REPUBLIC ACT NO. 4226

REPUBLIC ACT NO. 4226 - AN ACT REQUIRING THE LICENSURE OF ALL HOSPITALS IN THE PHILIPPINES AND AUTHORIZING THE BUREAU OF MEDICAL SERVICES TO

SERVE AS THE LICENSING AGENCY  

Section 1.    This Act shall also be known as the Hospital Licensure Act. 

Sec. 2.    Definitions. — As used in this Act — 

(a)    'Hospital' means a place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment and care of individuals suffering from illness, disease, injury or deformity, or in need of obstetrical or other medical and nursing care. The term 'hospital shall also be construed as any institution, building or place where there are installed beds, or cribs, or bassinets for twenty-four-hour use or longer by patients in the treatment of diseases, diseased-conditions, injuries, deformities, or abnormal physical and mental states, maternity cases, and all institutions such as those for convalescence, sanitarial or sanitarial care, infirmities, nurseries, dispensaries and such other names by which they may designated. 

(b)    'Government hospital' means a hospital operated and maintained either partially or wholly by the national, provincial, municipal or city government or other political subdivision, or by any department, division, board or other agency thereof. 

(c)    'Private hospital' means one which is privately owned, established and operated with funds raised or contributed through donations, or by private capital or other means, by private individuals, association, corporation, religious organization, firm, company or joint stock association.

(d)    'Clinic' means a place in which patients avail of medical consultations or treatments on an out-patient basis. However, any clinic or dispensary where there is at least six beds or cribs or bassinets installed for twenty-four-hour use by patients shall be construed to fall within the definition of a hospital as described in this Act. 

(e)    'Licensee' is the person or persons granted a license to operate and maintain a hospital according to an approved minimum standard. 

Sec. 3.    Construction Permit. — No hospital, government or private, shall be constructed unless plans have been approved and construction permit issued by the licensing agency as defined in this Act. 

Sec. 4.    Registration and license. — No hospital shall operate or be opened to the public unless it shall have been registered and a license for its operation obtained from the licensing agency provided in this Act. 

Sec. 5.    Licensing Agency. — For purposes of setting standards in hospital construction and operation, the Bureau of Medical Services in addition to its present duties shall act as

the licensing agency. The Secretary of Health shall reorganize this Bureau to include a staff of hospital architects, hospital administrators, sanitary engineers and such personnel as may be necessary to carry out the purposes of this Act without necessarily increasing the present personnel strength of this Bureau. 

Sec. 6.    Powers and duties of the licensing agency. — The Bureau of Medical Services, or the licensing agency shall have the following powers and duties: 

a.    To conduct an ocular survey of all existing hospitals in the Philippines, government or private, with a view to determine their fitness to operate considering their facilities and physical plant. 

b.    To prescribe standard plans for government hospital plants in consultation with the Division of Architecture, Bureau of Public Works. 

c.    To approve plans for hospital plants, government or private, and to issue permits or authority to construct hospitals in accordance with the provisions of this Act. 

d.    To keep a permanent register of approved hospitals or those issued licenses to operate indicating the name of the hospital, address or location, type of hospital, name of the director or administrator, ownership, number of authorized beds and bassinets and such other pertinent data as may be necessary.

e.    To grant licenses for the operation and maintenance of hospitals or revoke the same in accordance with the provisions of this Act. 

f.    To make periodic inspection of all hospitals so as to check compliance with rules and regulations legally promulgated or with the provisions of this Act and to make recommendations to directors or administrators of hospitals for the correction of defects found during such inspections. 

g.    To publish yearly a list of all approved hospitals indicating the name, location, type, authorized beds, and name of the director or administrator. 

h.    To submit yearly reports to the Secretary of Health, the Speaker of the House of Representatives, the President of the Senate and the chairmen and members of the Committees on Health of both Houses of Congress, such reports to include a list of approved hospitals indicating the name of the hospital, location, bed capacity and name of the director or administrator and make recommendations on hospital needs or requirements for hospital service in certain communities that do not enjoy such hospital services. 

Sec. 7.    Filing of Application for Construction Permit. — Application for a permit to construct a hospital shall be submitted to the Office of the Director, Bureau of Medical Services in a form prescribed by the latter and accompanied by a plan of the hospital plant proposed to be constructed. The application shall state the name of the hospital, ownership, number of beds proposed to be operated, location and type of hospital to be constructed. 

Sec. 8.    Minimum Standards of Construction. — In order that a permit to construct a hospital can be issued the hospital plan shall provide sufficient bed space for the hospital bed capacity proposed, a laboratory room, an operating room, including work rooms for

sterilization, anesthesia preparation, etc., an X-ray or radiology room, pharmacy, dispensary or out-patient department, delivery room, isolation rooms, autopsy room or morgue, sufficient quarters for residents, nurses, attendants and helpers and sufficient number of toilet facilities. 

Wards shall be constructed such that segregation of the sexes is observed and as far as practicable classified as to the type of cases to be confined. 

Sec. 9.    Application for Registration and Issuance of License. — Application for registration of a hospital and for the issuance of a license for its operation and maintenance shall be filed with the Bureau of Medical Services on a form prescribed by it. Registration may be made and license issued upon compliance with the provisions of Section eight hereof and the rules and regulations prescribed by the licensing agency pursuant to the provisions of this Act. 

SECTION 10.    Inspection. — Permit to construct a hospital or a major portion thereof and license to operate and maintain the same shall be issued by the licensing agency only after a representative of the licensing agency has conducted an ocular inspection and certified that the applicant has satisfactorily complied with requisites prescribed in this Act. The license to operate and maintain a hospital shall be renewed every year upon payment of the prescribed fees. 

SECTION 11.    Revocation of License. — The licensing agency may suspend or revoke a license already issued for any of the following grounds: (a) repeated violation by the licensee of any provision of this Act or of any other existing law; (b) repeated violation of rules and regulations prescribed in the implementation of this Act; or (c) repeated failure to make necessary corrections or adjustments required by the licensing agency in the improvement of facilities and services. 

SECTION 12.    Hearing. — Any person, association, corporation, or any other private entity who has been refused a license to operate and maintain a hospital or whose license for such hospital has been suspended or revoked shall be entitled to an administrative hearing to be conducted by the Secretary of Health and his two undersecretaries to determine the justifiability of such denial, suspension or revocation of the license: provided, that the licensee may resort to the courts, as in other cases provided by law. 

SECTION 13.    Separate Licenses Required. — Separate licenses shall be required for hospitals or branches thereof maintained in separate premises, even though they are operated under the same management: provided, however, that separate licenses shall not be required for separate buildings in the same compound: provided, further, that permits for construction or alteration of buildings within the same compound shall also be secured from the licensing agency to determine compliance with standards and requirements herein authorized. 

SECTION 14.    License not transferable. — License for the operation of hospitals shall not be transferable. The licensing agency shall be notified of any change in ownership, change of name of the hospital, and transfer of location and in the latter case, an application for a new license should be submitted. 

SECTION 15.    Rules and Regulations. — The Bureau of Medical Services acting as a licensing agency and subject to the approval of the Secretary of Health, shall promulgate

rules and regulations to implement the provisions of this Act. 

SECTION 16.    Classification of Hospitals. — The licensing agency shall study and adopt a system of classifying hospitals in the Philippines as to: (1) general or special; (2) hospital services capabilities; (3) size or bed capacity and (4) class of hospital whether training or not.

SECTION 17.    Fees. — Each applicant for a permit to construct a hospital shall pay the amount of five pesos as permit fee. A registration fee of five pesos and an annual license fee of ten pesos shall likewise be collected for each hospital and for each approved license: provided, that a government hospital shall be exempt from the payment of such fees. The amount herein collected shall be officially receipted by the licensing agency and shall constitute as a revolving fund for the use of the licensing agency. 

SECTION 18.    Penalties. — Any person, partnership, association, or corporation who establishes, operates, conducts, manages or maintains a hospital or hospital clinic within the meaning of this Act without first obtaining a license as provided for in this Act or violates any provision hereof shall be guilty of a misdemeanor, and upon conviction thereof shall be liable to a fine of not more than five hundred pesos for the first offense and not more than one thousand pesos for each subsequent offense, and each day that the hospital shall operate after the first conviction shall be considered a subsequent offense. 

SECTION 19.    Repeal. — Any law or laws or parts thereof inconsistent with the provisions of this Act are hereby repealed. 

Sec. 20.    Effectivity. — This Act shall take effect upon its approval. 

Approved: June 19, 1965

EO 292 – The Revised Administrative Code

Title IX

HEALTH

CHAPTER 1GENERAL PROVISIONS

Section 1. Declaration of Policy. - The State shall protect and promote the right to health of the people and instill health consciousness among them; adopt an integrated and comprehensive approach to health development, with priority for the underprivileged sick, elderly, disabled, women and children; endeavor to make essential goods, health and other social services available to all the people at affordable cost; establish and maintain an

effective food and drug regulatory system; and undertake appropriate health manpower development and research, responsive to the country's health needs and problems.

Section 2. Mandate. - The Department shall be primarily responsible for the formulation, planning, implementation, and coordination of policies and programs in the field of health. The primary function of the Department is the promotion, protection, preservation or restoration of the health of the people through the provision and delivery of health services and through the regulation and encouragement of providers of health goods and services.

Section 3. Powers and Functions. - The Department shall:

(1) Define the national health policy and formulate and implement a national health plan within the framework of the government's general policies and plans, and present proposals to appropriate authorities on national issues which have health implications;

(2) Provide for health programs, services, facilities and other requirements as may be needed, subject to availability of funds and administrative rules and regulations;

(3) Coordinate or collaborate with, and assist local communities, agencies and interested groups including international organizations in activities related to health;

(4) Administer all laws, rules and regulations in the field of health, including quarantine laws and food and drug safety laws;

(5) Collect, analyze and disseminate statistical and other relevant information on the country's health situation, and require the reporting of such information from appropriate sources;

(6) Propagate health information and educate the population on important health, medical and environmental matters which have health implications;

(7) Undertake health and medical research and conduct training in support of its priorities, programs and activities;

(8) Regulate the operation of and issue licenses and permits to government and private hospitals, clinics and dispensaries, laboratories, blood banks, drugstores and such other establishments which by the nature of their functions are required to be regulated by the Department;

(9) Issue orders and regulations concerning the implementation of established health policies; and

(10) Perform such other functions as may be provided by law.

Section 4. Organizational Structure. - The Department shall consist of the Department Proper, National Health Facilities, Regional Offices, Provincial Health Offices, District Health Offices and Local Health Agencies.

