an act - oslpr.org act to establish the “bill of rights and responsibilities of the patient”;...
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(S.B. 1871)
(No. 194)
(Approved August 25, 2000)
AN ACT To establish the “Bill of Rights and Responsibilities of the Patient”;
provide the rights and responsibilities of the patients and users of medical-hospital health services in Puerto Rico, as well as of the providers of said services and their insurers; define terms; set procedures for solving complaints; impose penalties; and for other related purposes.
STATEMENT OF MOTIVES
One of the main objectives of the Government of Puerto Rico in recent
years has been to ensure that all citizens obtain proper access to quality
medical-hospital services and facilities according to their needs and
regardless of their socioeconomic conditions and capability for paying. This
important social objective, which in great measure answers to a tacit
commitment of the Constitution of Puerto Rico, arises from the conviction
that proper access to quality health services is both an essential element of
any valid definition to explain the concept of quality of life and a
fundamental human right, as has been proven by several decades of accrued
experience.
In order to fulfill this vital commitment to the people of Puerto Rico,
numerous laws, administrative measures and executive actions have been
approved and implemented in recent years so as to make true the dream of
providing all Puerto Rican families with proper access to quality health
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services regardless of their socioeconomic conditions. This important
objective has already been achieved to a great extent with the approval of
Act No. 71 of September 7, 1993, known as the “Puerto Rico Health
Insurance Administration Act.” However, in order to protect the health of
our people it is not enough to ensure the availability of and access to quality
health services; it is also necessary for the users of said health services to
know their rights and responsibilities and have access to all the information
necessary for them to make their own decisions.
Recent changes in the industry that provides medical-hospital health
services also contribute to the search for the means of ensuring that the users
and consumers of such services obtain all pertinent information available to
them when having to select the medical-hospital health services they will
use. The growing emphasis given today to the control and reduction of
health care costs, to the limitations imposed on the benefits and treatment
alternatives provided by many health programs and plans, to the approach to
preventive measures in health care matters and to the proliferation of
managed care plans and programs and health maintenance organizations
(HMOs) give greater importance to the matter of guaranteeing the free flow
of thorough, reliable and truthful information to health services users and
consumers. It is important for the users and consumers of such services to
be aware not only of their rights but also of their responsibilities, both
financial and otherwise, concerning the various alternatives for health and
treatment services available to them. In the final analysis, we are
considering the two faces of the same coin, that is, to ensure that the people
who use such services do so fully aware of their rights, obligations,
prerogatives and responsibilities concerning the alternatives available to
them.
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The promulgation of this Act shall visibly contribute to the formation of
a better informed, more aware and responsible and to be sure, healthier
population, and shall thus promote the most efficient use of the resources
available in this important area and in the long run be of considerable benefit
to the people of Puerto Rico. When all is said and done, this shall be an
additional component of the health reform and another tool in the constant
search for new alternatives and solutions to the health problems of our
people, particularly the economically disadvantaged.
Lastly, the inclusion of penalties to hospital-medical health services
providers and insurers for noncompliance with certain requirements of this
Act, including the failure to disclose all the information required by this Act
or for intentionally or knowingly disclosing false information, ensures that
the consumers shall have the information they need and require to make
those decisions that concern one of the most important aspects of the life of
all human beings: decisions pertaining to their health and that of their loved
ones.
BE IT ENACTED BY THE LEGISLATURE OF PUERTO RICO:
Section 1.—Title.—
This Act shall be known and may be cited as the “Bill of Rights and
Responsibilities of the Patient.”
Section 2.—Definitions.—
For the purposes of this Act the following terms shall have the meaning
indicated below:
(a) “Insurer”: means any person or entity duly authorized by the
Insurance Commissioner to conduct business as such in Puerto Rico that
assumes a contractual risk in consideration of or exchange for the payment
of a premium.
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(b) “Cover”: means all the benefits included in a health care plan for
the insured and beneficiaries of the same.
(c) “Commissioner”: refers to the Insurance Commissioner of Puerto
Rico.
