Case Summary (G.R. No. 217455)
Contract Provisions on Emergency Care
– Section 3(A): Full coverage in accredited hospitals; 80% of professional fees for unaffiliated physicians, based on Philippine rates.
– Section 3(B): Total reimbursement for emergency care in non-accredited Philippine hospitals; for emergencies abroad, 80% of “approved standard charges” covering both hospitalization and professional fees.
Procedural History
– RTC (Makati City) dismissed respondent’s breach-of-contract claim, interpreting “approved standard charges” as Philippine rates.
– Respondent appealed; the CA reversed, awarding 80% of actual U.S. expenses less the ₱12,151.36 already paid.
– Fortune Care filed a petition under Rule 45, contesting the CA’s interpretation of “approved standard charges.”
Issue
Whether the phrase “approved standard charges” in Section 3(B) refers exclusively to Philippine cost standards or to the actual hospitalization and professional fees incurred abroad.
Lower Courts’ Rulings
– RTC: Concluded that reimbursement must be based on Philippine standard charges, applying Section 3(A) to the foreign emergency.
– CA: Held that the phrase is ambiguous and must be interpreted in favor of the member; awarded 80% of respondent’s actual U.S. expenses.
Legal Framework and Interpretation Principles
Health care agreements are characterized as non-life insurance contracts of indemnity. Under the 1987 Constitution and prevailing jurisprudence:
– Contracts of adhesion are strictly construed against the drafter (the insurer or provider).
– Ambiguities are resolved in favor of coverage and against exclusionary provisions.
– Limitations on liability must be clear, specific, and not inferred by isolation.
Supreme Court’s Analysis
The term “approved standard charges” is vague and susceptible to dual interpretation. The contract expressly contemplates foreign emergency care and limits liability only by percentage, not by geographic co
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Facts
- David Robert U. Amorin was a permanent employee of the House of Representatives and a member-cardholder of Fortune Medicare, Inc. (“Fortune Care”).
- Amorin’s medical benefits were governed by a Corporate Health Program Contract executed on January 6, 2000.
- In May 1999, while vacationing in Honolulu, Hawaii, Amorin underwent an emergency appendectomy at St. Francis Medical Center, incurring professional fees of USD 1,777.79 and hospitalization expenses of USD 7,242.35.
- Upon return to Manila, Amorin sought full reimbursement from Fortune Care but received only PHP 12,151.36, calculated on the average Philippine cost of an appendectomy, net of Medicare deductions.
- Amorin paid the PHP 12,151.36 under protest and sought adjustment to cover his actual U.S. expenses and 80% of American standard charges for emergency care abroad.
- Section 3, Article V of the Health Care Contract distinguished between:
- Emergency care in accredited hospitals, reimbursable at full coverage or 80% of professional fees if attended by non-affiliated physicians;
- Emergency care in non-accredited hospitals, reimbursable fully within Philippine territory, and at 80% of “approved standard charges” when abroad.
Issue
- Whether Fortune Care’s obligation for emergency care abroad is limited to costs based on a Philippine standard or extends to 80% of the actual “approved standard charges” incurred in the foreign territory.
RTC Decision (Makati, Branch 66)
- Dismissed Amorin’s breach of contract complaint.
- Held that “approved standard charges” must be rea