P.R. Laws tit. 24, § 3055
(a) Any patients, guardians, insured parties, consumers, or users of medical and hospital health care services and facilities who deem that their rights or those of their wards have been violated under this chapter 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 chapter; 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 chapter.
(7) An insurer refuses to cover the routine medical expenses of a patient undergoing clinical studies which should be covered pursuant to this chapter.
(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 chapter, 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 chapter.
(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 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 §§ 7001 et seq. of this title, 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 § 3057 of this title and pursuant to the provisions of §§ 2101 et seq. of Title 3, known as the “Uniform Administrative Procedures Act of the Commonwealth of Puerto Rico”. All complaints shall receive immediate attention.
History —Aug. 25, 2000, No. 194, § 17; Dec. 16, 2009, No. 176, § 9.