(d) “Terminal Condition”: refers to a medical condition whose
prognosis is that the life expectancy of the person is of six (6) months or
less.
(e) “Department”: means the Department of Health of the
Commonwealth of Puerto Rico.
(f) “Medical Emergency”: refers to a medical condition made
manifest by sufficiently severe acute symptoms, including severe pain,
whereby a reasonably prudent lay person with average knowledge of health
and medical matters, may expect that without immediate medical attention
his health would be dangerously undermined or that the proper function of
any bodily member or organ would be seriously impaired or when it
concerns a pregnant woman having contractions, when there is not sufficient
time to transfer her to other installations before going into labor, or that to
transfer her would entail endangering the health of the woman or the unborn
child.
(g) “Insuring Entity”: refers to a health services organization
authorized pursuant to Chapter XIX of the Puerto Rico Insurance Code, or
an insurer authorized to enter into insurance contracts such as those defined
in Article 4.030 of said Code, as well as to any mutual benefit nonprofit
partnership or association founded in Puerto Rico prior to April 11, 1899.
(h) “Health Facilities”: means any facilities identified and defined as
such in Act No. 101 of June 26, 1965, as amended, known as the “Puerto
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Rico Health Facilities Act,” or the provisions of any future law concerning
said subject.
(i) “Act”: means the “Bill of Rights and Responsibilities of the
Patient.”
(j) “Patient”: refers to any subscriber of a Health Care Plan.
(k) “Person”: means any natural or juridical person born, created or
established pursuant to the laws of Puerto Rico.
(l) “Health Care Plan”: refers to the health care plans defined in
Article 19.020 of the Puerto Rico Health Insurance Code or to any insurance
contract similar in nature to such plans, regardless of the type of insuring
entity providing the latter.
(m) “Premium”: means the money paid to an insurer for assuming a
risk through an insurance contract.
(n) “Health Professional”: means any practitioner duly allowed to
practice in Puerto Rico, according to the applicable laws and regulations,
any of the health and medical care health professions including but not
limited to, physicians, surgeons, dentists, pharmacists, nurses and medical
technologists, as authorized by the corresponding laws of Puerto Rico.
(o) “Provider”: means any person or entity authorized by the laws of
Puerto Rico to render or provide medical-hospital health care services in the
Commonwealth of Puerto Rico.
(p) “Secretary”: means the Secretary of the Department of Health of
Puerto Rico.
Section 3.—Applicability.—
This Act shall apply to medical-hospital health services facilities, health
professionals and insurers and health care plans throughout the whole
jurisdiction of the Commonwealth of Puerto Rico, as said terms are defined
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in this Act and within the specific terms and conditions herein provided. It
shall cover all users and consumers of such services and facilities in Puerto
Rico, regardless of the public or private nature of the providers of such
services and of any consideration of the criteria regarding race, color,
gender, age, religion, ethnic or national origin or identification, political
ideology, present or future physical or mental disability, medical or genetic
information, social condition, sexual orientation or capability to pay or
means of paying of the user or consumer or said services and facilities.
Section 4.—Right to High Quality Health Services.—
Any patient shall be entitled to receive health services of the highest
quality, consistent with generally accepted medical practice principles.
Section 5.—Rights Concerning the Acquisition and Disclosure of
Information.—
Concerning the acquisition or disclosure of information any patient,
user or consumer of medical-hospital health services and facilities in Puerto
Rico shall be entitled to:
(a) Receive true, reliable, timely, sufficient and easily understood
information fitting to his needs concerning those health insurance plans and
health facilities and professionals he has selected or whose services he has
solicited, so as to be able to make well informed and intelligent decisions as
to the plans, facilities and professionals selected and pertaining to the health
services he may require.