CHAPTER 2DEPARTMENT PROPER

Section 5. Department Proper. - The Department Proper shall be composed of the Office of the Secretary, the Office for Management Services, the Office for Public Health Services, the Office for Hospital and Facilities Services, the Office for Standards and Regulations, and the Executive Committee for National Field Operations.

Section 6. Office of the Secretary. - The Office of the Secretary shall be composed of the Secretary of Health and his immediate staff; the undersecretary acting as Chief of Staff in the Office of the Secretary; the Assistant Secretary for Legal Affairs; the Assistant Secretary for Financial, Operations and Front Line Services Audit; and the Staff Services for the Secretary.

Section 7. Duties of the Undersecretary Acting as Chief of Staff . - The Undersecretary acting as Chief of Staff in the Office of the secretary, shall supervise the Assistant Secretary for Legal Affairs, the Assistant Secretary for Financial Operations, and Front Line Services Audit, and the Staff Support Services to the Secretary; and head the secretariat of the Executive Committee for National Field Operations.

Section 8. Duties of the Assistant Secretary for Legal Affairs. - The Assistant Secretary for Legal Affairs shall head the office that shall provide the Secretary with legal advice on all policy, program and operational matters of the Department; act as Counsel for the Department in cases in which it is a party; handle administrative cases against Department personnel and submit recommendations pertaining thereto; and review legislative proposals.

Section 9. Duties of the Assistant Secretary for Financial Operation. - The Assistant Secretary for Financial Operations, and Front Line Services Audit shall head the office that shall monitor the Department's financial affairs, internal operations, and the delivery of frontline services with a view to assuring the integrity of the Department's financial operations and the requirements of the Commission on Audit; optimizing the internal operating efficiency of the Department and its field offices; and ensuring that the Department's constituencies are provided front line services from the Department with the adequacy, quality, and efficiency that they are entitled to.

Section 10. The Staff Support Services. - The following Staff Support Services shall undertake such staff services intended to assist the Secretary in performing his functions;

(1) Community Health Service which shall provide services related to formulating and implementing plans and programs for coordinating with local governments and non-government organizations in health related activities, programs and projects;

(2) Public Information and Health Education Service which shall provide services related to formulating and implementing plans, programs, and projects for public education on health and for the timely and accurate public communication of Department policy on health issues;

(3) Health Intelligence Service which shall provide services related to the formulation of disease intelligence, assessment of the state of health of the country and development and maintenance of effective and comprehensive health information system to support planning and implementation of health programs;

(4) Internal Planning Service which shall provide the Department with necessary services related to planning, programming and project development;

(5) Foreign Assistance Coordination Service which shall provide staff services related to the development, coordination, monitoring, reporting and assessment of foreign assisted projects of the Department.

Section 11. Undersecretaries. - The Secretary shall be assisted by five (5) Undersecretaries who shall exercise the following functions;

(1) Advise the Secretary in the promulgation of Department orders, administrative orders and other issuances;

(2) Exercise supervision and control over the offices, services, operating units and individuals under their authority and responsibility;

(3) Recommend the promulgation of rules and regulations, consistent with Department policies, that will effectively implement the activities of operating units under their authority and responsibility;

(4) Coordinate the functions and activities of the units under their authority with that of the Undersecretaries and regional health directors;

(5) Exercise delegated authority on substantive and administrative matters related to the functions and activities of agencies under their office to the extent granted by the Secretary through administrative issuances;

(6) Perform such other functions as may be provided by law or appropriately assigned by the Secretary.

CHAPTER 3DEPARTMENT SERVICES

Section 12. Office for Management Services. - The Office for Management Services, headed by an Undersecretary who shall be supported by an Assistant Secretary, shall

include six (6) staff services involved in providing support services to the Department Proper, field offices and attached agencies, which are as follows:

(1) Financial Services which shall provide the Department with staff advice and assistance on accounting, budget and financial matters; supervise the coordinated preparation and implementation of annual and long term financial and work plan and budget estimates; conduct periodic department-wide performance and financial reviews; and design and implement improvements in financial management systems, procedures and practices;

(2) Management Advisory Service which shall provide staff advice and assistance on internal control and management system improvement, including management information systems; supervise the establishment of a management accounting system, control procedures and management information systems for improved decision-making;

(3) Health Manpower Development and Training Service which shall formulate plans, policies, standards and techniques for the effective and efficient manpower development and training of Department personnel; provide consultative, training and advisory services to implementing agencies; conduct studies and research related to health manpower development and training; and develop plans and programs for improved recruitment, deployment, development, and maintenance of personnel;

(4) Procurement and Logistics Service which shall undertake the central procurement of the health care products and supplies needed by the Department and its field offices which are not produced by or beyond the production capacity of its in-house production facilities; and ensure the proper, adequate and timely flow of health products and services to the Department's field offices;

(5) Biological Production Services which shall formulate plans, policies, programs, standards and techniques for the processing, manufacture, standardization, and improvement of biological products for Department use; manufacture vaccines, sera, anti-iodins, and other biologicals; provide consultative training and advisory services to implementing agencies; and conduct studies and research related to biological production, distribution and use;

(6) Administrative Service which shall provide the Department with efficient and effective services relating to personnel, records, collections, disbursements, security, custodial work, and other general services not covered by the preceding Services.

CHAPTER 4OFFICES AND BUREAUS

Section 13. Office for Public Health Services. - The Office for Public Health Services, headed by an Undersecretary, shall include ten (10) staff services involved in policy

formulation, standards development, programs development, and program monitoring of disease control and service delivery programs implemented by the field offices. The Undersecretary for Public Health Services, who shall be supported by an Assistant Secretary, shall supervise the following:

(1) Maternal and Child Health Services which shall formulate plans, policies, programs, standards and techniques relative to maternal and child health; provide consultative training and advisory services to implementing agencies; and conduct studies and research related to health services for mothers and children;

(2) Tuberculosis Control Service which shall formulate plans, policies, programs, standards and techniques relative to control morbidity and mortality from tuberculosis; provide consultative, training and advisory services to implementing agencies; and conduct studies and research related to tuberculosis;

(3) Family Planning Service which shall formulate plans, policies, programs, standards and techniques relative to family planning in the context of health and family welfare; provide consultative, training and advisory services to implementing agencies; and conduct studies and research related to family planning;

(4) Environmental Health Service which shall formulate plans, policies, programs, standards and techniques relative to environmental health and sanitation; provide consultative, training and advisory services to implementing agencies; and conduct studies and research related to environmental health;

(5) Nutrition Service which shall formulate plans, policies, programs, standards and techniques relative to nutrition services in the context of primary health care, provide consultative, training and advisory services to implementing agencies; and conduct studies and research related to Nutrition;

(6) Dental Health Service which shall formulate plans, policies, programs, standards and techniques relative to dental health services; provide consultative, training and advisory services to implementing agencies; and conduct studies and research related to dental services.

(7) Malaria Control Service which shall formulate plans, policies, programs, standards and techniques relative to the control of malaria; provide consultative, training and advisory services to implementing agencies; and conduct studies and research to malaria and its control;

(8) Schistosomiasis Control Service which shall formulate plans, policies, programs, standards and techniques relative to the control of schistosomiasis; provide consultative, training and advisory services to implementing agencies; and conduct studies and research related to schistosomiasis and its control;

(9) Communicable Disease Control Service which shall formulate plans, policies, programs, standards and techniques relative to the control of communicable

diseases, other than the major causes or mortality and morbidity, such as leprosy, sexually transmitted diseases, filariasis and others; provide consultative, training and advisory services to implementing agencies; and conduct studies and research related to these other communicable diseases;

(10) Non-communicable Disease Control Services which shall formulate plans, policies, programs, standards and techniques relative to the control of non-communicable diseases; provide consultative, training and advisory services to implementing agencies; and conduct studies and research related to mental illness, cardiovascular-diseases, cancer, other non-communicable diseases, and occupational health.

Section 14. Office for Hospital and Facilities Services. - The Office for Hospital and Facilities Services, headed by an Undersecretary who shall be supported by an Assistant Secretary, shall include four (4) staff services involved in policy formulation, standards development, program monitoring and provision of specialized assistance in the operations of hospitals and the management of facilities, which are as follows:

(1) Hospital Operations and Management Service which shall formulate and implement plans, programs, policies, standards and techniques related to management improvement and quality control of hospital operations; provide consultative, training and advisory services to field offices in relation to the supervision and management of hospital components; and conduct studies and research related to hospital operations and management;

(2) Radiation Health Service which shall formulate and implement plans, policies, programs, standards and techniques to ensure radiation health safety; provide consultative, monitoring, training and advisory services to private and government facilities with radiation-emitting apparatus; and conduct studies and research related to radiation health;

(3) Hospital Maintenance Service which shall formulate and implement plans, programs, policies, standards and techniques related to assuring the proper maintenance of Department equipment; provide consultative, training and advisory services to implementing agencies in relation to preservation, repair and maintenance of medical and non-medical equipment of the Department; and conduct studies and research related to equipment and facility maintenance;

(4) Health Infrastructure Service which shall formulate and implement plans, policies, programs, standards and techniques related to development and preservation of health infrastructure; provide consultative, training and advisory services to implementing agencies in relation to infrastructure projects to assure economical and efficient implementation; and conduct studies and research related to infrastructure development and utilization.

Section 15. Office for Standards and Regulations. - The Office for Standards and Regulations, headed by an Undersecretary and supported by an Assistant Secretary, shall include three (3) bureaus and one (1) national office that shall be responsible for the

formulation of regulatory policies and standards over the various areas of concern in the health sector, whose implementation shall be the general responsibility of the Department's regional field offices. The same bureaus shall also be responsible for those areas of activity covered by regulatory policy to provide the Secretary with current information on the status of these regulated areas of activity and to provide the Secretary with a basis for preliminary evaluation of the efficiency of the Department's field offices in performing their regulatory functions. The same bureaus shall conduct studies and research pertinent to their areas of responsibility . In certain instances the bureaus may also perform consultative, training and advisory services to the practitioners and institutions in the area of regulated activity. The same bureaus and national office are the following:

(1) Bureau of Research and Laboratories which shall develop and formulate plans, standards and policies for the establishment and accreditation and licensing of laboratories; blood banks and entities handling biological products, provide consultative, training and advisory services to public and private laboratories; and conduct studies and research related to laboratory procedures and operations;

(2) Bureau of Food and Drugs which shall act as the policy formulation and sector monitoring arm of the Secretary on matters pertaining to foods, drugs, traditional medicines, cosmetics and household products containing hazardous substances, and the formulation of rules, regulations and standards in accordance with Republic Act 3720 (1963), as amended by Executive Order No. 175, s. 1987, and other pertinent laws for their proper enforcement; prescribe general standards and guidelines with respect to the veracity of nutritional and medicinal claims in the advertisement of food, drugs and cosmetics in the various media, to monitor such advertisements; advise the Department's field offices to call upon any erring manufacturer, distributor, or advertiser to desist from such inaccurate or misleading nutritional or medicinal claims in their advertising; should such manufacturer, distributor, or advertiser refuse or fail to obey the desistance order issued by the Bureau, he shall be subject to the applicable penalties as may be prescribed by law and regulations; the Bureau shall provide consultative, training and advisory services to all agencies and organizations involved in food and drug manufacturing and distribution with respect to assuring safety and efficacy of food and drugs; conduct studies and research related to food and drug safety; maintain a corps of specially trained food and drugs inspectors for assignment to the various field offices of the Department; while these inspectors shall be under the technical supervision and guidance of the Bureau, they shall be under the administrative supervision of the head of the field office to which they shall be assigned, the latter being responsible for regulatory program implementation within the geographic area of his jurisdiction;

(3) Bureau of Licensing and Regulation which shall formulate policies and establish the standards for the licensing and regulation of hospitals, clinics and other health facilities; establish standards that shall be the basis of inspections and licensure procedures of the Department's field offices; and provide consultative, training and advisory services to field offices on the conduct of licensing and regulatory functions over hospitals, clinics and other health facilities.

