PHILAMCARE HEALTH SYSTEMS, INC. vs.

COURT OF APPEALS
FACTS:
Ernani Trinos applied for a health care coverage with Philamcare Health Systems, Inc. To the question
Have you or any of your family members ever consulted or been treated for high blood pressure, heart
trouble, diabetes, cancer, liver disease, asthma or peptic ulcer?, Ernani answered No. Under the
agreement, Ernani is entitled to avail of hospitalization benefits and out-patient benefits. The coverage
was approved for a period of one year from March 1, 1988 to March 1, 1989. The agreement was
however extended yearly until June 1, 1990 which increased the amount of coverage to a maximum
sum of P75,000 per disability.
During the period of said coverage, Ernani suffered a heart attack and was confined at the Manila
Medical Center (MMC) for one month. While in the hospital, his wife Julita tried to claim the benefits
under the health care agreement. However, the Philamcare denied her claim alleging that the
agreement was void because Ernani concealed his medical history. Doctors at the MMC allegedly
discovered at the time of Ernanis confinement that he was hypertensive, diabetic and asthmatic,
contrary to his answer in the application form. Thus, Julita paid for all the hospitalization expenses.
After Ernani was discharged from the MMC, he was attended by a physical therapist at home. Later, he
was admitted at the Chinese General Hospital. Due to financial difficulties, however, respondent
brought her husband home again. In the morning of April 13, 1990, Ernani had fever and was feeling
very weak. Respondent was constrained to bring him back to the Chinese General Hospital where he
died on the same day.
Julita filed an action for damages and reimbursement of her expenses plus moral damages attorneys
fees against Philamcare and its president, Dr. Benito Reverente. The Regional Trial court or Manila
rendered judgment in favor of Julita. On appeal, the decision of the trial court was affirmed but deleted
all awards for damages and absolved petitioner Reverente. Hence, this petition for review raising the
primary argument that a health care agreement is not an insurance contract; hence the
incontestability clause under the Insurance Code does not apply.

ISSUES:
(1) Whether or not the health care agreement is not an insurance contract
(2) Whether or not there is concealment of material fact made by Ernani

HELD:
(1)YES. Section2 (1)of the Insurance Code defines a contract of insurance as an agreement whereby
one undertakes for a consideration to indemnify another against loss, damage, or liability arising from
an unknown or contingent event.
Section 3 of the Insurance Code states that any contingent or unknown event, whether past or future,
which my damnify a person having an insurable against him, may be insured against. Every person has
an insurable interest in the life and health of himself.
Section 10 provides that every person has an insurable interest in the life and health (1) of himself, of
his spouse and of his children.
The insurable interest of respondents husband in obtaining the health care agreement was his own
health. The health care agreement was in the nature of non-life insurance, which is primarily a contract
of indemnity. Once the member incurs hospital, medical or any other expense arising from sickness,
injury or other stipulated contingent, the health care provider must pay for the same to the extent
agreed upon under the contract.
(2) NO. The answer assailed by petitioner was in response to the question relating to the medical
history of the applicant. This largely depends on opinion rather than fact, especially coming from
respondents husband who was not a medical doctor. Where matters of opinion or judgment are called
for answers made I good faith and without intent to deceive will not avoid a policy even though they
are untrue.
The fraudulent intent on the part of the insured must be established to warrant rescission of the
insurance contract. Concealment as a defense for the health care provider or insurer to avoid liability is
an affirmative defense and the duty to establish such defense by satisfactory and convincing evidence
rests upon the provider or insurer. In any case, with or without the authority to investigate, petitioner is
liable for claims made under the contract. Having assumed a responsibility under the agreement,
petitioner is bound to answer to the extent agreed upon. In the end, the liability of the health care
provider attaches once the member is hospitalized for the disease or injury covered by the agreement
or wherever he avails of the covered benefits which he has prepaid.
Being a contract of adhesion, the terms of an insurance contract are to be construed strictly against
the party which prepared the contract the insurer. By reason of the exclusive control of the insurance
company over the terms and phraseology of the insurance contract, ambiguity must be strictly
interpreted against the insurer and liberally in favor of the insured, especially to avoid forfeiture. This is
equally applicable to Health Care Agreements.