performing duties (P4), and the illness/injury ts expected to be long, continuous and of indefinite duration are grounds for recommendation for retirement and/or separation from the active service through Total Permanent Physical Disability (TPPD) b. Scope and Coverage: Benefits derived thereof shall include the hospitalization expenses for injuries and/or illnesses incurred in line of duty of 1) All active PNP personnel confined/admitted at the PNPGH and/or PNP Medical Facility who underwent diagnostics/procedures not available at PNPGH: 2) All active PNP personnel confined/admitted for emergency medical/surgical cases in government/private hospitals provided that the patient is immediately evacuated to PNPGH/PNP Medical Facility as soon as the condition permits; 3) All active PNP personnel confined/admitted as non-emergency case in private and/or government hospitals under the following circumstances: a) In case there is no PNP Hospital/Medical Facility within a reasonable distance; and b) In case that there is a nearby PNP Hospital/Medical Facility, but the management of the patient is not within its capability In both circumstances, the concerned PNPGH Medical Officer or Chief, Medical Dispensary shall issue a certification to that effect. 4) All active PNP personnel confined/admitted in any government hospital arising from mental health issues. c Additional Benefits Alll active female PNP personnel confined/admitted in any private and/or government hospital due to pregnancy are entitled to not more than three claims for Normal Spontaneous Delivery or Caesarean Section reimbursement package. d Grounds for Denial of Claims: 1) Those personnel who are suffering from administrative disabilities at the time the condition is incurred or contracted including but not limited to suspensions, restrictions to specified limits, withholding of privileges and other similar disabilities, 2) When injuries/ilinesses were incurred or contracted during his absence without authority from his assigned place of duty Page 5 of 163) 4) 5) 6) 7) 8) Failure to meet/submit the documentary requirements within 90 working days (reckoned from the date of discharge from confinement); ‘Supporting documents attached to the application/claim are false, incorrect, altered, and/or tampered with; RHE claims shall be denied when expenses incurred in any hospital by patient due to injury and/or sickness are occasioned by any of the following a) Intoxication or drunkenness or various immoral habits or intemperate use of regulated or prohibited drugs: b) Unlawful aggression or provocation on the part of the claimant ©) Sustained as a result of the personnel’s abuse of authority misconduct, willful disobedience, or gross negligence; or 4d) Absolute indication of lifestyle abuse and failure to modify after repeated warning by health authorities. Previous Annual Physical Examination (APE) records may form part of the documentary evidence RHE claims on the following shall be denied or excluded: a) If drugs prescribed and dispensed and other procedures do not conform or apply to the diagnosis (nature of iliness) as determined/reviewed by the C, Medical Dispensary for PROs and RSUs and C, RHE Section for NHQ; b) Ifreceipts submitted cover non-medical items such as bath soaps, toiletries, perfumes, and the like to include medical aide equipment such as wheelchair, nebulizer, suction machine, and ‘similar items; ) If receipts include purchase of other services such as hiring special nurse, nurse aide and/or caregivers, or d) If dates of receipts for purchase of medicines, medical supplies. and other medical services rendered do not conform to the inclusive dates of confinement. In case of illness andlor injury caused by a 3% party (1* party claimant, 2 party the PNP) with intent to cause harm or due to negligence, the claimant shall be advised to exhaust all means for claims for hospitalization from the 3" party or those liable to answer for his iliness and/or injury. The PNP is not liable for damages caused by 3" parties; In case the patient has availed himself of the services of an HMO, the PNP will reimburse part/portion of the