(4) National Quarantine Office which shall formulate and implement quarantine laws and regulations and, through its field offices, exercise supervision over rat-proof zones in designated international ports and airports and over medical examination of aliens for immigration purposes.

Republic of the PhilippinesCongress of the Philippines

Metro Manila

Thirteenth CongressThird Regular Session

Begun and held in Metro Manila, on Monday, the nineteenth day of February, two thousand seven.

REPUBLIC ACT NO. 9439             April 27, 2007

AN ACT PROHIBITING THE DETENTION OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS ON GROUNDS OF NONPAYMENT OF HOSPITAL BILLS OR MEDICAL

EXPENSES

Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled:

SECTION 1. It shall be unlawful for any hospital or medical clinic in the country to detain or to otherwise cause, directly or indirectly, the detention of patients who have fully or partially recovered or have been adequately attended to or who may have died, for reasons of nonpayment in part or in full of hospital bills or medical expenses.

SEC. 2. Patients who have fully or partially recovered and who already wish to leave the hospital or medical clinic but are financially incapable to settle, in part or in full, their hospitalization expenses, including professional fees and medicines, shall be allowed to leave the hospital or medical clinic, with a right to demand the issuance of the corresponding medical certificate and other pertinent papers required for the release of the patient from the hospital or medical clinic upon the execution of a promissory note covering the unpaid obligation. The promissory note shall be secured by either a mortgage or by a guarantee of a co-maker, who will be jointly and severally liable with the patient for the unpaid obligation. In the case of a deceased patient, the corresponding death certificate and other documents required for interment and other purposes shall be released to any of his surviving relatives requesting for the same: Provided, however, That patients who stayed in private rooms shall not be covered by this Act.

SEC. 3. Any officer or employee of the hospital or medical clinic responsible for releasing patients, who violates the provisions of this Act shall be punished by a fine of not less than Twenty thousand pesos (P20,000.00), but not more than Fifty thousand pesos (P50,000.00), or imprisonment of not less than one month, but not more than six months, or both such fine and imprisonment, at the discretion of the proper court.

SEC. 4. The Department of Health shall promulgate the necessary rules and regulations to carry out the provisions of this Act.

SEC. 5. If any provision of this Act is declared void and unconstitutional the remaining provisions hereof not affected thereby shall remain in full force and effect.

SEC. 6. All laws, decrees, orders, rules and regulations or part thereof inconsistent with this Act are hereby repealed or amended accordingly.

SEC. 7. This Act shall take effect fifteen (15) days after its publication in two national newspapers of general circulation.

Republic of the PhilippinesCongress of the Philippines

Metro Manila

Tenth Congress

Republic Act No. 8344             August 25, 1997

AN ACT PENALIZING THE REFUSAL OF HOSPITALS AND MEDICAL CLINICS TO ADMINISTER APPROPRIATE INITIAL MEDICAL TREATMENT AND SUPPORT IN

EMERGENCY OR SERIOUS CASES, AMENDING FOR THE PURPOSE BATAS PAMBANSA BILANG 702, OTHERWISE KNOWN AS "AN ACT PROHIBITING THE DEMAND OF DEPOSITS OR ADVANCE PAYMENTS FOR THE CONFINEMENT OR TREATMENT OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS IN CERTAIN

CASES"

Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled::

Section 1. Section 1 of Batas Pambansa Bilang 702 is hereby amended to read as follows:

"SECTION 1. In emergency or serious cases, it shall be unlawful for any proprietor, president, director, manager or any other officer, and/or medical practitioner or employee of a hospital or medical clinic to request, solicit, demand or accept any deposit or any other form of advance payment as a prerequisite for confinement or

medical treatment of a patient in such hospital or medical clinic or to refuse to administer medical treatment and support as dictated by good practice of medicine to prevent death or permanent disability: Provided, That by reason of inadequacy of the medical capabilities of the hospital or medical clinic, the attending physician may transfer the patient to a facility where the appropriate care can be given, after the patient or his next of kin consents to said transfer and after the receiving hospital or medical clinic agrees to the transfer: Provided, however, That when the patient is unconscious, incapable of giving consent and/or unaccompanied, the physician can transfer the patient even without his consent: Provided, further, That such transfer shall be done only after necessary emergency treatment and support have been administered to stabilize the patient and after it has been established that such transfer entails less risks than the patient's continued confinement: Provided, furthermore, That no hospital or clinic, after being informed of the medical indications for such transfer, shall refuse to receive the patient nor demand from the patient or his next of kin any deposit or advance payment: Provided, finally, That strict compliance with the foregoing procedure on transfer shall not be construed as a refusal made punishable by this Act."

Section 2. Section 2 of Batas Pambansa Bilang 702 is hereby deleted and in place thereof, new sections 2, 3 and 4 are added, to read as follows:

"SEC. 2. For purposes of this Act, the following definitions shall govern:

"(a) 'Emergency' - a condition or state of a patient wherein based on the objective findings of a prudent medical officer on duty for the day there is immediate danger and where delay in initial support and treatment may cause loss of life or cause permanent disability to the patient.

"(b) 'Serious case' - refers to a condition of a patient characterized by gravity or danger wherein based on the objective findings of a prudent medical officer on duty for the day when left unattended to, may cause loss of life or cause permanent disability to the patient.

"(c) 'Confinement' - a state of being admitted in a hospital or medical clinic for medical observation, diagnosis, testing, and treatment consistent with the capability and available facilities of the hospital or clinic.

"(d) 'Hospital' - a facility devoted primarily to the diagnosis, treatment and care of individuals suffering from illness, disease, injury or deformity, or in need of obstetrical or other medical and nursing care. It shall also be construed as any institution, building or place where there are facilities and personnel for the continued and prolonged care of patients.

"(e) 'Emergency treatment and support' - any medical or surgical measure within the capability of the hospital or medical clinic that is administered by qualified health care professionals to prevent the death or permanent disability of a patient.

"(f) 'Medical clinic' - a place in which patients can avail of medical consultation or treatment on an outpatient basis.

"(g) 'Permanent disability' - a condition of physical disability as defined under Article 192-C and Article 193-B and C of Presidential Decree No 442; as amended, otherwise known as the Labor Code of the Philippines.

"(h) 'Stabilize' - the provision of necessary care until such time that the patient may be discharged or transferred to another hospital or clinic with a reasonable probability that no physical deterioration would result from or occur during such discharge or transfer.

"SEC. 3. After the hospital or medical clinic mentioned above shall have administered medical treatment and support, it may cause the transfer of the patient to an appropriate hospital consistent with the needs of the patient, preferably to a government hospital, specially in the case of poor or indigent patients.

"SEC. 4. Any official, medical practitioner or employee of the hospital or medical clinic who violates the provisions of this Act shall, upon conviction by final judgment, be punished by imprisonment of not less than six (6) months and one (1) day but not more than two (2) years and four (4) months, or a fine of not less than Twenty thousand pesos (P20,000.00), but not more than One hundred thousand pesos (P100,000.00) or both, at the discretion of the court: Provided, however, That if such violation was committed pursuant to an established policy of the hospital or clinic or upon instruction of its management, the director or officer of such hospital or clinic responsible for the formulation and implementation of such policy shall, upon conviction by final judgment, suffer imprisonment of four (4) to six (6) years, or a fine of not less than One hundred thousand pesos (P100,000.00), but not more than Five hundred thousand pesos (P500,000.00) or both, at the discretion of the court."

Section 3. Section 3 of Batas Pambansa Bilang 702 is hereby repealed.

Section 4. Section 4 of Batas Pambansa Bilang 702 shall become Section 5 thereof and shall be amended to read as follows:

"SEC. 5. The Department of Health shall promulgate the necessary rules and regulations to carry out the provisions of this Act."

Section 5. This Act shall take effect fifteen (15) days after its publication in two (2) national newspapers of general circulation.

Approved: August 25, 1997

REPUBLIC ACT NO. 6615

REPUBLIC ACT NO. 6615  - AN ACT REQUIRING GOVERNMENT AND PRIVATE HOSPITALS AND CLINICS TO EXTEND MEDICAL ASSISTANCE IN EMERGENCY

CASES  

Section 1.    All government and private hospitals or clinic duly licensed to operate as such are hereby required to render immediate emergency medical assistance and to provide facilities and medicine within its capabilities to patients in emergency cases who are in danger of dying and/or who may have suffered serious physical injuries. 

Sec. 2.    The expenses and losses of earnings incurred by a private hospital of clinic for medicines, facilities and services beyond first aid extended to emergency cases as required herein, and not to exceed fifty thousand pesos per year, shall be deductible expenses and losses for income tax purposes which may be carried over for a period of five years, any provision of law or regulation to the contrary notwithstanding. 

Sec. 3.    Any hospital director, administrator, officer-in-charge or physician in the hospital, medical center or clinic, who shall refuse or fail without good cause to render the appropriate assistance pursuant to the requirements of section one after said case had been brought to his attention, or any nurse, midwife or medical attendant who shall refuse to extend the appropriate assistance, subject to existing rules, or neglect to notify or call a physician shall be punished by imprisonment of one month and one day to one year and one day, and a fine of three hundred pesos to one thousand pesos, without prejudice to the provisions of Republic Act Numbered Twenty-three hundred eighty-two in the case of physicians.

In the case of Government hospitals, the imposition of the penalty upon the person or persons guilty of the violations shall be without prejudice to the administrative action that might be proper. 

