Cops and firemen sue HMO for stopping health services

MANILA, Philippines — A savings and loans association set up by policemen, firemen and their families have filed complaints against their health maintenance organization (HMO) with the Department of Health, Securities and Exchange Commission and the Quezon City regional trial court.

The Public Safety Savings and Loans Association Inc., through its lawyer Roland Cruz, said the complaints were filed against Medocare Health Systems Inc. (Medocare) for allegedly failing to comply with its obligation to provide continued health care services to PSSLAI members.

In a statement, Cruz said the complaints filed against Medocare last month were for misrepresentation, fraud and betrayal of public trust for its alleged refusal to comply with its obligation to provide continued health care services to more than 1,000 PSSLAI members in good standing who have been carrying HMO cards issued by Medocare.

The association’s court case also seeks moral and exemplary damages. The complaints before the DOH and the SEC, on the other hand, seek the suspension of the accreditation and license to operate of Medocare.

In the complaints, PSSLAI claimed that it entered into a Corporate Health Care Program Contract with Medocare covering delivery of dental, preventive, diagnostic and treatment services, annual physical examination, medical emergency care, out-patient and in-patient hospital access to PSSLAI member-account holders.

However, Cruz said that last July 31, Medocare ceased to provide HMO services claiming that the effectivity of the contract was only one year or from Aug. 1, 2014 until July 31, 2015.

“Without formal notice to the PSSLAI and its members, Medocare stopped honoring its own cards even though they indicate validity dates beyond July 31, 2015,” Cruz said.

Cruz said PSSLAI members from the Philippine National Police who enrolled late with Medocare, filed membership applications and paid premium payments after Aug. 1, 2014 or beyond the start of the effective date of coverage under the contract were issued HMO cards with validity dates beyond July 31, 2015.

PSSLAI also alleged that a total of 1,130 applications from late enrolees were accepted by Medocare in October 2014 to July 2015 with total premium payments amount of P8,530,700. Medocare allegedly served no formal notice of termination upon PSSLAI.

Cruz said that due to the numerous complaints from its members, PSSLAI was compelled to refund the unutilized portions of health care program coverage under the contract.

As of Oct. 16, 2015, PSSLAI has reportedly refunded a total amount of P670,817.85 to 92 affected members. There were also more members seeking refund of their premiums.

According to Cruz, PSSLAI is seeking actual damages against Medocare with the QCRTC, stating in its first cause of action that Medocare was estopped from denying outright health care services under the contract since it accepted and made use of the premium / membership payments even after the start of the effectivity date of the contract.

Medocare has yet to answer the PSSLAI’s allegations.

PSSLAI is an entity registered under Republic Act No. 8367 or the Revised Non-Stock Savings and Loan Association Act of 1997. The association, established in 2003, is composed mostly of members from the PNP, Bureau of Fire Protection and various private security agencies. Among its primary mandates is to encourage frugality and the judicious credit among its members.

The DOH’s Bureau of Health Facilities and Services primarily regulates the operation of HMOs in the Philippines.

An HMO is a business entity that arranges for prepaid health care services for their members by contracting with hospitals, physicians and other health professionals. BHFS data show there are 22 accredited and licensed HMOs operating in the country.  SFM