Philamcare Health Systems, Inc. vs.

Court of Appeals
G.R. No. 125678. March 18, 2002.

FACTS:

Ernani Trinos applied for a health care coverage with Philamcare Health Systems, Inc
and was approved for the period of one year from March 1, 1998 to March 1, 1999. Under
the agreement, he was entitled to avail hospitalisation whether ordinary or emergency.
Upon termination of the agreement, it was extended for another year from March 1, 1989
to March 1, 1990 and then, from March 1, 1990 to June 1, 1990.

During the period of coverage, Ernani suffered a heart attack and was confined at the
Manila Medical Centre (MMC) for one month beginning March 1, 1990. While in the
hospital, his wife tried to claim the benefits under the health care agreement. Philamcare
denied her claim saying the agreement was void for concealment of Ernani’s medical
history.

Ernani was discharged from MMC but was attended by a physical therapist at home. He
was later admitted at the Chinese General Hospital but due to financial difficulties, he was
brought home again. On April 13, 1990, Ernani had fever and was brought back to
Chinese General Hospital where he died the same day.

On July 24, 1990, Julia Trinos, wife of Ernani, instituted with the Regional Trial Court of
Manila an action for the reimbursement of her expenses and an action for damages
against petitioner. The RTC rendered judgement in favour of Julia.

On appeal, the Court of Appeals affirmed the decision of the trial court. Petitioner’s motion
for reconsideration was denied. Hence, this petition.

ISSUE:

Whether a health care agreement is an insurance contract.

HELD:

YES. A health care agreement is in the nature of non-life insurance, which is primarily a
contract of indemnity.—In the case at bar, the insurable interest of respondent’s husband
in obtaining the health care agreement was his own health. The health care agreement
was in the nature of non-life insurance, which is primarily a contract of indemnity. Once
the member incurs hospital, medical or any other expense arising from sickness, injury or
other stipulated contingent, the health care provider must pay for the same to the extent
agreed upon under the contract.

Since a health care agreement is in the nature of a contract of indemnity, payment should
be made to the party who incurred the expenses.—Petitioner alleges that respondent was
not the legal wife of the deceased member considering that at the time of their marriage,
the deceased was previously married to another woman who was still alive. The health
care agreement is in the nature of a contract of indemnity. Hence, payment should be
made to the party who incurred the expenses. It is not controverted that respondent paid
all the hospital and medical expenses. She is therefore entitled to reimbursement. The
records adequately prove the expenses incurred by respondent for the deceased’s
hospitalization, medication and the professional fees of the attending physicians.