hospital expenses not paid Page 6 of 16for by the particular HMO, provided such expenses do not exceed the limits set by this MC and that professional fees for doctors and other services fall within the set limits and that instances of excessive compensation be eliminated; and 9) Violation of traffic rules and regulations such as but not limited to the following, as provided for under RA No. 4136 a) Driving without license b) Driving without helmet; ©) Driving without wearing seatbelt d) Driving under the influence of alcoholiillegal drugs e) Careless driving, f) Driving without valid vehicle registration: Q) Driving an illegally modified vehicle: fh) Running a nght-hand car, i) Driving a car without proper/authorized devices, equipment. accessories, or car part, ) Operating a car with an improper attachmentunauthorized motor vehicle license plate, and k) Other related LTO violations, © Maximum Hospitalization Benefits: Claims for RHE shall be categorized into the following a) Police Operations Casualty Case - Claims shall be reimbursed in full, b) Catastrophic Case - maximum reimbursable amount shall be Three Hundred Fifty Thousand Pesos (PhP350,000.00) c) Surgical - maximum reimbursable amount shall be One Hundred Thousand Pesos (PhP 100,000.00) d) Medical Case - maximum reimbursable amount shali be Sixty Thousand Pesos (PhP60,000.00) 1 Authorized Rates: Following authorized rates shall be applied to set ceiling and take full advantage of the maximum reimbursable amount Page 7 of 16Room and Board " not exceeding PhP 1,500.00/day i ~~ subject to prevailing rate of the hospital IntensivelCritical Care ang shall be limited until patient's crisis Unit Admission is over Ha ‘Medical Case — not exceeding PhP350.00/day/doctor Catastrophic Case - not exceeding PhP750.00/day/doctor Professional Fees Surgical Case (a) Minor Surgery - not exceeding PhP10,000.00 (cumulative) (b) Major — not exceeding PhP60,000.00 (cumulative) Medicines, Medical Supplies, Ambulance Fee, Medical Devices, not exceeding PhP100,000.00 Impiants/Prosthesis and Equipment Laboratory and Ancillary Work- not exceeding PhP30,00.00 ups/Procedures Pregnancy Package (a) Normal Spontaneous Delivery = not exceeding PhP 10,000.00 (b) Caesarean Section — not exceeding PhP20,000.00 Additional Benefits for female PNP personnel 9. Creation and Function of the RHE Adjudication Board: 1) NHQ RHE Adjudication Board Deputy, PRM ‘Deputy Director, HS Jeputy, Directorate ef, PNP General Hospi Chief, Moral and Welfare Division, DPRM ‘Administrative Officer, DI Servicing Legal Officer, HS Member Chief, RHE Section, HS Secretariat 2) PRO RHE Adjudication Board Deputy Regional Director for Administration Chairman Chief, Regional Health Service Vice Chairman Page 6 of 16Chief Medical Dispensary. RHS ~ Chief RPRMD Chief, RCD Chief, RIDMD Chief, RLO “Chief Nurse, RHS 3) Functions of RHE Adjudication Board The Board shall review, verify and evaluate all matters pertaining to the claim and shall ascertain that the claim is within set guidelines, scope and coverage, and does not fall under the grounds for denial before recommending approval to designated approving authority NHQ RHE Adjudication Board shall adjudicate hospitalization claims of all PNP personnel assigned in National Headquarters and make recommendation based on its findings to the designated approving authority PRO RHE Adjudication Board shall adjudicate all hospitalization claims of PNP personnel assigned in the PROs to include personnel assigned at Regional Support Units and make recommendation based on its findings to the designated approving authority 4) Functions of RHE Secretariat RHE Secretariat shall receive and screen applications for RHE Claims and shall prepare presentation for the RHE Adjudication Board and prepare disbursement voucher before forwarding to DPRM for processing of funds h. Approving Authorities: RHE Board Resolution/Report must be signed by the approving authority within three working days after receipt TDCA aot adjudicated by the National Adjudication All claims adjudicated by the Regional Adjudication RD, PROS Board 7. PROCEDURE OF RHE CLAIMS: a, Documentary