(b) Receive adequate and sufficient information regarding the
benefits covered by the health plan; the cost of the premiums and deductible
payments; the mechanisms and procedures for recovering costs and
resolving disputes; the facilities and professionals participating in the plan
and their location; the quality control mechanisms and procedures and the
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guarantees for insured and beneficiary satisfaction; the procedures that
govern access to specialists and emergency services and the rules and
procedures, including the institutional policy of the plan, relative to health
care management.
(c) Receive adequate and sufficient information concerning the
education, licensing, certification and re-certification of health professionals;
their years in practice; their experience in providing treatment or conducting
pertinent tasks or procedures; the reasonable alternatives for treatment for
diagnosed conditions or ailments, including their cost and likelihood of
success; the quality control mechanisms and procedures and the guarantees
for patient, user or consumer satisfaction.
(d) Receive from medical and hospital health care facilities all
adequate and sufficient information in relation to the personnel and the
technical resources available for conducting a given procedure or service; to
the education, training, and experience of the personnel available to conduct
said procedures or services; to the mechanisms and procedures for quality
control and guarantees as to the satisfaction of patients, consumers or users
of their services.
Section 6.—Rights Concerning Plan and Provider Selection.—
Regarding the selection of health care plans and medical and hospital
health care service providers, all patients, consumers or users of such plans
and services in Puerto Rico are entitled to:
(a) An adequate and sufficient selection of health care plans and
medical and hospital health care service providers to guarantee access to
high-quality health care and services, in order for patients to be able to
choose the health care plans and providers that best suit their needs and
wishes, regardless of their social or financial status, or their ability to pay.
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(b) A network of sufficient authorized providers to guarantee that all
services covered under the plan will be accessible and available with no
undue delays and within reasonable geographical proximity in relation to the
homes and work places of the insured parties and beneficiaries, including
access to emergency services twenty-four (24) hours a day, seven (7) days a
week. All health care plans that offer health care service coverage in Puerto
Rico shall allow patients to receive their primary health care services from
any participating primary care service provider that the patients have chosen
pursuant to the provisions contained in the health care plan.
(c) All health care plans shall allow patients to receive specialized
health care services as necessary or appropriate for health maintenance
within the procedures for referrals under the health care plan. This includes
access to specialists qualified to render health care services to patients with
special conditions or needs as to their medical or health care, in order to
guarantee that insured parties and their beneficiaries shall have direct and
speedy access to the providers or qualified specialists of their choice from
among those in the plan’s network of providers to meet their health needs in
this sense; in the event that special authorization be required under the plan
for having such access to providers or qualified specialists, the plan shall
guarantee an appropriate number of consultations, in order for the health
needs of such insured parties and beneficiaries to be met.
Section 7.—Right of the Patient to Continue Health Care Services.—
All patients, consumers or users of medical and hospital health care
services in Puerto Rico are entitled to:
(a) All health care plans shall contain a clause providing that in cases
in which health care plan coverage is terminated or cancelled, or coverage
by a provider is terminated or cancelled, the insurer shall notify the patient
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of such termination or cancellation thirty (30) calendar days before the date
such termination or cancellation becomes effective.
(b) Subject to payment of premium as required, all health care plans
must contain a clause providing that should the plan or the provider
terminate coverage, the patient may continue receiving the benefits thereof
for a transitional period of ninety (90) days as of the date the plan or the
provider terminates coverage.
1. In those cases in which the patient is hospitalized at the time of
the date of said termination of coverage, and the release of the patient from
the hospital has been scheduled for a date preceding the date of termination
of coverage, the transition period shall be extended from said date to ninety
(90) days after the date the patient is released.
2. In those cases in which the patient is in her second trimester of
pregnancy as of the date of termination of coverage and the provider has
been offering medical treatment pertinent to the pregnancy before the date of
termination of coverage, the transitional period concerning pregnancy-
related health care shall be extended to the date the mother is released from
hospital after childbirth, or the date the newborn is released from the
hospital, or both, whichever occurs later.
3. In those cases in which the patient is diagnosed a terminal
condition before the date of termination of coverage and the provider has
been offering medical treatment pertinent to the condition before said date,
the transitional period shall be extended for the remainder of the patient’s
life.
