Title
Fortune Medicare, Inc. vs. Amorin
Case
G.R. No. 195872
Decision Date
Mar 12, 2014
A health care contract dispute arose when Fortune Care reimbursed only Philippine rates for emergency surgery abroad, despite the contract's ambiguity favoring the subscriber. The Supreme Court ruled in favor of the subscriber, holding that "approved standard charges" referred to actual expenses incurred, not Philippine rates.
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Case Digest (G.R. No. 195872)

Facts:

  1. Parties Involved:

    • Petitioner: Fortune Medicare, Inc. (Fortune Care), a health maintenance organization.
    • Respondent: David Robert U. Amorin, a cardholder/member of Fortune Care and a permanent employee of the House of Representatives.

  2. Health Care Contract:

    • A Corporate Health Program Contract was executed on January 6, 2000, between Fortune Care and the House of Representatives, covering Amorin.
    • The contract provided terms for medical coverage, including emergency care in accredited and non-accredited hospitals.

  3. Emergency Surgery Abroad:

    • In May 1999, while on vacation in Honolulu, Hawaii, Amorin underwent an emergency appendectomy at St. Francis Medical Center.
    • He incurred professional fees of US$7,242.35 and hospitalization expenses of US$1,777.79.

  4. Reimbursement Claim:

    • Upon returning to Manila, Amorin sought reimbursement from Fortune Care for the full amount of his expenses.
    • Fortune Care approved only P12,151.36, based on the average cost of appendectomy in Metro Manila, net of medicare deductions.
    • Amorin accepted the amount under protest and requested an adjustment to cover 80% of the "approved standard charges" based on American standards, citing Section 3, Article V of the Health Care Contract.

  5. Fortune Care’s Defense:

    • Fortune Care argued that the contract did not cover hospitalization costs and professional fees incurred abroad, as its operation was confined to Philippine territory.
    • It also claimed that its liability was extinguished when Amorin accepted the P12,151.36 reimbursement.

  6. RTC Ruling:

    • The Regional Trial Court (RTC) of Makati dismissed Amorin’s complaint, ruling that the "approved standard charges" referred to Philippine rates, as the contract only covered nationwide accredited hospitals.

  7. CA Ruling:

    • The Court of Appeals (CA) reversed the RTC decision, holding that the contract should be liberally construed in favor of the subscriber.
    • The CA ordered Fortune Care to reimburse 80% of Amorin’s actual expenses, less the amount already paid.

Issue:

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Ruling:

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Ratio:

  1. Health Care Agreements as Contracts of Adhesion:

    • Health care agreements, like insurance contracts, are contracts of adhesion. Any ambiguity must be strictly construed against the provider and liberally in favor of the subscriber.

  2. Interpretation of "Approved Standard Charges":

    • The phrase "approved standard charges" in Section 3(B), Article V of the contract refers to the actual hospitalization costs and professional fees incurred, not the Philippine standard.
    • The contract expressly distinguished between emergency care in accredited hospitals (Philippine standard) and non-accredited hospitals (actual expenses).

  3. Liability for Emergency Care Abroad:

    • The contract recognized Fortune Care’s liability for emergency care in foreign territories, limiting it to 80% of the "approved standard charges."
    • The absence of a qualifying term limiting the charges to Philippine standards means Fortune Care’s liability should not be confined to Philippine rates.

  4. Rule on Ambiguity in Contracts:

    • Ambiguities in a contract are interpreted against the party that drafted it. Fortune Care, as the drafter, could have explicitly limited its liability to Philippine standards but failed to do so.


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