Requirements All documentary requirements must be accomplished by the claimant and unit prior to submission to HS/RHS RHE Section 1) To be prepared by the claimant. a) RHE Application Form; Page 9 of 15b) Clinical Abstract or Discharge Summary - Legible and shall include the complete medical history, course in the ward, final diagnosis to include the procedure/surgery done, if any, it shall also include the full name of the attending physician with affixed signature and his/her license number, c) Operative Technique and Histopathology Report ~ for those who underwent surgical procedures: 4) Statement of Account; e) Original Official Receipts; f) Photocopy of PNP ID: and 4g) Photocopy of Landbank ATM with clear account number. h) Investigation Report; 2) To be preparediprovided by Unit assignmentistation a) Sick Leave Order. b) Verification from PAIS; c) Cerificate of Non-payment from Finance Service; and d) Traffic Accident Report (to include photocopy of vehicle's OR/CR and Driver's license and other pertinent documents) - for vehicular accidents only 3) Incase of Death (additional documents to be processed by claimant). a) Certificate of Declared Legal Beneficiaries (PRBS) b) Photocopy of valid ID of Legal Beneficiary, c) Death Certificate; 4) Birth Certificate of claimants’ children; and e) Marriage Certificate Adjudication Proper 1) The Board shall convene every first Friday of the month or as deemed necessary by the Chairman. The Board shall review, verify and evaluate all matters pertaining to the claim before recommending approval. 2) Within five working days after Adjudication, 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 certifiedivalidated supporting documents, compilation sheet and recommendation c. Preparation of Disbursement Voucher and Release of Funds Upon the approval of approving authority, disbursement voucher shall then be prepared by the secretariat and forwarded to BFO, DPRM for processing of funding Disbursement Vouchers of claims adjudicated by NHQ Adjudication Board shall be signed by D, HS while claims adjudicated by PRO Adjudication Board shall be signed by RD, PROs. Page 10 of 169. FUNDING: The Directorate for Personnel and Records Management (DPRM) and Directorate for Comptrollership (DC) shall program the funds to support the reimbursement of hospitalization expenses under this MC. 10. PENAL CLAUSE: The following shall be held administratively liable without prejudice to the filing of a criminal case on any court, tribunal or quasi-judicial bodies: a. Any PNP personnel or his representative who, for the purpose of securing entitlement to any benefit or payment under this MC commit fraud, collusion, falsification, misrepresentation, influence or pressure or cause any other kind of anomaly shall be. subject to criminal and administrative action as deemed appropriate by the investigating body b. The Board or any of its member who cause unreasonable delay or fails, to act without justifiable reason on any claim for RHE submitted for investigation and adjudication, and c. After compliance with the substantive and procedural due process, any act such as but not limited to the following will constitute violation of this wc. 1) Refusal to accept application and/or request within the prescribed period or any document being submitted by a client, 2) Failure to act on an application and/or request or failure to refer back to the client a request, which cannot be acted upon due to lack of requirements within the prescribed period, 3) Failure to attend to clients who are within the premises of the office or agency concerned prior to the end of official working hours and during lunch break; 4) Failure to render frontline services within the prescribed period on any application and/or request without due cause: 5) Failure to give the client a written notice on the disapproval of an application or request, 6) Imposition of additional irrelevant requirements other than those listed in the first notice; and 7) Fixing and/or collusion with fixers in consideration of economic and/or other gain or advantage shall be ground for dismissal and Perpetual disqualification from