Providers that continue the treatment of the insured parties or their
beneficiaries during said period must accept the payments and rates fixed by
the plan as full payment for services rendered, as well as continue providing
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the plan with all the necessary information required by the plan for purposes
of quality control, and surrender or transfer the medical records
corresponding to the patients upon termination of said transitional period.
Section 8.—Rights Concerning Access to Emergency Services and
Facilities.—
All patients, consumers, and users of medical and hospital health care
services in Puerto Rico are entitled to:
(a) Have free, direct and unrestricted access to emergency services
and facilities whenever and wherever the need may arise for such services
and facilities, regardless of the social or financial status or the ability to pay
of said consumer or user, and no health care plan may refuse payment or
coverage for emergency medical and hospital health care services to any
insured party or beneficiary.
(b) Health care plans shall provide their insured parties and
beneficiaries with reliable and thorough information concerning the
availability, location, and proper use of emergency services and facilities in
their respective area, as well as any provisions on the payment of premiums
and refund for costs related to said services and the availability of
comparable medical care outside said emergency facilities and services.
(c) All health care plans in Puerto Rico shall provide emergency
service benefits with no waiting period. The previous authorization of the
insurer shall not be required when providing these emergency services;
furthermore, these services shall be provided regardless of whether the
provider of such emergency services is a participating provider. In the event
that a patient is provided services by a provider not contracted by the
insurer, the patient shall not be held liable for the payment of services in an
amount exceeding the amount applicable if the patient had received such
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services from a provider contracted by the insurer. The insurer shall
compensate the provider offering the services, and the provider shall be
under the obligation to accept said compensation, for an amount not to be
less than the agreed with the providers contracted by the insurer to offer the
very same services. Moreover, under these circumstances, such emergency
services shall be provided regardless of the conditions set forth by the
corresponding health care plan.
(d) In those cases in which the patient receives health care services
after receiving the emergency services or post-stabilization services which
would be covered under the health care plan, except for the fact that a
nonparticipating provider is involved, the insurer shall compensate the
patient for that portion of the costs regarding said services received which
differs from the amount the patient would have paid under the plan’s
arrangement, provided there are sound medical grounds for which the patient
can not be transferred to the care of a participating provider.
(e) The personnel rendering services at an emergency facility shall
contact the patient’s primary care physician, should the patient have one, as
soon as the circumstances will allow to discuss the follow-up treatment
administered to the patient at said facility, the post-stabilization care given to
the patient, and the continuation of services, if any, required by the patient’s
condition.
Section 9.—Rights Concerning Participation in Decisions on
Treatment.—
All patients, consumers, or users of medical and hospital health care
services in Puerto Rico are entitled to:
(a) Participate fully in all decisions concerning their medical and
health care. In the cases of patients, consumers, or users of medical and
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hospital health care services who are unfit to participate fully in decisions
concerning their medical and health care, such patients, consumers, or users
shall be entitled to be represented in said decision-making process by either
parent; their guardian, custodian, tutor, or spouse; a relative; or by legal
counsel, proxy, or any person appointed by court for such purposes.
(b) All physicians and health care professionals shall provide their
patients with sufficient and appropriate information, as well as with the real
opportunity to have substantial participation in decisions concerning their
medical and health care, in order for the patients to be able to give their
consent in said decisions, including but not limited to the discussion of
treatment options in a manner comprehensible to the patients and the option
of refusing or not receiving any treatment at all; the costs, risks, and chances
of success of each of the treatment options or of no treatment at all; and any
future preference of the patients in the event they could lose their capability
to validly state their consent concerning the various treatment options.
(c) Give instructions or guidelines in advance regarding their
treatment, or appoint a person to act as their guardian should it become
necessary for the decision-making process. All physicians or health care
professionals shall discuss with their patients and the patients’ relatives the
matter of using such advanced instructions or guidelines to state their
preferences, including but not limited to the use of powers of attorney or
living wills. The provider shall honor such wishes to the extent these wishes
are allowed by law.