In the case of private hospitals, aside from the imposition of penalty upon the person or persons guilty of the violations, the license of the hospital to operate shall, whenever justified, be suspended or revoked. 

Sec. 4.    Subject to the approval of the Secretary of Health, the Bureau of Medical Services shall promulgate the necessary rules and regulations to carry out the provisions of this Act. 

Sec. 5.    Any law or laws or parts thereof inconsistent with the provisions of this Act is hereby repealed. 

Sec. 6.    This Act shall take effect upon its approval.

Republic of the PhilippinesSUPREME COURT

Manila

FIRST DIVISION

G.R. No. 150355             July 31, 2006

MANILA DOCTORS HOSPITAL, petitioner, vs.SO UN CHUA and VICKY TY, respondents.

D E C I S I O N

AUSTRIA-MARTINEZ, J.:

Before this Court is a Petition for Review on Certiorari under Rule 45 questioning the Decision1 dated October 2, 2001 promulgated by the Court of Appeals (CA) in CA-G.R. CV No. 61581, which affirmed the Decision dated September 30, 1997 of the Regional Trial Court (RTC), Branch 159, Pasig City, but which reduced the award of damages.

This case originated from an action for damages filed with the RTC by respondents So Un Chua and Vicky Ty against petitioner Manila Doctors Hospital.2 The complaint is premised on the alleged unwarranted actuations of the petitioner towards its patient, respondent So Un Chua (Chua), who was confined for hypertension, diabetes, and related illnesses.

The antecedents of the case follow:

On December 13, 1993, respondents filed a Complaint averring that on October 30, 1990, respondent Chua, the mother of respondent Vicky Ty, was admitted in petitioner's hospital for hypertension and diabetes; that while respondent Chua was confined, Judith Chua, the sister of respondent Ty, had been likewise confined for injuries suffered in a vehicular accident; that partial payments of the hospital bills were made, totaling P435,800.00; that after the discharge of Judith Chua, respondent Chua remained in confinement and the hospital bills for both patients accumulated; that respondent Chua was pressured by the petitioner, through its Credit and Collection Department, to settle the unpaid bills; that respondent Ty represented that she will settle the bills as soon as the funds become available; that respondent Ty pleaded to the management that in view of the physical condition of her mother, respondent Chua, the correspondences relating to the settlement of the unpaid hospital bills should be relayed to the former; that these pleas were unheeded by the petitioner; that petitioner threatened to implement unpleasant measures unless respondent Ty undertakes her mother's obligation as well as the obligation of her sister, Judith Chua, to pay the hospitalization expenses; that petitioner made good its threat and employed unethical, unpleasant and unlawful methods which allegedly worsened the condition of respondent Chua, particularly, by (i) cutting off the telephone line in her room and removing the air-conditioning unit, television set, and refrigerator, (ii) refusing to render medical attendance and to change the hospital gown and bed sheets, and (iii) barring the private nurses or midwives from assisting the patient. Respondents thus prayed for the award of moral damages, exemplary damages, and attorney's fees.

In its Answer, Amended Answer, and Rejoinder, petitioner specifically denied the material averments of the Complaint and Reply, and interposed its counterclaims arguing that as early as one week after respondent Chua had been admitted to its hospital, Dr. Rody Sy, her attending physician, had already given instructions for her to be discharged, but respondents insisted that Chua remain in confinement; that, through its staff, petitioner accordingly administered medical examinations, all of which yielded negative results; that respondent Ty voluntarily undertook, jointly and severally, to pay the hospital bills for both patients; that although respondent Ty paid up to P435,000.00, more or less, she reneged on her commitment to pay the balance in violation of the Contract for Admission and Acknowledgment of Responsibility for Payment dated October 30, 1990 which she voluntarily executed; that she signed a Promissory Note on June 5, 1992 for the unpaid balance of P1,075,592.95 and issued postdated checks to cover the same; that no such undue pressure had been imposed upon respondent Chua to settle the bills, the truth being that, as a matter of standard procedure, the reminders to settle the bills were transmitted not to the patients but to their relatives who usually undertook to pay the same; that respondent Ty deliberately evaded the staff of the Credit and Collection Department; that the cutting-off of the telephone line and removal of the air-conditioning unit, television set, and refrigerator cannot constitute unwarranted actuations, for the same were resorted to as cost-cutting measures and to minimize respondents' charges that were already piling up, especially after respondent Ty refused to settle the balance notwithstanding frequent demands; that respondent Ty evaded the staff when the latter attempted to inform her that the room facilities will be cut off to minimize the rising charges; and that respondents instituted the present civil case purposely as leverage against the petitioner after the latter had filed criminal charges for violation of Batas Pambansa (B.P.) Blg. 22 against respondent Ty for issuing checks, later dishonored, totaling P1,075,592.95, the amount referring to the unpaid hospital bills. In its compulsory counterclaim, petitioner prayed, among other items, for the award of no less than P1,000,000.00 as compensatory damages due to the filing of a malicious and unfounded suit, and, in its permissive counterclaim, petitioner prayed for respondents to pay P1,075,592.95, the amount representing the due and demandable obligation under the Promissory Note dated June 5, 1992, including the stipulated interest therein and the 25 percent of the total amount due as attorney's fees.

During pre-trial, the parties stipulated on the following issues: First, whether the respondents are liable to the petitioner to pay the hospital bills arising from the hospitalization of respondent Chua and Judith Chua; and second, whether the parties are entitled to their respective claims for damages.3 Furthermore, the parties stipulated on the following facts: a) Judith Chua was confined from June 14, 1991 to May 2, 1992; b) respondents failed to pay the balance despite repeated reminders; c) the said reminders referred to the hospital bills of respondent Chua and Judith Chua; d) one of the attending physicians of respondent Chua was Dr. Rody Sy; and e) the petitioner ordered the removal of the facilities in question from the room of its patient, respondent Chua, with the qualification that they were constrained to discontinue the same after the representative of respondent Chua refused to update the hospital bills or refused to transfer her to semi-deluxe room or ward to lessen costs.4

On September 30, 1997, the RTC rendered its Decision in favor of the respondents, the dispositive portion of which states:

WHEREFORE, premises considered, judgment on the complaint is hereby rendered in favor of the [respondents] as against the [petitioner] as follows:

[O]rdering the [petitioner] to pay the [respondents] the following, to wit:

a) P200,000.00 as moral damages;

b) P100,000.00 as exemplary damages; and

c) P50,000.00 as attorney's fees and the amount of P50,000.00 as litigation costs.

SO ORDERED.5

In brief, the RTC held that the removal of the facilities of the room triggered the hypertension of respondent Chua; that the petitioner acted in bad faith in removing the facilities without prior notice; that her condition was aggravated by the pressure employed by the administration upon her to pay the hospital bills; that the food always came late as compared to the other patients; that the beddings and clothes of respondent Chua were no longer changed and, as a result, bed sores emerged on her body; that there was an utter lack of medical attendance; that, because of these, respondent Chua suffered from self-pity and depression; that petitioner clearly discriminated against the respondents; that respondent Ty had no choice but to sign the promissory notes in order to secure the release of her mother, respondent Chua; that the foregoing actuations constitute an abuse of rights; that petitioner failed to establish the pecuniary loss it suffered and, hence, it is not entitled to compensatory damages; and that, since the promissory note is a contract of adhesion, the petitioner is not entitled to the award of attorney's fees as stipulated thereon.

On appeal to the CA, the petitioner assigned the following errors:

A.

THE HONORABLE TRIAL COURT COMMITTED REVERSIBLE ERROR BY FINDING THE ACTUATIONS OF THE ADMINISTRATION OF DEFENDANT-APPELLANT TO BE IN BAD FAITH, OPPRESSIVE AND UNNECESSARY AS TO MAKE IT LIABLE TO PLAINTIFFS-APPELLEES FOR DAMAGES AND ATTORNEY'S FEES.

B.

THE HONORABLE TRIAL COURT COMMITTED REVERSIBLE ERROR BY NOT RULING UPON THE PERMISSIVE COUNTERCLAIM OF DEFENDANT-APPELLANT WITH RESPECT TO THE P1,075,592.95 REPRESENTING THE HOSPITAL BILL OF PLAINTIFFS-APPELLEES, WHICH OBLIGATION IS NOT DISPUTED AND WHICH AMOUNT WAS NEVER CONTROVERTED BY PLAINTIFFS-APPELLEES.6

On October 2, 2001, the CA promulgated its Decision the dispositive portion of which reads:

IN VIEW OF ALL THE FOREGOING, the appealed Decision is hereby AFFIRMED with the modification that the award of moral damages, exemplary damages as well as attorney's fees is reduced to Seventy Five Thousand Pesos (P75,000.00), Thirty Thousand Pesos (P30,000.00) and Twenty Thousand Pesos (P20,000.00), respectively. Litigation costs are hereby deleted. Costs against appellant.

SO ORDERED.7

Apart from the reduction in the award of damages, the CA affirmed all salient portions of the RTC Decision and declined to disturb the findings of fact.

Petitioner is now before this Court raising essentially the same grounds heard by the CA.

Incidentally, with respect to the related criminal case against respondent Ty, this Court, on September 27, 2004, promulgated its Decision entitled Ty v. People of the Philippines,8 which affirmed the decisions of the lower courts finding respondent Ty guilty of violating B.P. Blg. 22 and ordering her to pay the private complainant, herein petitioner, the total amount of the dishonored checks.

The petition is impressed with merit.

While, as a rule, only questions of law may be raised in a petition for review on certiorari under Rule 45, under certain exceptions, the Court may re-examine the evidence presented by the parties during the trial. At least four exceptions exist in this case, namely: (a) when the conclusion is a finding grounded entirely on speculation, surmises, or conjectures; (b) when the judgment is based on a misapprehension of facts; (c) when the findings of fact are premised on the supposed absence of evidence and contradicted by the evidence on record; and (d) when the courts a quo manifestly overlooked certain relevant facts not disputed by the parties and which, if properly considered, would justify a different conclusion.9

The principal questions are, first, whether the actuations of the petitioner amount to actionable wrongs, andsecond, whether the counterclaims of the petitioner can be backed up by the measure of preponderant evidence.

In brief, the courts a quo concurred in the holding that the petitioner and its staff failed to take into consideration the physical condition of its patient, respondent Chua, when it removed the facilities provided in her room;10 that the removal of these facilities, namely, the air-conditioner, telephone lines, television, and refrigerator, aggravated the condition of the patient, triggered her hypertension, and caused her blood pressure to fluctuate,11 considering that there was no proper ventilation in the room.12 In view of the foregoing, the courts a quo concluded that the actuations of the petitioner were oppressive, unnecessary,13 and anti-social,14 done in bad faith without proper notice,15 with no intention other than to harass or irritate the respondents,16 all of which constitute an abuse of rights.17

We do not agree. The conclusions of the courts a quo are either haphazard conjectures, or founded on a misapprehension of facts. The record is replete with evidence that justifies a different conclusion.

