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Hospitals group decries PhilHealth’s ‘arbitrary denial’ of claims amounting to P13.8B

The Philippine Hospital Association Inc. (PHA) on Tuesday slammed the Philippine Health Insurance Corp. (PhilHealth) for its alleged “arbitrary denial” of billions of pesos worth of benefits claims, which are already hurting the finances of hospitals.

During the virtual hearing of the House committee on health, PHA president Dr. Jaime Almora said the private hospitals have P86,079,590,987.21 worth of claims to PhilHealth from January 2020 to June 2021, of which about P26 billion are still being processed while P46.6 billion were returned to hospitals and around P13.8 billion were denied.

With this, Almora said, “arbitrary denial of payment, resulting in losses to hospitals is not only unlawful but also morally wrong.”

“If we look at the denied claims alone, there is P13,800,958,485 comprising 619,956 claims,” he said.

“It would translate like P13,800,958 per hospital that was not paid, that was denied to the hospital. That would be translated to improvement of the hospital,” he added.

For his part, Private Hospitals Association of the Philippines Inc. (PHAPI) board member Dr. Gerry Gonzales said the group has the same problems as PHA.

“Weekly we even look at our expenses if we can pay the salaries of our health workers. We hope we resolve these issues in private hospitals,” Gonzales said.

A representative from PhilHealth said the state insurer found that there were abuses in the hospitals claiming probable cases “that’s why we take it to be removed or modified the probable cases.”

Bayan Muna Representative Carlos Zarate said that “it is true that profiteering is a motive of some but it is not an excuse.”

The problem on denied hospital claims arises from the PhilHealth’s Circular No. 2021-0008, issued in June, which provides clarification on the coverage for COVID-19 inpatient benefit package.

Under the circular, patients who are probable COVID-19 cases but eventually had negative RT-PCR test results are covered by Intermediate Package which amounts to P18,000 for moderate pneumonia and P38,000 for severe or critical pneumonia.

The latest circular is retroactive, meaning it applies to patients admitted in hospital starting November 26, 2020.

The PhilHealth Circular No. 2021-0008 clarifies the Circular No. 2020-0009, which earlier provided coverage for patients confined as probable or confirmed cases of COVID-19.

The Circular 2020-0009 provides a P43,997 coverage for mild pneumonia, P143,267 for moderate pneumonia, P333,519 for severe pneumonia, and P786,384 for critical pneumonia regardless if the patient is probable or confirmed COVID-19 case.

With this, PhilHealth president Dante Gierran said, “I would certainly recommend to the board, being the highest authority in the corporation, to have this matter be taken into consideration for favorable actions.”


During the hearing, PhilHealth admitted that there was delay in the retroactivity of its circular on COVID-19 benefit packages.

Attorney Eli Dino Santos of PhilHealth admitted that they were at fault over the delay.

"I admit, it cannot be denied that there is delay in this. There's so many reasons and we will not provide excuses. It's just that there were several circumstances that went beyond our control. It's already late when the circular was published," Santos said.—AOL, GMA News