(d) All physicians or health care professionals shall respect and abide
by the decisions and preferences stated by their patients concerning the
treatment options discussed.
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(e) All physicians and health care professionals, as well as health care
plans, shall provide their patients, insured parties, and beneficiaries with
sufficient and adequate information pertaining to any factors, including
methods of payment and rates, as well as property, shares or interest held in
the medical and hospital health care services facility which could influence
the recommendation of the treatment options or alternatives.
(f) All health plans shall ascertain that their contracts with health care
providers of medical and hospital services are free from any gag clauses,
penalty clauses, or any other contractual mechanisms which may impair the
ability or capability of providers to contact the insured or the beneficiaries to
discuss all treatment options available, or to make specific recommendations
for treatment to the insured or the beneficiaries according to the professional
opinion and judgment of said providers.
(g) All health plans shall contain a provision setting forth that the
insurer shall pay the routine medical expenses of any patient suffering from
a life-threatening condition for which there is no effective treatment, when
the patient is eligible for participating in an authorized clinical treatment
study pursuant to the study protocol provisions concerning said treatment,
provided the participation of the patient offers a potential benefit to the
patient and the physician referring the patient believes that participation in
said study is pertinent, or the patient presents evidence of the fact that
participation in said study is pertinent. “Routine medical expenses of the
patient” shall not be construed to be expenses related to the study, or tests
administered to be used as part of the study, or expenses the entity
conducting the study is likely to pay.
(h) All physicians or health care professionals shall provide their
patients with the medical order for laboratory tests, X-rays or medication, in
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order for the patient to be able to freely select the health care facility to
receive these services.
Section 10.—Rights Concerning Respect and Equal Treatment.—
All patients, consumers, or users of medical and hospital health services
in Puerto Rico are entitled to be treated equally, courteously, and with
respect by all members of the health care industry, including but not limited
to health care professionals, health care plans, and health care facility
operators and providers at all times and under any circumstance. No
patient, consumer or user of health care medical and hospital services shall
be discriminated against for reason of the public or private nature of the
facilities or the provider of said services, or for reason of race, color, sex,
age, religion, ethnic origin or background, nationality, political ideology,
present or future physical or mental disability, medical or genetic
information, social status, sexual orientation, ability to pay, or means of
payment of the consumer or user of said services and facilities.
Section 11.—Rights Concerning the Confidentiality of Medical
Records and Information.—
All patients, consumers and users of medical and hospital services in
Puerto Rico are entitled to:
(a) Communicate freely, at ease, and in strict confidentiality with
their medical and hospital services health care providers.
(b) Feel fully confident that their medical and health information will
be kept in strict confidentiality by their medical and hospital services health
care providers, and that said information will not be disclosed without the
patients’ written consent, and any case, solely for medical or treatment
purposes, including the continuation or modification of medical care or
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treatment, or for prevention or quality control purposes, or in regards to the
payment of medical and hospital health care services.
(c) Feel confident that the unauthorized disclosure of information
contained in medical or health records will be made solely after a court order
has been issued or by specific authorization under the law, including but not
limited to investigations concerning the commission of fraud or crimes.
(d) All providers and insurers are to keep confidential all those files,
clinical records or documents containing information on the medical status
of any patient. All providers and insurers shall also take measures to protect
the privacy of their patients, safeguarding their identity.
(e) All providers and insurers shall allow all patients swift access to
their own records. Patients are entitled to receive a copy of their medical
record.
Section 12.—Rights Concerning Complaints and Grievances.—
All patients, consumers and users of medical and hospital health care
services in Puerto Rico are entitled to:
(a) Be afforded simple, fair, and effective mechanisms or procedures
to settle any differences with their health care plans, health care
professionals, and medical and hospital facilities and services health care
providers, as well as to be assured that said mechanisms and procedures
include internal quality controls and external supervision to guarantee their
reliability and efficiency.