Indeed the operation of private pay hospitals and medical clinics is impressed with public interest and imbued with a heavy social responsibility. But the hospital is also a business, and, as a business, it has a right to institute all measures of efficiency commensurate to the ends for which it is designed, especially to ensure its economic viability and survival. And in the legitimate pursuit of economic considerations, the extent to which the public may be served and cured is expanded, the pulse and life of the medical sector quickens, and the regeneration of the people as a whole becomes more visibly attainable. In the institution of cost-cutting measures, the hospital has a right to reduce the facilities and services that are deemed to be non-essential, such that their reduction or removal would not be detrimental to the medical condition of the patient.18 For the moment, the question to be considered is whether the subject facilities are indeed non-essential – the air-conditioner, telephone, television, and refrigerator – the removal of which would cause the adverse health effects and emotional trauma the respondents so claimed. Corollary to this question is whether the petitioner observed the diligence of a good father of the family19 in the course of ascertaining the possible repercussions of the removal of the facilities prior to the removal itself and for a reasonable time thereafter, with a view to prevent damage.20

After an extensive analysis of the record, it becomes rather worrisome to this Court that the courts a quounreservedly drew their conclusions from the self-serving and uncorroborated testimonies of the respondents the probative value of which is highly questionable.21 We hold that the respondents failed to prove the damages so claimed.

The evidence in the record firmly establishes that the staff of the petitioner took proactive steps to inform the relatives of respondent Chua of the removal of facilities prior thereto, and to carry out the necessary precautionary measures to ensure that her health and well-being would not be adversely affected: as early as around two weeks after her admission on October 30, 1990, to the time when the facilities had been removed sometime in the middle of May 1992,22 and even up to the point when she actually left the premises of the hospital three weeks later, or during the first week of June 1992,23 the medical condition of respondent Chua, as consistently and indisputably confirmed by her attending physician, Dr. Rody Sy, a cardiologist, who was called as witness for both parties,24 whom even respondent Chua repeatedly praised to be "my doctor" and "a very good doctor"25 at that, and whose statements at times had been corroborated as well by Sister Mary Philip Galeno, SPC, the Administrator of the hospital and who also happens to be a registered nurse, had been "relatively well,"26 "ambulatory,"27 "walking around in the room,"28 and that she was "able to leave the hospital on her own without any assistance;"29 that although she complained of symptoms such as dizziness, weakness,30 and abdominal discomfort,31 Dr. Sy requested several medical examinations, such as the laboratory tests, renal tests, MRI, ultrasound, and CT scan,32 all of which were administered after procuring the consent of respondent Chua's family33 as admitted by respondent Ty herself,34 and even called on other specialists, such as a neurologist, endocrinologist, and gastroenterologist, to look into her condition35 and conduct other tests as well36 according to their fields of specialty, all of which yielded no serious finding;37 that her illnesses were "lifelong illnesses"38 at a stage where they cannot be totally removed or abolished,39 making it clear to her family that "one hundred percent recovery is not possible" despite being given daily medication in the

hospital;40 but that her condition, nonetheless, is not serious,41 as the blood pressure is more or less controlled and within acceptable limits,42 "not that critical to precipitate any acute attack,"43 nor likely to fall into any emergency,44 nor yet does she require continuous or prolonged hospitalization45 since she was stable enough to be treated at home and on an "out-patient" basis, so much so that Dr. Sy encouraged her to exercise and avoid resting all the

time,46 and recommended that "anytime she may be discharged"47

even in just "two weeks after confinement,"48 the propriety of his order of discharge concurred upon by the other specialists as well,49 had it not been for respondents' insistence to stay in the hospital in view of their hope for absolute recovery50 despite the admission of respondent Chua herself that she cannot anymore be totally cured.51

It is also undisputed that the hospital administrator, Sister Galeno, prior to the removal of the facilities, consulted the attending physician, Dr. Sy.52 To Sister Galeno, also a registered nurse, the matter of removal and its possible repercussions on the health of the patient, as a matter of hospital policy, is a critical and sensitive maneuver, and, hence, it is carried out only after discussing with the doctors to evaluate all important factors.53The fact of prior consultation54 as well as the medical determination to the effect that it was safe to remove the facilities and would cause no harmful effect55 had been amply corroborated by respondent Chua's own doctor himself.56 When Dr. Sy testified as rebuttal witness for the respondents themselves and whose credibility respondents failed to impeach, he categorically stated that he consented to the removal since the removal of the said facilities would not by itself be detrimental to the health of his patient, respondent Chua.57 And in this respect, he had been advising respondent Ty, the daughter of the patient, that the facilities, such as the air-conditioner, television, refrigerator, and telephone, are not absolutely necessary, and, that although they may add to the comfort of the patient, if absent, they will not cause any significant deterioration of her condition,58 given that, in his experience as a cardiologist, and after personally attending respondent Chua on a daily basis before, during, and after the removal and even up to the time of her actual discharge,59 he concluded that many hypertensive and diabetic patients, as in her case, do not at all need in particular an air-conditioning unit, among the other facilities aforementioned.60 And, contrary to the findings of the courts a quo and the self-serving testimonies of respondents that the lack of ventilation, after the removal of the air-conditioner, triggered her hypertension, Dr. Sy categorically stated that during his daily rounds with the patient he was certain that, although admittedly the blood pressure in general would fluctuate daily, there had been no adverse effect on her, and that her blood pressure were within acceptable limits,61 especially considering that he treated the patient on a daily basis up to the point of actual discharge,62 and accordingly, as confirmed by the medical records, he made no change in the medications thereafter.63 In support of Dr. Sy's findings, Sister Galeno, testified that she knew the condition of the ventilation of the patient's deluxe room, located at the fifth floor, even without the air-conditioning, notably in times of brownout, and that there had been enough ventilation since the grilled window of that room was large enough which, if opened, would permit sufficient ventilation.64 The Court finds that the premise of the RTC judgment refers merely to hypothetical statements which fail to establish any clear and direct link to the injury allegedly suffered by the patient:

Q — You found it safe to remove these facilities from the room of the patient suffering from diabetes and hypertension?

A — Yes, Sir. Many hypertensive, diabetic patients do not need air-conditioning, or T.V. or refrigerator.

Q — Do you agree with me that hypertension is triggered sometimes by excitement, anger or (sic) a person suffering from such illness?

A — Hypertension can be triggered by anything.

Court:

Q — And even in other words the discomfort can also trigger?

A — Sometimes mental stress can trigger.

x x x x

Court:

Q — You mentioned earlier that this hypertension may be triggered mentally?

A — Yes, Your Honor.

Court:

Q — Will the removal of these facilities not affect the patient including the relatives?

A — It may to a certain extent. And well, maybe the days after the removal would prove that fluctuation in blood pressure are within acceptable limits.65

With respect to the findings of the courts a quo that bed sores appeared on the body of respondent Chua, that she suffered from depression after the disconnection of the said facilities, that her private midwives were barred, and that the delivery of food was delayed, this Court holds, as above, that these conclusions are bereft of sound evidentiary basis, self-serving and uncorroborated as they are. Again, Dr. Sy affirmed that during the daily rounds he would make on the patient, he did not detect any skin lesion or any other abnormality up to the time she was actually discharged.66 Nor did he find any sign of depression, although, admittedly, he observed that she had been "very angry" because of the removal of the facilities.67 All the while he did not receive any complaint from respondent Chua indicating that she suffered from the foregoing infirmities,68 considering that it is the responsibility of the family of the patient to specifically inform the attending physician or the nurses during their rounds whatever they feel is important, or if there were any new

developments since the last visit.69 As corroborated by Sister Galeno, throughout respondent Chua's confinement, she never received any complaint from the latter or her relatives that she had not been attended to by the nursing staff.70 Worth noting again is the fact that the nursing staff and the attending physicians, which included Dr. Sy, in accordance with hospital policy, would routinely make their rounds on a daily basis, or would visit the patient whenever they are called for any problem,71 and, in the case of the specialists other than the attending physician, they would visit the patient about once a week.72 The nurses, on the other hand, would make their rounds more frequently, that is, at least once per shift, or every eight hours.73 Apart from the self-serving statements of respondents, which by now have become rather indicative of being mere afterthoughts, there is no clear showing from the record that the petitioner and its medical staff deviated from the foregoing policy and practice, nor had they been called upon to look into the alleged physical reactions or emotional trauma respondent Chua claims to have suffered during and after the removal of the facilities. It must be emphasized that, as stated above, respondent Chua herself explicitly found Dr. Sy to be a "very good doctor" because he personally attended to her "almost every hour."74 And throughout her confinement, Dr. Sy positively stated that her family employed a private midwife who attended to her all the time.75

The evidence in the record overwhelmingly demonstrates that respondent Chua had been adequately attended to, and this Court cannot understand why the courts a quo had declared that there was an "utter lack of medical attendance," or that her health suffered during the period after the removal of the facilities. The Court finds that the facilities in question are non-essential for the care of respondent Chua and, hence, they may be lessened or removed by the petitioner for the sake of economic necessity and survival.

