Case Digest (G.R. No. 125678)
Facts:
Philamcare Health Systems, Inc. v. Court of Appeals and Julita Trinos, G.R. No. 125678, March 18, 2002, First Division, Ynares‑Santiago, J., writing for the Court. Petitioner Philamcare Health Systems, Inc. issued Health Care Agreement No. P010194 to Ernani Trinos for coverage from March 1, 1988, initially for one year and later extended through June 1, 1990; coverage was raised to a maximum of P75,000 per disability. The application form asked whether the applicant or any family member had ever consulted or been treated for listed illnesses (including high blood pressure, heart trouble, diabetes, asthma); Ernani answered “no.” The application included an authorization to obtain medical records and an express clause declaring that false statements would invalidate the Agreement and limit liability to return of membership fees.During the coverage period, Ernani suffered a heart attack and was hospitalized at Manila Medical Center beginning March 9, 1990. While confined, his wife, respondent Julita Trinos, sought to claim benefits under the Agreement; Philamcare denied the claim, asserting concealment because attending physicians allegedly discovered that Ernani was hypertensive, diabetic and asthmatic—contrary to his application. Respondent paid approximately P76,000 for hospitalization. Ernani was subsequently treated at home and later admitted to Chinese General Hospital, where he died on April 13, 1990.
On July 24, 1990, respondent sued Philamcare and its president, Dr. Benito Reverente, in the Regional Trial Court (RTC) of Manila, Branch 44 (Civil Case No. 90‑53795), seeking reimbursement of expenses, moral and exemplary damages, and attorney’s fees. The RTC rendered judgment for respondent ordering reimbursement of P76,000 with interest, moral damages P10,000, exemplary damages P10,000, attorneys’ fees P20,000 and costs. On appeal, the Court of Appeals affirmed the RTC’s ruling but d...(Pro-only)
Issues:
- Is a Health Care Agreement issued by Philamcare a contract of insurance (non‑life insurance) governed by the Insurance Code?
- May Philamcare avoid liability on the ground of concealment/misrepresentation of the insured’s medical history where the application contained answers allegedly untrue and an invalidation clause?
- Is respondent entitled to reimbursement of medical and hospitalization expenses she paid despite the insurer’s contention that she...(Pro-only)
Ruling:
- (Pro-only)
Ratio:
- (Pro-only)
Doctrine:
- (Pro-only)