(b) Be afforded internal mechanisms or procedures for appeals
concerning said institutional health care plans or providers, including the
timely written notice of any decision denying, limiting, or terminating the
services, or refusing payment for services, as well as the grounds or basis for
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such denial, limitation, or termination, and the mechanisms and procedures
available to appeal such decision.
(c) Prompt and timely settlement of all appeals filed by said
consumers or users, including the speedy solution of those cases concerning
urgent or emergency care, within the scope or standards required under
Medicare.
(d) Have their claims reviewed by duly qualified and fully accredited
health care professionals with training in the field pertaining to the treatment
in question, who have not taken part in the initial decision of which a review
is requested.
(e) Receive final written notice of the decision of which a review has
been requested by the patient, consumer, or user, including the basis or
grounds supporting said final decision and the external mechanisms or
remedies available under the law to appeal said decision before and external
entity.
(f) Simple, fair, and affordable mechanisms or procedures to settle
any differences in matters such as waiting periods, operating hours, conduct
of the personnel who handles the public, and the state and conditions of the
facilities.
(g) Any external system of appeals provided by a health care plan or
provider shall be available only in those cases in which consumers or users
have exhausted all internal remedies. Said system shall be under the
direction of duly qualified and fully accredited health professionals with
training in the field pertaining to the treatment in question, who have not
participated in the initial decision of which the review has been requested.
Said system shall follow reviewing standards based on the proof presented
and objective medical evidence. The system shall settle appeals in a fair,
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efficient and timely manner, which shall apply to any decision to deny, limit
or terminate coverage or payment for services on the grounds that the
treatment in question is on the experimental or research stage, or is not
necessary from the medical standpoint and exceeds reasonable costs, or
endangers the life or the health of the patient.
Section 13.—Responsibilities of Patients, Consumers or Users of
Medical and Hospital Health Care Services and Facilities.—
The vital nature of health care services calls for patients, consumers, or
users of medical and hospital health care facilities, and their relatives, to
participate in their care. However, patient satisfaction and health care
effectiveness is partially contingent upon the patients’ adequate fulfillment
of their responsibilities. These responsibilities are, among others:
(a) Patients are responsible for providing, to the best of their
knowledge, complete and accurate information regarding their present health
condition, past illnesses, medications, hospitalizations, and other related
matters.
(b) Patients are responsible for reporting unexpected changes in their
condition to the health care professional in charge of their treatment.
(c) Patients are responsible for informing that they clearly understand
the course of action expected from them.
(d) Patients are responsible for providing copies of their written
instructions or guidelines, if any, in advance, stating their wishes concerning
future medical treatment to extend their lives.
(e) Patients are responsible for informing their health care
professionals if they foresee any problems with the prescribed treatment.
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(f) Patients are responsible, as members of the community, for
knowing that providers are under the obligation to be efficient and fair in
providing care for other patients.
(g) Patients and their relatives are responsible for making reasonable
arrangements in order for the demands on the hospital, the medical staff, or
other employees, or the needs of other patients not to be burdened for the
actions of the patients or their relatives.
(h) Patients are responsible for furnishing the necessary health plan
information and for collaborating with their providers concerning their
respective financial arrangements when necessary for the timely payment of
all accounts and bills being remitted to patients.
(i) Patients are responsible for being aware of the effect their lifestyle
has on their health and for assuming the initial responsibility for their own
health and care. Patients themselves shall assume the responsibility for
preserving their health and for looking after their relatives.
(j) Patients are responsible for participating in all decisions
concerning their care.
(k) Patients are responsible for reporting to the pertinent authorities
any fraud or improper action they are aware of concerning medical and
hospital health care services and facilities.
(l) Patients are responsible for employing the internal mechanisms
and procedures established by health care providers or health plans to settle
their differences.
(m) Patients are responsible for being well-informed concerning their
health plan in terms of their coverage, options, benefits, limitations,
exclusions, and referrals, as well as procedures for filing, reviewing, and
settling complaints.