Though human experience would show that the deactivation of the air-conditioner may cause a temperature differential that may trigger some physical discomfort, or that the removal of entertainment facilities such as the television set, or the disconnection of communication devices such as the telephone, may cause some exasperation on the part of the one who benefits from these, nevertheless, all things considered, and given the degree of diligence the petitioner duly exerted, not every suppression of the things that one has grown accustomed to enjoy amounts to an actionable wrong, nor does every physical or emotional discomfort amount to the kind of anguish that warrants the award of moral damages under the general principles of tort. The underlying basis for the award of tort damages is the premise that an individual was injured in contemplation of law. Thus, there must first be the breach of some duty and the imposition of liability for that breach before damages may be awarded; it is not sufficient to state that there should be tort liability merely because the plaintiff suffered some pain and suffering.76

Moreover, this Court must reiterate the standard of tort to arrive at a proper award for damages premised on matters that suggest the application of medical knowledge, especially in the description of the causal link between external or environmental factors, on one hand, and their effect unto the physical or emotional health of the patient, on the other, expert opinion, as discussed in Cruz v. Court of Appeals,77 is generally required:

All three courts below bewail the inadequacy of the facilities of the clinic and its untidiness; the lack of provisions such as blood, oxygen, and certain medicines; the failure to subject the patient to a cardio-pulmonary test prior to the operation;

the omission of any form of blood typing before transfusion; and even the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on her by the petitioner. But while it may be true that the circumstances pointed out by the courts below seemed beyond cavil to constitute reckless imprudence on the part of the surgeon, this conclusion is still best arrived at not through the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of expert witnesses. For whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is, in the generality of cases, a matter of expert opinion. The deference of courts to the expert opinions of qualified physicians stems from its realization that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating. Expert testimony should have been offered to prove that the circumstances cited by the courts below are constitutive of conduct falling below the standard of care employed by other physicians in good standing when performing the same operation. It must be remembered that when the qualifications of a physician are admitted, as in the instant case, there is an inevitable presumption that in proper cases he takes the necessary precaution and employs the best of his knowledge and skill in attending to his clients, unless the contrary is sufficiently established. This presumption is rebuttable by expert opinion which is so sadly lacking in the case at bench.78

With respect to the propriety of the notice of removal of facilities, the evidence shows that the hospital staff, accompanied by Sister Gladys Lim, SPC, Finance Administrative Assistant of the hospital,79 through written and verbal notices as per hospital policy, forewarned the respondents, through respondent Ty and her sister, Judith Chua, of the impending removal of the facilities over a week beforehand80 in view of their obstinate refusal to vacate and transfer to a lower rate room81 or to update the mounting hospital bills82 which, by then, had swollen to approximately one million pesos.83 Respondent Ty refused to read many of the written notices sent by the Credit

Department.84 After repeated attempts to contact respondent Ty85 and before the actual removal of the facilities, the staff of the petitioner tried to personally serve the final notice dated April 23, 1992,86 signed by Sister Gladys Lim, addressed to respondent Ty, which adopted the tenor of the prior verbal warnings, and which expressly and sternly warned the respondents that the hospital shall be constrained to take legal action and that they shall be compelled to transfer the patient, respondent Chua, to a lower rate room unless the balance could be satisfied.87Respondent Ty, for no justifiable reason, and sticking to her inclination to avoid the staff, refused to receive or acknowledge this letter as well.88 Worth noting is that Sister Galeno, testified that, as a matter of hospital policy the tenor of which respondents, by virtue of the Contract for Admission dated October 30, 1990, agreed to comply with,89 the hospital can only cut off the non-essential facilities – and only in extreme cases90 – if the patient occupies a private room all to herself; had the room been semi-private shared by other patients, or had it been the ward, the hospital cannot disconnect the facilities since this would unduly prejudice the other patients. But respondent Chua herself insisted on staying in a private room despite her being fully aware of the ballooning charges,91 and even if she could have freely gone home anytime to her condominium unit which, as admitted, was equipped with an air-conditioner.92 With respect to the "pressure" and "harassment" respondents allegedly suffered daily whenever the hospital staff would follow up the billing during odd hours, or at 10pm, 11pm, 12 midnight, 1am, or 2am,93 this averment had been

convincingly refuted by the witnesses for the petitioner, namely, Editha L. Vecino, the Head of Credit and Collection, and Sister Galeno, in that the Credit and Collection Department would only hold office hours from 8am to 5pm and, hence, it is impossible to "harass" the respondents during the times they so claimed.94

The courts a quo found that respondent Ty had "no choice but to sign the promissory note in order for her mother to be released from the hospital,"95 thus suggesting that the hospital refused to actually discharge or bodily release its patient, respondent Chua, until arrangements had been made to settle the charges.

While there are portions of the testimonies of the witnesses for the petitioner which state that although, as per standard procedure, the patient "cannot leave"96 the hospital without the "discharge,"97 "clearance" or "gate pass" issued only after

arrangements on the settlement of bills had been made,98 still, it must be understood that these are only demonstrative of the precondition that a patient cannot step out of the premises "without the consent" of the hospital, or, in other words, that the "clearance" merely indicates that the hospital expressly consented to the actual release of the patient,99 but, even without its consent, the patient is still free to leave "anytime" as a matter of policy, in spite of the refusal to issue a "clearance" or "gate pass,"100 or even in cases where the accounts have not yet been liquidated or settled,101 or yet even if no promissory note or post-dated check were executed in favor of the petitioner, as testified by no less than Sister Galeno,102 and corroborated by Editha Vecino;103 and that, petitioner, a private hospital established for profit,104 being also a business, by warning respondents that it shall withhold clearance, is simply exercising its right to protest against an absconding patient as a precursor to avail of other appropriate legal remedies; that, on the contrary, the respondents opted not to leave because of their own promise not to leave unless the hospital bills were fully settled;105 that the accusations found in the Demand Letter dated May 19, 1992, and signed by the counsel for the respondents,106 particularly, that the petitioner "refused to discharge the patient, [respondent Chua,] despite orders from the attending physician, Dr. Rody Sy," had all been refuted by Sister Galeno when she read its contents in front of the counsel for respondents, emphatically telling him that "we are not detaining his clients;" that "[respondent Ty] was the one who told us that they are not going to leave the hospital unless they have fully paid the hospital;"107 and that, most importantly, no physical restraint upon the person of respondent Chua or upon the person of her relatives had been imposed by the staff.

Authorities, including those of common law origin, explicitly declare that a patient cannot be detained in a hospital for non-payment of the hospital bill. If the patient cannot pay the hospital or physician's bill, the law provides a remedy for them to pursue, that is, by filing the necessary suit in court for the recovery of such fee or bill.108 If the patient is prevented from leaving the hospital for his inability to pay the bill, any person who can act on his behalf can apply in court for the issuance of the writ of habeas corpus.109

The form of restraint must be total; movement must be restrained in all directions. If restraint is partial, e.g., in a particular direction with freedom to proceed in another, the restraint on the person's liberty is not total.110However, the hospital may legally detain a patient against his will when he is a detained or convicted prisoner, or when the patient is suffering from a

very contagious disease where his release will be prejudicial to public health, or when the patient is mentally ill such that his release will endanger public safety,111 or in other exigent cases as may be provided by law. Moreover, under the common law doctrines on tort, it does not constitute a trespass to the person to momentarily prevent him from leaving the premises or any part thereof because he refuses to comply with some reasonable condition subject to which he entered them. In all cases, the condition of this kind of restraint must be reasonable in the light of the circumstances.112 At any rate, as stated above, the patient is free to leave the premises, even in the ostensible violation of these conditions, after being momentarily interrupted by the hospital staff for purposes of informing him of those reasonable conditions, such as the assessment of whether the patient is fit to leave, insane, or suffering from a contagious disease, etc., or simply for purposes of making a demand to settle the bill. If the patient chooses to abscond or leave without the consent of the hospital in violation of any of the conditions deemed to be reasonable under the circumstances, the hospital may nonetheless register its protest and may choose to pursue the legal remedies available under law, provided that the hospital may not physically detain the patient, unless the case falls under the exceptions abovestated.

Authorities are of the view that, ordinarily, a hospital, especially if it is a private pay hospital,113 is entitled to be compensated for its services, by either an express or an implied contract, and if no express contract exists, there is generally an implied agreement that the patient will pay the reasonable value of the services rendered;114when a hospital treats a patient's injuries, it has an enforceable claim for full payment for its services, regardless of the patient's financial status.115 At this juncture, it must be noted that there is testimony, though to a degree disputable, to the effect that the execution of the promissory note and the issuance of postdated checks were conditions imposed not by the petitioner but voluntarily offered by the counsel for respondents.116 At any rate, however, this Court holds, in view of the foregoing authorities, that the requirement to have the relative of respondent Chua to execute a promissory note as part of the arrangement to settle the unpaid obligations is a formality that converts any implied contract into written form and, moreover, amounts to a reasonable condition, the non-fulfillment of which, in itself, however, as discussed, cannot allow the hospital to detain the patient. It must also be stressed, contrary to the findings of the courts a quo, that such an agreement embodied in a promissory note, as well as the Contract for Admission and Acknowledgment of Responsibility for Payment dated October 30, 1990, do not become contracts of adhesion simply because the person signing it was under stress that was not the result of the actions of the hospital,117 especially taking into account that there is testimony to the effect that respondent Ty signed the Promissory Note dated June 5, 1992 in the presence of counsel and acting under his advise.118

But as to the propriety of the circumstances surrounding the issuance of the postdated checks to cover the amount stated in the Promissory Note dated June 5, 1992, this Court must refer to the discussion of the recent case of Ty v. People of the Philippines119 where this Court affirmed the conviction of respondent Ty for the issuance of bouncing checks addressed to the petitioner herein. While the instant case is to be distinguished from the Ty case in nature, applicable law, the standards of evidence, and in the defenses available to the parties, hence, the judgment of conviction in that case should not at all prejudice the disposition of this case, even if the facts coincide, nonetheless, for purposes of convenience and instructive utility, the Court quotes the relevant portions:

In this case, far from it, the fear, if any, harbored by Ty was not real and imminent. Ty claims that she was compelled to issue the checks a condition the hospital allegedly demanded of her before her mother could be discharged for fear that her mother's health might deteriorate further due to the inhumane treatment of the hospital or worse, her mother might commit suicide. This is speculative fear; it is not the uncontrollable fear contemplated by law.

To begin with, there was no showing that the mother's illness was so life-threatening such that her continued stay in the hospital suffering all its alleged unethical treatment would induce a well-grounded apprehension of her death. Secondly, it is not the law's intent to say that any fear exempts one from criminal liability much less petitioner's flimsy fear that her mother might commit suicide. In other words, the fear she invokes was not impending or insuperable as to deprive her of all volition and to make her a mere instrument without will, moved exclusively by the hospital's threats or demands.

Ty has also failed to convince the Court that she was left with no choice but to commit a crime. She did not take advantage of the many opportunities available to her to avoid committing one. By her very own words, she admitted that the collateral or security the hospital required prior to the discharge of her mother may be in the form of postdated checks or jewelry. And if indeed she was coerced to open an account with the bank and issue the checks, she had all the opportunity to leave the scene to avoid involvement.

Moreover, petitioner had sufficient knowledge that the issuance of checks without funds may result in a violation of B.P. 22. She even testified that her counsel advised her not to open a current account nor issue postdated checks "because the moment I will not have funds it will be a big problem." Besides, apart from petitioner's bare assertion, the record is bereft of any evidence to corroborate and bolster her claim that she was compelled or coerced to cooperate with and give in to the hospital's demands.

Ty likewise suggests . . . that the justifying circumstance of state of necessity under par. 4, Art. 11 of the Revised Penal Code may find application in this case.

We do not agree. The law prescribes the presence of three requisites to exempt the actor from liability under this paragraph: (1) that the evil sought to be avoided actually exists; (2) that the injury feared be greater than the one done to avoid it; (3) that there be no other practical and less harmful means of preventing it.

