Source: http://lawlibrary.chanrobles.com/index.php?option=com_content&view=article&id=82843:56685&catid=1581&Itemid=566
Timestamp: 2019-04-23 04:13:33+00:00

Document:
G.R. No. 195872, March 12, 2014 - FORTUNE MEDICARE, INC., Petitioner, v. DAVID ROBERT U. AMORIN, Respondents.
FORTUNE MEDICARE, INC., Petitioner, v. DAVID ROBERT U. AMORIN, Respondents.
This is a petition for review on certiorari1 under Rule 45 of the Rules of Court, which challenges the Decision2 dated September 27, 2010 and Resolution3 dated February 24, 2011 of the Court of Appeals (CA) in CA- G.R. CV No. 87255.
David Robert U. Amorin (Amorin) was a cardholder/member of Fortune Medicare, Inc. (Fortune Care), a corporation engaged in providing health maintenance services to its members. The terms of Amorin’s medical coverage were provided in a Corporate Health Program Contract4 (Health Care Contract) which was executed on January 6, 2000 by Fortune Care and the House of Representatives, where Amorin was a permanent employee.
A. EMERGENCY CARE IN ACCREDITED HOSPITAL. Whether as an in-patient or out-patient, the member shall be entitled to full coverage under the benefits provisions of the Contract at any FortuneCare accredited hospitals subject only to the pertinent provision of Article VII (Exclusions/Limitations) hereof. For emergency care attended by non affiliated physician (MSU), the member shall be reimbursed 80% of the professional fee which should have been paid, had the member been treated by an affiliated physician. The availment of emergency care from an unaffiliated physician shall not invalidate or diminish any claim if it shall be shown to have been reasonably impossible to obtain such emergency care from an affiliated physician.
Still, Fortune Care denied Amorin’s request, prompting the latter to file a complaint7 for breach of contract with damages with the Regional Trial Court (RTC) of Makati City.
For its part, Fortune Care argued that the Health Care Contract did not cover hospitalization costs and professional fees incurred in foreign countries, as the contract’s operation was confined to Philippine territory.8 Further, it argued that its liability to Amorin was extinguished upon the latter’s acceptance from the company of the amount of P12,151.36.
On the basis of the clause providing for reimbursement equivalent to 80% of the professional fee which should have been paid, had the member been treated by an affiliated physician, the Court concludes that the basis for reimbursement shall be Philippine rates. That provision, taken with Article V of the health program contract, which identifies affiliated hospitals as only those accredited clinics, hospitals and medical centers located “nationwide” only point to the Philippine standard as basis for reimbursement.
Dissatisfied, Amorin appealed the RTC decision to the CA.
WHEREFORE, all the foregoing premises considered, the instant appeal is hereby GRANTED. The May 8, 2006 assailed Decision of the Regional Trial Court (RTC) of Makati City, Branch 66 is hereby REVERSED and SET ASIDE, and a new one entered ordering Fortune Medicare, Inc. to reimburse [Amorin] 80% of the total amount of the actual hospitalization expenses of $7,242.35 and professional fee of $1,777.79 paid by him to St. Francis Medical Center pursuant to Section 3, Article V of the Corporate Health Care Program Contract, or their peso equivalent at the time the amounts became due, less the [P]12,151.36 already paid by Fortunecare.
Fortune Care’s motion for reconsideration was denied in a Resolution16 dated February 24, 2011. Hence, the filing of the present petition for review on certiorari.
The Court finds no cogent reason to disturb the CA’s finding that Fortune Care’s liability to Amorin under the subject Health Care Contract should be based on the expenses for hospital and professional fees which he actually incurred, and should not be limited by the amount that he would have incurred had his emergency treatment been performed in an accredited hospital in the Philippines.
In Philamcare Health Systems, Inc. v. CA, we ruled that a health care agreement is in the nature of a non-life insurance. It is an established rule in insurance contracts that when their terms contain limitations on liability, they should be construed strictly against the insurer. These are contracts of adhesion the terms of which must be interpreted and enforced stringently against the insurer which prepared the contract. This doctrine is equally applicable to health care agreements.
The point of dispute now concerns the proper interpretation of the phrase “approved standard charges”, which shall be the base for the allowable 80% benefit. The trial court ruled that the phrase should be interpreted in light of the provisions of Section 3(A), i.e., to the extent that may be allowed for treatments performed by accredited physicians in accredited hospitals. As the appellate court however held, this must be interpreted in its literal sense, guided by the rule that any ambiguity shall be strictly construed against Fortune Care, and liberally in favor of Amorin.
The Court agrees with the CA. As may be gleaned from the Health Care Contract, the parties thereto contemplated the possibility of emergency care in a foreign country. As the contract recognized Fortune Care’s liability for emergency treatments even in foreign territories, it expressly limited its liability only insofar as the percentage of hospitalization and professional fees that must be paid or reimbursed was concerned, pegged at a mere 80% of the approved standard charges.
The word “standard” as used in the cited stipulation was vague and ambiguous, as it could be susceptible of different meanings. Plainly, the term “standard charges” could be read as referring to the “hospitalization costs and professional fees” which were specifically cited as compensable even when incurred in a foreign country. Contrary to Fortune Care’s argument, from nowhere in the Health Care Contract could it be reasonably deduced that these “standard charges” referred to the “Philippine standard”, or that cost which would have been incurred if the medical services were performed in an accredited hospital situated in the Philippines. The RTC ruling that the use of the “Philippine standard” could be inferred from the provisions of Section 3(A), which covered emergency care in an accredited hospital, was misplaced. Evidently, the parties to the Health Care Contract made a clear distinction between emergency care in an accredited hospital, and that obtained from a non-accredited hospital. The limitation on payment based on “Philippine standard” for services of accredited physicians was expressly made applicable only in the case of an emergency care in an accredited hospital.
The proper interpretation of the phrase “standard charges” could instead be correlated with and reasonably inferred from the other provisions of Section 3(B), considering that Amorin’s case fell under the second case, i.e., emergency care in a non-accredited hospital. Rather than a determination of Philippine or American standards, the first part of the provision speaks of the full reimbursement of “the total hospitalization cost including the professional fee (based on the total approved charges) to a member who receives emergency care in a non-accredited hospital” within the Philippines. Thus, for emergency care in non-accredited hospitals, this cited clause declared the standard in the determination of the amount to be paid, without any reference to and regardless of the amounts that would have been payable if the treatment was done by an affiliated physician or in an affiliated hospital. For treatments in foreign territories, the only qualification was only as to the percentage, or 80% of that payable for treatments performed in non-accredited hospital.
WHEREFORE, the petition is DENIED. The Decision dated September 27, 2010 and Resolution dated February 24, 2011 of the Court of Appeals in CA-G.R. CV No. 87255 are AFFIRMED.
2 Penned by Associate Justice Franchito N. Diamante, with Associate Justices Josefina Guevara-Salonga and Mariflor P. Punzalan Castillo, concurring; id. at 199-211.
9 Issued by Pairing Judge Rommel O. Baybay; id. at 100-104.
18Philamcare Health Systems, Inc. v. CA, 429 Phil. 82, 90 (2002); see also Philippine Health Care Providers, Inc. v. Commissioner of Internal Revenue, G.R. No. 167330, September 18, 2009, 600 SCRA 413, 435-436.
19 429 Phil. 82 (2002).
21 568 Phil. 526 (2008).
25Garcia v. CA, 327 Phil. 1097, 1111 (1996).

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