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(n) Patients are responsible for observing administrative and
operating procedures set forth by their health plans and their health care
service providers, and by government health benefit programs.
The responsibilities of patients set forth in this Section shall be
construed according to each specific case, considering the education and
social and financial status of the patient, in benefit of the patient; these
responsibilities shall not be construed to be a limitation on the exercise of
the powers conferred under Section 18 of this Act.
Section 14.—Powers and Responsibilities for Implementing this
Act.—
The Department of Health shall be responsible for implementing the
provisions of this Act. The Department shall therefore adopt and
promulgate the regulations necessary to meet these purposes, including but
not limited to the mechanisms for filing, processing, and settlement of
complaints and grievances.
Section 15.—Informative Sign Required.—
The Secretary of Health shall prepare and distribute before the date this
Act becomes effective and in sufficient amounts to be distributed among the
persons and entities indicated below, chargeable to the regular expenses
budget of the Department, an official sign, announcement or notice
concerning the approval of this Act and the provision of this Section
requiring that all persons and entities thus specified shall have at their
offices or place of business a copy or several copies of this Act available and
in sufficient amounts so that the patients, consumers or users of medical and
hospital health care services contracting their services may inspect said copy
at leisure.
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All insurers, health care plan, health care professional, and medical and
hospital health care service provider authorized to conduct business as such
in Puerto Rico shall have visibly displayed in their physician practice
offices, dispensaries, clinics, offices, admissions rooms, emergency rooms,
drug stores, or places of business at least one (1) copy of the official sign,
announcement or notice prepared by the Secretary of Health referred to in
the above paragraph, as well as copies of this Act in an amount sufficient to
allow consumers or users of medical and hospital health services contracting
or using their services to inspect said copies at leisure.
Section 16.—Statement by User or Consumer Required.—
All insurers, health care plans, health care professionals, and medical
and hospital health care services providers authorized to conduct business as
such in Puerto Rico shall require and demand from all their patients, insured
parties, or service users or consumers, or in the case of disabled or underage
persons, from the parents, guardians, custodians or tutors of the said persons,
that before signing any contract they read and be familiar with the “Bill of
Rights and Responsibilities of the Patient” or a suitable and reasonable
summarized version thereof, as prepared or authorized by the Department of
Health. As proof that this requirement has been fulfilled, the insurers, health
care plans, health care professionals, and medical and hospital health care
service providers shall also require from all patients, insured parties, users or
consumers of medical and hospital health care services contracting their
services, or in the case of disabled or underage persons, from the parents,
guardians, custodians, or tutors of the said persons, that before signing any
contract they sign a written statement or release attesting that they were
furnished a copy of, and have read and are familiar with the “Bill of Rights
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and Responsibilities of the Patient” or the summarized version approved by
the Department of Health.
Section 17.—Complaints and Related Procedures.—
(a) Any patients, insured parties, consumers or users of medical and
hospital health care services and facilities who deem that their rights under
the present Act have been violated, may file an administrative complaint
against the provider or insurer in question with the Department, concerning
matters such as:
1. The patient has not been provided with written
communications in Spanish or in English, according to the request of
the patient.
2. The patient is not being provided health services of a quality
consistent with the generally accepted principles in the practice of the
medical profession.
3. A provider refuses to provide emergency services which
should be covered pursuant to this Act; or an insurer has refused to
cover such services, or to pay the provider that provided such services,
or to reimburse the amount paid by the patient for such services which
the insurer is required to reimburse.
4. An insurer refuses to authorize a change of main provider as
requested by the patient.
5. A provider or an insurer impairs the right of the patient to
have access to specialized health care services.
6. An insurer refuses to continue the health care coverage
during the transition period as required by this Act.
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7. An insurer refuses to cover the routine medical expenses of
a patient undergoing clinical studies which should be covered pursuant
to this Act.
8. An insurer does not have a suitable infrastructure for
providing health care services, including specialized services.
