P.R. Laws tit. 26, § 1912
(1)
(a) Every health services organization shall establish and maintain a complaints procedure approved by the Commissioner upon consultation with the Secretary of Health, which shall establish a reasonable procedure for the prompt solution of complaints filed by any subscriber or provider, and which are related to the provisions of the health care plan. Said procedure shall, at least, contemplate the solution of matters such as claims for reimbursements, cancellation, nonrenewal or denial of a health care plan or any benefit thereunder, and complaints regarding the quality of the health care services offered by the providers or the organization itself.
(b) The complaints procedure shall include the designation of a Grievance Committee which shall not exceed five (5) members and on which the subscribers of individual contracts, the subscribers of the different group plans and the providers shall be represented. The representatives shall not be employees, officials, directors or shareholders of the health services organization, and shall be members of the Committee for a period of not less than one (1), nor more than three (3) years.
The Commissioner shall establish by regulations the procedures to be used in selecting the Complaints Committee.
(c) Every health services organization shall give a reasonable answer through its Complaints Committee to each written complaint received by it, within the period of thirty (30) days after said written complaint was filed.
(d) Any complaint in which an unfair practice or a violation of any applicable provision of this Code is imputed shall be referred to the Commissioner.
(e) In addition to establishing an individual file for each complaint, each health services organization shall keep a complete registry of all the complaints it receives. Said registry shall include, at least, the complainant’s name and address, the subject of the complaint, the date the complaint was resolved, how the complaint was disposed of and how long it took to resolve it. The individual files as well as the registries mentioned in this section shall be subject to inspection by the Commissioner or the Secretary of Health.
(f) Each health service organization shall submit an annual report to the Commissioner and to the Secretary of Health, in the manner prescribed by the Commissioner on or before March 31 of the year following the report year. The fee for the filing of said annual report shall be twenty-five dollars ($25).
(2) This section shall not hinder the subscriber or complainant from seeking other remedy available in this title.
History —Ins. Code, added as § 19.120 on July 2, 1987, No. 88, p. 337, § 7.