In the instant case, the evil sought to be avoided is merely expected or anticipated. If the evil sought to be avoided is merely expected or anticipated or may happen in the future, this defense is not applicable. Ty could have taken advantage of an available option to avoid committing a crime. By her own admission, she had the choice to give jewelry or other forms of security instead of postdated checks to secure her obligation.

Moreover, for the defense of state of necessity to be availing, the greater injury feared should not have been brought about by the negligence or imprudence, more so, the willful inaction of the actor. In this case, the issuance of the bounced checks was brought about by Ty's own failure to pay her mother's hospital bills.

The Court also thinks it rather odd that Ty has chosen the exempting circumstance of uncontrollable fear and the justifying circumstance of state of necessity to absolve her of liability. It would not have been half as bizarre had Ty been able to prove that the issuance of the bounced checks was done without her full volition. Under the circumstances, however, it is quite clear that neither uncontrollable fear nor avoidance of a greater evil or injury prompted the issuance of the bounced checks.

Parenthetically, the findings of fact in the Decision of the trial court in the Civil Case for damages filed by Ty's mother against the hospital is wholly irrelevant for purposes of disposing the case at bench. While the findings therein may establish a claim for damages which, we may add, need only be supported by a preponderance of evidence, it does not necessarily engender reasonable doubt as to free Ty from liability.120

In view of the foregoing, the Court therefore holds that the courts a quo committed serious errors in finding that the petitioner was "biased,"121 "discriminated" against the respondents,122 and "purposely intended to irritate"123or "harass"124 them; that it "acted in bad faith in removing the facilities without prior notice;"125 and that its acts were "anti-social."126 The aforequoted declarations of the witnesses, significant portions of which this Court considers as expert testimony, are reliable and remain considerably trustworthy to controvert respondents' assertions as well as to reverse the conclusions of fact and law of the CA and the RTC that respondent Chua suffered the physical and emotional anguish so claimed, and so, for these reasons, the Court holds that the petitioner inflicted no actionable wrong.

This Court observes that the courts a quo awarded both respondents moral damages. But it is well-settled that in case of physical injuries, with some exceptions,127 moral damages are recoverable only by the party injured and not by her spouse, next of kin, or relative who happened to sympathize with the injured party.128 Hence, even if the courts a quo were correct in their basis for damages, they should have declined to award damages to respondent Ty.

The last issue to be resolved is the question whether the counterclaims of the petitioner are supported by a preponderance of evidence.

We agree with the petitioner that the courts a quo seriously erred in mistaking the case of its compulsory counterclaim for its permissive counterclaim and for failing to consider the evidence which impressively supports the latter. First, for failure without justifiable cause of respondents' counsel to comment on the Partial Formal Offer of Evidence dated February 14, 1996129 filed by the petitioner, the RTC issued an order during the course of the trial, which counsel for respondents neither contested nor raised on appeal, admitting Exhibits "1" to "16", together with their submarkings and the purposes for which the same were

offered,130 all of which had also been previously authenticated and their contents verified by the witnesses for the petitioner.131 These documents include the Contract for Admission of respondent Chua dated October 30, 1990, duly executed by respondent Ty, incorporating therein the rules and regulations of the hospital, including the duty to understand the same132 as well as the undertaking of respondent Ty to be jointly and severally liable for the payment of the hospital bills of respondent Chua;133 the Promissory Note dated June 5, 1992 in the amount of P1,075,592.95 duly executed by respondent Ty in favor of the petitioner agreeing to be jointly and severally liable to pay the unpaid obligations of respondent Chua and Judith Chua, including interest and attorney's fees in case of default;134 the Undertakings signed by respondent Ty dated March 3, 1992 and April 7, 1992 to maintain regular deposits;135 and the credit memos and statements of account that support the amount referring to the unpaid obligation.136 Second, the parties stipulated during pre-trial that respondents failed to pay the balance despite repeated reminders.137 Andthird, respondent Ty in open court identified and admitted that she signed the Contract of Admission dated October 30, 1990 as well as the Undertakings dated March 3, 1992 and April 7, 1992 but which, for no justifiable reason, she "did not bother to read,"138 and, what is more, she repeatedly admitted during the course of the trial that she failed to fully settle the foregoing hospital bills.139 In fact, while the Ty case cannot control the incidents of the instant case as heretofore stated, it is still worth mentioning, at least for informative purposes, the findings of this Court in Ty with respect to respondents' obligations to the petitioner:

Ty's mother and sister availed of the services and the facilities of the hospital. For the care given to her kin, Ty had a legitimate obligation to pay the hospital by virtue of her relationship with them and by force of her signature on her mother's Contract of Admission acknowledging responsibility for payment, and on the promissory note she executed in favor of the hospital.140

In view of all these findings, the Court earnestly disagrees with the sweeping conclusion of the CA that "[Petitioner] failed to present any iota of evidence to prove his claim,"141 a statement apparently referring to the permissive counterclaim of P1,075,592.95. However, with respect to the compulsory counterclaim predicated on the filing of a baseless suit and injury to its reputation, petitioner did not raise this matter on appeal and, hence, is deemed to have waived the same.

But the Court in Ty made a partial finding on the civil liability of respondent Ty with respect to the amount covered by seven of the several dishonored checks she issued equivalent to

P210,000.00.142 Since this amount forms a fraction of her total civil liability, then this amount, in deference to Ty, should be deducted therefrom.

The claim for attorney's fees, as stipulated under the Promissory Note dated June 5, 1992, should be reduced for being unreasonable under the circumstances, from 25 percent to 12 percent of the total amount due.143

As a final word, the Court takes judicial notice of the pending Senate Bill No. 337, entitled "An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Non-Payment of Hospital Bills or Medical Expenses," which declares, among others, that it

shall be unlawful for any hospital or medical clinic to cause directly or indirectly the detention of patients for non-payment, in part or in full, of their hospital bills,144 and, furthermore, requires patients who have fully recovered and are financially incapable to settle the hospitalization expenses to execute a promissory note, co-signed by another individual, to the extent of the unpaid obligation before leaving the hospital.145 While this Court may have touched upon these matters in the adjudication of the instant case, it must be stated that this decision should in no way preempt any constitutional challenge to the provisions of Senate Bill No. 337 if passed into law, bearing in mind the standards for the exercise of the power of judicial review146 as well as the recognition that the tenor of the bill may adjust with the times, or that the bill itself may fail to pass, according to the dynamism of the legislative process, especially in light of the objections interposed by interest groups to date.147

WHEREFORE, the petition is GRANTED. The Decision of the Court of Appeals dated October 2, 2001, together with the Decision dated September 30, 1997 of the Regional Trial Court in Civil Case No. 63958, is REVERSEDand SET ASIDE. Another judgment is entered dismissing the Complaint and ordering respondents, jointly and severally, to pay the petitioner the amount of P865,592.95, with stipulated interest of 12 percent reckoned from the date of extrajudicial demand until full payment, and 12 percent of the total amount due as attorney's fees.

No pronouncement as to costs.

SO ORDERED.

Panganiban, C.J., Ynares-Santiago, Callejo, Sr., Chico-Nazario, J.J., concur.

Republic of the PhilippinesSUPREME COURT

Manila

SECOND DIVISION

G.R. No. 176287               January 31, 2011

HOSPITAL MANAGEMENT SERVICES, INC. - MEDICAL CENTER MANILA, Petitioner, vs.HOSPITAL MANAGEMENT SERVICES, INC. - MEDICAL CENTER MANILA EMPLOYEES ASSOCIATION-AFW and EDNA R. DE CASTRO, Respondents.

D E C I S I O N

PERALTA, J.:

Before this Court is a petition for review on certiorari seeking to set aside the Decision1 dated May 24, 2006 and Resolution2 dated January 10, 2007 of the Court of Appeals (CA), Special First Division, in CA-G.R. SP No. 73189, entitled Hospital Management Services, Inc.-Medical Center Manila Employees Association-AFW and Edna R. De Castro v. National Labor Relations Commission, Hospital Management Services, Inc.-Medical Center Manila and Asuncion Abaya-Morido, which reversed and set aside the Decision3 dated February 28, 2002 of the National Labor Relations Commission (NLRC), Second Division, in NLRC NCR No. 00-07-07716-99 (CA No. 027766-01), and its Resolution4 dated May 31, 2002. The assailed CA decision ordered petitioner Hospital Management Services, Inc.-Medical Center Manila to reinstate respondent Edna R. De Castro to her former position without loss of seniority rights or by payroll reinstatement, pursuant to the Labor Arbiter's Decision dated January 18, 2001, but with payment of full backwages and other benefits or their monetary equivalent, computed from the expiration of the 14-day suspension period up to actual reinstatement.

The antecedent facts are as follows:

Respondent De Castro started working as a staff nurse at petitioner hospital since September 28, 1990, until she was dismissed on July 20, 1999.

Between 2:00 a.m. to 3:00 a.m. of March 24, 1999, while respondent De Castro and ward-clerk orientee Gina Guillergan were at the nurse station on night duty (from 10:00 p.m. of March 23, 1999 to 6:00 a.m. of March 24, 1999), one Rufina Causaren, an 81-year-old patient confined at Room 724-1 of petitioner hospital for "gangrenous wound on her right anterior leg and right forefoot" and scheduled for operation on March 26, 1999, fell from the right side of the bed as she was trying to reach for the bedpan. Because of what happened, the niece of patient Causaren staying in the room was awakened and she sought assistance from the nurse station. Instead of personally seeing the patient, respondent De Castro directed ward-clerk orientee Guillergan to check the patient. The vital signs of the patient were normal. Later, the physician on duty and the nursing staff on duty for the next shift again attended to patient Causaren.

Chief Nurse Josefina M. Villanueva informed Dr. Asuncion Abaya-Morido, president and hospital director, about the incident and requested for a formal investigation. On May 11, 1999, the legal counsel of petitioner hospital directed respondent De Castro and three other nurses on duty, Staff Nurse Janith V. Paderes and Nursing Assistants Marilou Respicio and Bertilla T. Tatad, to appear before the Investigation Committee on May 13, 1999, 2:00 p.m., at the conference room of petitioner hospital. During the committee investigation, respondent De Castro explained that at around 2:30 a.m. to 3:00 a.m., she was attending to a newly-admitted patient at Room 710 and, because of this, she instructed Nursing Assistant Tatad to check the vital signs of patient Causaren, with ward-clerk orientee Guillergan accompanying the latter. When the two arrived at the room, the patient was in a squatting position, with the right arm on the bed and the left hand holding on to a chair.

