G.R. No. 125678 - Philamcare Health Systems, Inc. vs. Court of Appeals

On March 1, 1988, Ernani Trinos applied for health coverage with PhilamCare Health Systems, Inc., answering “no” to prior consultations or treatments for specified diseases.
PhilamCare issued Health Care Agreement No. P010194 for one year (March 1, 1988–March 1, 1989), renewed to March 1, 1990 and then to June 1, 1990, increasing coverage to a maximum of ₱75,000 per disability.

On March 9, 1990, Ernani suffered a heart attack and was confined at Manila Medical Center. Julita Trinos filed a claim under the Agreement.
PhilamCare denied the claim, alleging concealment of hypertension, diabetes, and asthma; respondent paid approximately ₱76,000 out of pocket. Ernani later received home therapy, was readmitted to Chinese General Hospital, and died on April 13, 1990.

On July 24, 1990, respondent sued in RTC Manila for reimbursement of medical expenses, moral and exemplary damages, and attorney’s fees. The trial court ordered PhilamCare to reimburse ₱76,000 plus interest, pay moral damages (₱10,000), exemplary damages (₱10,000), and attorney’s fees (₱20,000).
The Court of Appeals affirmed reimbursement but deleted all damages awards and absolved PhilamCare’s president, Dr. Reverente. PhilamCare’s motion for reconsideration was denied. PhilamCare then sought review before the Supreme Court.

Whether a Health Care Agreement is an insurance contract subject to the Insurance Code’s incontestability clause.
Whether concealment or misrepresentation of the applicant’s medical history voids the Agreement.
Whether respondent is entitled to reimbursement of medical and hospital expenses under the Agreement.