police service Page 11 of 1611. RESCISSION: All MCs contrary or in direct conflict with this MC are hereby rescinded/ nullified upon approval 12. EFFECTIVITY: This MC shall take effect 15 days from filing of a copy hereof at the University of the Philippines Law Center in consonance with Section 3 and 4 of Chapter 2, Book Vil of Executive Order No. 292, otherwise known as “The Revised Administrative Code of 1997,” as amended 4 ‘lice General Chief, PNP, Distribution, Command Group CPN un 3005493, Data MLA A P-Staff 5085493 D.NSUs RD, PROs wav 6 21 SPAto the SILG Page 12 of 16ANNEX “A”: Tab A Tab Tab Tab Tab Tab Tab Tab Tab | Tab J Tab K mramnmoowo DOCUMENTARY REQUIREMENTS RHE Application Form and Computation Sheet Clinical Abstract or Discharge Summary Operative Technique and Histopathology Report Statement of Account Original Official Receipts Photocopy of PNP ID Photocopy of Landbank ATM Sick Leave Order from Unit Verification from PAIS from Unit Certificate of Non-payment Investigation Report from Unit ADDITIONAL REQUIREMENTS IF NECESSARY Tab L Tab M Tab N Tab O Tab P Tab Q Tab R Traffic Accident Report Photocopy of Driver's License and OR/CR Certificate of Declared Legal Beneficiaries Photocopy of valid ID of Legal Beneficiary Death Certificate Birth Certificate of claimants’ children Marriage Certificate Page 13 of 16RHE APPLICATION FORM and CHECKLIST Republic of the Philippines NATIONAL POLICE COMMISSION PHILIPPINE NATIONAL POLICE HEALTH SERVICE Camp 8Gen Rafael T Crame Quezon City REIMBURSEMENT OF HOSPITALIZATION EXPENSES APPLICATION FORM NAME __ BADGE No ADDRESS: PNP ION. CONTACT No LBP Acct. NO UNIT ASSIGNMENT esses taeisecne IMMEDIATE SUPERIOR: Contacto | DATE OF ADMISSION No. of Daye DATE OF DISCHARGE NAME OF HOSPITAL: Contact No. NAME OF DOCTOR: Contact No DIAGNOSIS PROCEDURE RHE Application Form Ciinical Abstract or Discharge Summary Operative Technique and Histopathology Report Statement of Account Original Official Receipts Photocopy of PNP ID Photocopy of Landbank ATM Sick Leave Order from Unit Verification from PAIS trom Unit Certificate of Non-payment trom Finance Service Investigation Report from Unit Tratfic Accident Report Photocopy of Diver's License and ORICR Certificate of Declared Legal Beneficiaries (PRES) Photocopy of valid ID of Legal Beneficiary, Death Certificate Birth Certifcate of claimants’ children Marriage Certifcate Checked and Received by’ [|| RHE SECRETARIAT DATE: Page 14 of 16ANNEX “C”: COMPUTATION SHEET WwioL HLWAHTINd SS37 Town ssa vio ans: I ‘wlieyoea U0RTES UeaIESeOD | eye BNC TRULON Tpulosied atid ere) 10) SveveR ELON |) senpeoaigisén-non Keay pue Koo] 6 audinby pue swousoig/sUEGUI| 8 | seoveqieompen| Z aang 9] uF Pee ee niin T see KaBing sole | Taabing vOut | 356 SABOASEIED | (2820 FEORON | $984 (@UOISSOHPIg) 1 UosSiIpY TON 878 ROMO /ANSVALI] _Z [ (pieog pue wou) (va) NnoWy Sava | Sidi303u/vOS sraisunamigy | WOL8NS | 40'ON| NOANnOWY | 24VEGRZOHLAV swall (AONYNDSYd =| TvoIGaW | YONI ‘WNIGRW 'YOrWW - TVOIDUNS | OIHdONLSYLVD | 90d ) :ANOUaLWO| SLNAWANIJNOO 4O SAVO Se NO STOO "3OUVHOSIG 4O 3Lva a PEErEL SE Eee ree a en HINBWANIINOO 40 aLva Se vl Page 15 of 16ANNEX “D”: PROCESS FLOW OF RHE CLAIMS ADNDKATETO | EXTEND GRACE | “SopAysTO COMPLY Jp councte> PERIOD OR TO DENY | "APPROVING AUTHORITY (trauma ys tam cap _— [RHE SECRETARIAT, HS ‘TOPRWRPRMD zh eee ene Tarmuririn) [>| WFORMPERSOIEL | [ane secreranar, s tcp econo ae 35d fue) BFO, DPRM. pocesonged DV fr 3S doe) FISCAL DIMSION, DC _ trees ot es 51 ey) | ‘RFSO LANDBANK. [anon] PNP PERSONNEL PNP PERSONNEL Page 16 of 16| HA UIE UH orcs 054395soon vomy penny” pana Pepa. —anasae, soured paunedsiey owes wonry smn sonevonc ut onewnee in oneronwert Buidy on vous on wrong on uno on «a0 ow nao suede ror zssor 990 202 was, awa. ivy NOP ‘aM Wes 4¥SSaN OIA IOVS: 53 O1G¥H 35¥S5IN OIG F040 day 22u¥4 NWT Wa A) S35N3EKI Woz NOIIYZINwuldSOH1 40 JROMSENBRNDH {INAS ANLIDW 3 ME TANNOSRA <2Ns 30 SLUSNIWiNdSOH 3HL0 ONY '535N3@X3 NOWWZHTVAldSOM 03193NNOI zoo “35195 40 INZMSHNBMBY IHL 0c SNIPRIANOD SiN CAVA NO DW aN nea 200 afans, ons owsie ons ons on vida wituo) \o9r801 apooueg room oer >po>09 Nano savas arsus 01s 195915