DIGEST/ KRIZABEL MARTINEZ/ GODOFREDO SISON vs CA

 

G.R. No. 124086             June 26, 2006

GODOFREDO S. SISON, in his capacity as Deputy Administrator, Social Security System, Petitioner,

vs.

COURT OF APPEALS and DR. CONCEPCION O. LIM-TAN, Respondents.

FACTS

SSS Cebu City Regional Office, then managed by petitioner, received several Medicare claims from respondent Dr. Concepcion O. Lim-Tan. Respondent is the proprietor of Leona O. Lim Memorial Hospital in Valencia, Bohol and the administrator of Paulina Lim Memorial Hospital in Guindulman, Bohol. The claims were supposedly for the medical care services by the hospitals to persons who represented themselves as SSS members or as dependents of SSS members.

Respondent made oral and written demands for payment upon petitioner. However, petitioner told respondent that there would be delays in the payment of her claims because there were irregularities which require further investigation.

In a demand letter, respondent again asked petitioner for payment of her claims. Respondent premised her demand on Medicare Circular No. 258, s. of 1988.

Respondent asserted that because no case has been filed suspending payment within the reglementary 90-day period, SSS Cebu City Regional Office should pay respondent within the 90-day period and subject the claim to pre-audit, without prejudice to the filing of a case at a later time.

Respondent filed a civil case for Mandamus and Damages before the RTC of Tagbilaran City. He wanted petitioner to pay not only the Medicare claims, but also included interest on the claims, moral and exemplary damages, and attorney’s fees and costs of the suit.

 

ISSUE

Whether petitioner can be compelled by mandamus to pay respondent’s claims

RULING

Yes. As a general rule, the performance of an official act or duty which necessarily involves the exercise of judgment cannot be compelled by mandamus. It is nonetheless also available to compel action, when refused, in matters involving judgment and discretion, but not to direct the exercise of judgment in a particular manner. However, this rule admits of exceptions. Mandamus is the proper remedy in cases where there is gross abuse of discretion, manifest injustice, or palpable excess of authority. The exception applies to the present case.

The court agrees with petitioner that his office has the discretionary authority to withhold payment of fraudulent claims. Contrary to petitioner’s assertions, the exercise of his discretionary authority to approve and deny claims is not absolute. Petitioner’s exercise of authority is defined by the limits provided by Circular No. 258. He can only deny a patently wrongful claim. For doubtful claims, petitioner only has two options: (1) file a case within 90 days and suspend payment or (2) pay within 90 days and subject the claim to pre-audit. Payment of the claim does not prejudice petitioner from filing a case at a later time. As in the present case, government’s inaction puts the financial standing of participating hospitals in a precarious position. Indeed, instead of placing a premium on participation in the government’s Medicare program, petitioner effectively punished an accredited provider by refusing to provide payment for services already rendered.