In the Investigation Report5 dated May 20, 1999, the Investigation Committee found that the subject incident happened between 11:00 a.m. to 11:30 a.m. of March 23, 1999. The three other nurses for the shift were not at the nurse station. Staff Nurse Paderes was then in another nurse station encoding the medicines for the current admissions of patients, while

Nursing Assistant Respicio was making the door name tags of admitted patients and Nursing Assistant Tatad delivered some specimens to the laboratory. The committee recommended that despite her more than seven years of service, respondent De Castro should be terminated from employment for her lapse in responding to the incident and for trying to manipulate and influence her staff to cover-up the incident. As for Staff Nurse Paderes and Nursing Assistants Respicio and Tatad, the committee recommended that they be issued warning notices for failure to note the incident and endorse it to the next duty shift and, although they did not have any knowledge of the incident, they should be reminded not to succumb to pressure from their superiors in distorting the facts.

On July 5, 1999, Janette A. Calixijan, HRD Officer of petitioner hospital, issued a notice of termination, duly noted by Dr. Abaya-Morido, upon respondent De Castro, effective at the close of office hours of July 20, 1999, for alleged violation of company rules and regulations, particularly paragraph 16 (a), Item 3, Chapter XI of the Employee's Handbook and Policy Manual of 1996 (Employee's Handbook):6 (1) negligence to follow company policy on what to do with patient Rufina Causaren who fell from a hospital bed; (2) failure to record and refer the incident to the physician-[on- duty and] allow[ing] a significant lapse of time before reporting the incident; (3) deliberately instructing the staff to follow her version of the incident in order to cover up the lapse; and (4) negligence and carelessness in carrying out her duty as staff nurse-on-duty when the incident happened.

On July 21, 1999, respondent De Castro, with the assistance of respondent Hospital Management Services Inc.-Medical Center Manila Employees Association-AFW, filed a Complaint7 for illegal dismissal against petitioners with prayer for reinstatement and payment of full backwages without loss of seniority rights, P20,000.00 moral damages, P10,000.00 exemplary damages, and 10% of the total monetary award as attorney's fees.

On January 18, 2001, the Labor Arbiter rendered a Decision,8 ordering petitioner hospital to reinstate respondent De Castro to her former position or by payroll reinstatement, at the option of the former, without loss of seniority rights, but without backwages and, also, directing petitioners to notify her to report to work. Her prayer for damages and attorney's fees was denied. The Labor Arbiter concluded that although respondent De Castro committed the act complained of, being her first offense, the penalty to be meted should not be dismissal from the service, but merely 7 to 14 days suspension as the same was classified as a less serious offense under the Employee’s Handbook.

On appeal by respondent De Castro, the NLRC rendered a Decision dated February 28, 2002, reversing the findings of the Labor Arbiter and dismissing the complaint against the petitioners. It observed that respondent De Castro lacked diligence and prudence in carrying out her duty when, instead of personally checking on the condition of patient Causaren after she fell from the bed, she merely sent ward-clerk orientee Guillergan to do the same in her behalf and for influencing her staff to conceal the incident.

On May 31, 2002, the NLRC denied respondent De Castro's Motion for Reconsideration dated April 16, 2002.

On May 24, 2006, the CA reversed and set aside the Decision of the NLRC and reinstated the Decision of the Labor Arbiter, with modification that respondent De Castro should be entitled to payment of full backwages and other benefits, or their monetary equivalent, computed from the expiration of the 14-day-suspension period up to actual reinstatement. The CA ruled that while respondent De Castro's failure to personally attend to patient Causeran amounted to misconduct, however, being her first offense, such misconduct could not be categorized as serious or grave that would warrant the extreme penalty of termination from the service after having been employed for almost 9 years. It added that the subject infraction was a less serious offense classified under "commission of negligent or careless acts during working time or on company property that resulted in the personal injury or property damage causing expenses to be incurred by the company" stated in subparagraph 11, paragraph 3 (B), Chapter XI [on the Rules on Discipline] of the Employee's Handbook9 of petitioner hospital. The CA did not sustain the NLRC's ruling that respondent De Castro's dismissal was proper on the ground that her offense was aggravated to serious misconduct on account of her alleged act of asking her co-employees to lie for her as this fact was not proven.

Petitioners' motion for reconsideration was denied by the CA in the Resolution dated January 10, 2007.

Hence, this present petition.

Petitioners allege that the deliberate refusal to attend to patient Causaren after the latter fell from the bed justifies respondent De Castro's termination from employment due to serious misconduct. They claim that respondent De Castro failed to: (a) personally assist the patient; (b) check her vital signs and examine if she sustained any injury; (c) refer the matter to the patient's attending physician or any physician-on-duty; and (d) note the incident in the report sheet for endorsement to the next shift for proper monitoring. They also aver that respondent De Castro persuaded her co-nurses to follow her version of what transpired so as to cover up her nonfeasance.

In her Comment, respondent De Castro counters that there was no serious misconduct or gross negligence committed, but simple misconduct or minor negligence which would warrant the penalty of 7 to 14 days of suspension under the Employee's Handbook of petitioner hospital. She denies exerting influence over the four nursing personnel, but points out that it was Chief Nurse Villanueva, a close friend of patient Causaren's niece, who persuaded the four nursing staff to retract their statements appearing in the incident reports as to the approximate time of occurrence, from 2:00 a.m. to 3:00 a.m. of March 24, 1999 to 11:00 p.m. to 11:30 p.m. of March 23, 1999, so as to pin her for negligence. She appeals for leniency, considering that the subject infraction was her first offense in a span of almost nine years of employment with petitioner hospital.

We affirm with modification the CA ruling which declared petitioners guilty of illegal dismissal.

Article 282 (b) of the Labor Code provides that an employer may terminate an employment for gross and habitual neglect by the employee of his duties. The CA ruled that per the Employee’s Handbook of petitioner hospital, respondent De Castro’s infraction is classified

as a less serious offense for "commission of negligent acts during working time" as set forth in subparagraph 11, paragraph 3 (B) of Chapter XI10 thereof. Petitioners anchor respondent De Castro’s termination of employment on the ground of serious misconduct for failure to personally attend to patient Causaren who fell from the bed as she was trying to reach for the bedpan. Based on her evaluation of the situation, respondent De Castro saw no necessity to record in the chart of patient Causaren the fact that she fell from the bed as the patient did not suffer any injury and her vital signs were normal. She surmised that the incident was not of a magnitude that would require medical intervention as even the patient and her niece did not press charges against her by reason of the subject incident.

It is incumbent upon respondent De Castro to ensure that patients, covered by the nurse station to which she was assigned, be accorded utmost health care at all times without any qualification or distinction. Respondent De Castro’s failure to personally assist patient Causaren, check her vital signs and examine if she sustained any injury, refer the matter to the patient's attending physician or any physician-on-duty, and note the incident in the report sheet for endorsement to the next shift for proper monitoring constitute serious misconduct that warrants her termination of employment. After attending to the toxic patients under her area of responsibility, respondent De Castro should have immediately proceeded to check the health condition of patient Causaren and, if necessary, request the physician-on-duty to diagnose her further. More importantly, respondent De Castro should make everything of record in the patient’s chart as there might be a possibility that while the patient may appear to be normal at the time she was initially examined, an injury as a consequence of her fall may become manifest only in the succeeding days of her confinement. The patient’s chart is a repository of one’s medical history and, in this regard, respondent De Castro should have recorded the subject incident in the chart of patient Causaren so that any subsequent discomfort or injury of the patient arising from the incident may be accorded proper medical treatment.

Neglect of duty, to be a ground for dismissal, must be both gross and habitual.  Gross negligence connotes want of care in the performance of one's duties. Habitual neglect implies repeated failure to perform one's duties for a period of time, depending upon the circumstances. A single or isolated act of negligence does not constitute a just cause for the dismissal of the employee.11 Despite our finding of culpability against respondent De Castro; however, we do not see any wrongful intent, deliberate refusal, or bad faith on her part when, instead of personally attending to patient Causaren, she requested Nursing Assistant Tatad and ward-clerk orientee Guillergan to see the patient, as she was then attending to a newly-admitted patient at Room 710. It was her judgment call, albeit an error of judgment, being the staff nurse with presumably more work experience and better learning curve, to send Nursing Assistant Tatad and ward-clerk orientee Guillergan to check on the health condition of the patient, as she deemed it best, under the given situation, to attend to a newly-admitted patient who had more concerns that needed to be addressed accordingly. Being her first offense, respondent De Castro cannot be said to be grossly negligent so as to justify her termination of employment. Moreover, petitioners’ allegation, that respondent De Castro exerted undue pressure upon her co-nurses to alter the actual time of the incident so as to exculpate her from any liability, was not clearly substantiated.

Negligence is defined as the failure to exercise the standard of care that a reasonably prudent person would have exercised in a similar situation.12 The Court emphasizes that the nature of the business of a hospital requires a higher degree of caution and exacting

standard of diligence in patient management and health care as what is involved are lives of patients who seek urgent medical assistance. An act or omission that falls short of the required degree of care and diligence amounts to serious misconduct which constitutes a sufficient ground for dismissal.

However, in some cases, the Court had ruled that sanctioning an erring employee with suspension would suffice as the extreme penalty of dismissal would be too harsh.13 Considering that this was the first offense of respondent De Castro in her nine (9) years of employment with petitioner hospital as a staff nurse without any previous derogatory record and, further, as her lapse was not characterized by any wrongful motive or deceitful conduct, the Court deems it appropriate that, instead of the harsh penalty of dismissal, she would be suspended for a period of six (6) months without pay, inclusive of the suspension for a period of 14 days which she had earlier served. Thereafter, petitioner hospital should reinstate respondent Edna R. De Castro to her former position without loss of seniority rights, full backwages, inclusive of allowances and other benefits, or their monetary equivalent, computed from the expiration of her suspension of six (6) months up to the time of actual reinstatement.

WHEREFORE, the petition is DENIED. The Decision dated May 24, 2006 and Resolution dated January 10, 2007 of the Court of Appeals, Special First Division, in CA-G.R. SP No. 73189, which reversed and set aside the Decision dated February 28, 2002 and Resolution dated May 31, 2002 of the National Labor Relations Commission, Second Division, are AFFIRMED WITH MODIFICATION insofar as respondent Edna R. De Castro is found guilty of gross negligence and is SUSPENDED for a period of SIX (6) MONTHS without pay, inclusive of the suspension for a period of 14 days which she had earlier served. Petitioner Hospital Management Services, Inc.-Medical Center Manila is ORDERED to reinstate respondent Edna R. De Castro to her former position without loss of seniority rights, full backwages, inclusive of allowances and other benefits, or their monetary equivalent, computed from the expiration of her suspension of six (6) months up to the time of actual reinstatement.