(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