9. A provider or an insurer has acted discriminatorily against a
patient for reason of race, ethnic background, national origin, religion,
sex, age, social background or status, political ideology, mental or
physical condition, sexual orientation, genetic makeup, and source or
means of payment for the health care services.
10. An insurer or a provider has disclosed patient information in
violation of this Act, or an insurer or provider has failed to take
measures to protect the patient’s right to privacy.
11. A provider refuses to furnish information to the patient as to
the health care services the patient will receive, or the provider does not
furnish comprehensible information on the matter.
12. An insurer does not inform the patient of the health care
services covered under the insurer’s health care plan as required under
this Act.
13. A provider restrains the patient from communicating with
the provider, without notifying the patient of the grounds for such a
restraint.
(b) Once the complaint is filed with the Department, the Department
shall determine whether the matter being brought before its consideration
falls under its scope of jurisdiction or under that of the Commissioner or the
Health Insurance Administration, after which the Department shall make a
referral as pertinent. Matters under the scope of jurisdiction of the
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Commissioner shall be construed to be matters involving disputes
concerning coverage or rights emanating from provisions set forth in a
health care plan, or disputes involving improper conduct or unfair practices
by an insurer pursuant to the Puerto Rico Insurance Code. Matters under the
scope of jurisdiction of the Health Insurance Administration shall be
construed to be those cases of which the processing corresponds to the
Administration pursuant to Act No. 72 of September 7, 1993, as amended,
known as the “Puerto Rico Health Insurance Administration Act.” In all
other cases remaining, the Department shall process the complaint.
The Department of Health, the Health Administration, and the Office of
the Insurance Commissioner of Puerto Rico shall be empowered, as part of
the complaint processing procedures, to impose fines as authorized under
Section 19 of this Act and pursuant to the provisions of Act No. 170 of
August 12, 1988, as amended, known as the “Uniform Administrative
Procedures Act of the Commonwealth of Puerto Rico.” All complaints shall
receive immediate attention.
Section 18.—Effect on Other Laws and Regulations.—
None of the provisions of this Act shall be construed to be excluding,
curtailing, limiting, undermining, or otherwise impairing the rights of any
natural or juridical person concerning the filing or claiming of any rights,
remedies, causes of action, or proceedings as granted, recognized, or
allowed under other laws or regulations, whether of a criminal, civil, or
administrative nature, before the pertinent judicial or administrative forums.
Section 19.—Penalties.—
Any insurer, health care plan, health care professional, or medical and
hospital health care service provider who defaults compliance of any of its
responsibilities or obligations imposed by this Act, shall be guilty of an
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administrative fault and sanctioned by a fine of not less than five hundred
(500) dollars and not greater than five thousand (5,000) dollars for each
instance or violation of the law.
Section 20.—Severability Clause.—
Should a court with competent jurisdiction find any section, subsection,
clause, subclause, paragraph, or item of this Act to be unconstitutional, such
finding shall have no effect on the remaining sections, subsections, clauses,
subclauses, paragraphs or items of this Act.
Section 21.—Appointed Guardian.—
These rights may be exercised by an appointed guardian when the
patient is not capable of making decisions, is declared legally incompetent,
or is underage.
Section 22.—Effectiveness.—
This Act shall take effect immediately after its approval, but shall be
applicable to those health care plans or renewals thereof entering into effect
as of the date of approval of this Act.
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October 19, 2001 Rolando Quevedo-Motta, Esq., Director of the Office of Legislative Services of the
Legislature of Puerto Rico, hereby certifies to the Secretary of State that he has duly
compared the English and Spanish texts of Act No. 194 (S.B. 1871) of the 7th Session of
the 13th Legislature of Puerto Rico, entitled:
AN ACT to establish the “Bill of Rights and Responsibilities of the Patient”; provide the rights and responsibilities of the patients and users of medical-hospital health services in Puerto Rico, as well as of the providers of said services and their insurers; define terms; set procedures for solving complaints; impose penalties; and for other related purposes,
and finds the same are complete, true and correct versions of each other. Rolando Quevedo-Motta
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