Case Digest (G.R. No. 195872) Core Legal Reasoning Model
Core Legal Reasoning Model
Facts:
In Fortune Medicare, Inc. v. David Robert U. Amorin (G.R. No. 195872, March 12, 2014; Decision dated November 17, 2014), petitioner Fortune Medicare, Inc. (“Fortune Care”) and respondent David Robert U. Amorin entered into a Corporate Health Program Contract on January 6, 2000, under which Fortune Care agreed to provide health maintenance services to its members. Amorin, a permanent House of Representatives employee, underwent an emergency appendectomy on May 1999 at St. Francis Medical Center in Honolulu, Hawaii, incurring professional fees of US$1,777.79 and hospitalization expenses of US$7,242.35. Upon his return to Manila, he filed for full reimbursement but Fortune Care only paid ₱12,151.36, computed on the basis of average Philippine costs for the same procedure. Relying on Section 3, Article V of the contract, which provided 100% coverage for emergency care in accredited Philippine hospitals and 80% coverage of approved standard charges for emergency care in non-accredite Case Digest (G.R. No. 195872) Expanded Legal Reasoning Model
Expanded Legal Reasoning Model
Facts:
- Parties and Contract
- Fortune Medicare, Inc. (Fortune Care) is a health maintenance organization that entered into a Corporate Health Program Contract on January 6, 2000 with the House of Representatives, covering its permanent employees, including respondent David Robert U. Amorin.
- The Contract’s Article V, Section 3 distinguishes between emergency care in accredited hospitals (Section 3(A)) and in non-accredited hospitals (Section 3(B)), and contemplates emergency confinement both within the Philippines and in foreign territories, prescribing reimbursement formulas and limitations.
- Emergency Surgery and Initial Reimbursement
- In May 1999, while on vacation in Honolulu, Hawaii, Amorin underwent an emergency appendectomy at St. Francis Medical Center, incurring professional fees of US$7,242.35 and hospitalization expenses of US$1,777.79.
- Upon return to Manila, he filed a claim with Fortune Care, which reimbursed him ₱12,151.36 based on the Philippine average cost for appendectomy net of Medicare deductions. Amorin accepted the amount under protest and demanded full professional fees plus 80% of the “approved standard charges” as per the Contract’s emergency-abroad provision.
- Judicial Proceedings
- Fortune Care denied further liability, arguing the Contract covered only Philippine-territory emergencies and that payment of ₱12,151.36 extinguished its obligation. Amorin filed a breach-of-contract suit with damages in RTC Makati.
- The RTC dismissed the complaint, ruling that “approved standard charges” must be Philippine rates. The CA reversed on September 27, 2010, ordering Fortune Care to reimburse 80% of the actual U.S. hospital and professional charges, less the ₱12,151.36 already paid. Fortune Care’s motion for reconsideration was denied (February 24, 2011), prompting this Rule 45 petition before the Supreme Court.
Issues:
- Contract Interpretation
- Does Section 3(B)’s phrase “approved standard charges” refer exclusively to Philippine standard charges even for emergency confinement in foreign territory?
- Does the Corporate Health Care Contract cover hospitalization costs and professional fees incurred abroad?
- Effect of Prior Payment
- Did Fortune Care’s payment of ₱12,151.36 under protest fully discharge its contractual liability?
- Can Amorin recover additional benefits despite having accepted partial reimbursement?
Ruling:
- (Subscriber-Only)
Ratio:
- (Subscriber-Only)
Doctrine:
- (Subscriber-Only)