Fortune Medicare v. Amorin
REITERATIONFacts
The Antecedents: David Robert U. Amorin (Amorin), a member of Fortune Medicare, Inc. (Fortune Care), incurred professional and hospitalization expenses amounting to US$7,242.35 and US$1,777.79, respectively, for an emergency appendectomy performed at St. Francis Medical Center in Honolulu, Hawaii, U.S.A. Upon his return, Fortune Care approved a reimbursement of ₱12,151.36, based on the average cost of an appendectomy in an accredited hospital in Metro Manila, net of medicare deduction. Amorin protested, demanding reimbursement of 80% of the total professional fees and hospitalization expenses based on "American standard" or "approved standard charges" as per Section 3, Article V of their Health Care Contract. Procedural History: The Regional Trial Court (RTC) dismissed Amorin's complaint, ruling that the contract intended to use the Philippine standard as the basis for reimbursement and that the amount paid extinguished Fortune Care's liability. The Court of Appeals (CA) reversed the RTC decision, ordering Fortune Care to reimburse 80% of the actual expenses incurred in the U.S.A., less the amount already paid. Fortune Care's motion for reconsideration was denied. The Petition: Fortune Care filed a petition for review on certiorari, arguing that the CA gravely erred in interpreting "approved standard charges" as not automatically meaning "Philippine Standard" and in affirming the application of the "American Standard Cost."
Issue(s)
Whether the phrase "approved standard charges" in the Health Care Contract, in the context of emergency confinement in a foreign territory, refers to the Philippine standard or the actual costs incurred; and whether Fortune Care intended to limit its liability to Philippine costs, given the contract's ambiguity. Whether Fortune Care's liability is limited to the costs that would have been incurred had the procedure been performed in an accredited hospital in the Philippines.
Ruling
The petition is bereft of merit. The Court affirms the decision of the Court of Appeals, ordering Fortune Medicare, Inc. to reimburse David Robert U. Amorin 80% of the actual hospitalization expenses and professional fees incurred in the U.S.A., less the amount already paid.
Ratio Decidendi
On the interpretation of "approved standard charges" and Fortune Care's liability for emergency confinement in a foreign territory: The Court held that health care agreements are in the nature of non-life insurance and are contracts of adhesion, which must be liberally construed in favor of the subscriber and strictly against the provider. The phrase "approved standard charges" in Section 3(B) of Article V of the Health Care Contract, pertaining to emergency care in a foreign territory, is ambiguous and does not explicitly state that it refers to the "Philippine standard." The contract recognized Fortune Care's liability for emergency treatments in foreign territories and expressly limited it to 80% of the "approved standard charges." The Court found no basis to deduce that these "standard charges" referred to the Philippine standard, as such a limitation was not clearly specified. The Court emphasized that if Fortune Care intended to limit its liability to Philippine costs, such limitations should have been distinctly specified in the contract. The absence of qualifying words limiting Fortune Care's liability to costs applicable in the Philippines means the amount payable should not be limited to the cost of treatment in the Philippines, to avoid disadvantaging the member. The Court noted that Fortune Care's subsequent agreement with the House of Representatives in 2006 modified the provision to clarify payment under "approved Philippine Standard covered charges," indicating that such limitations were not inherent in the original contract's wording. Therefore, the CA's interpretation, which favored the subscriber by applying the actual incurred costs as the basis for the 80% reimbursement, was correct. On Fortune Care's liability regarding costs incurred as if the procedure were performed in an accredited hospital: The RTC's inference of a "Philippine standard" from Section 3(A) was misplaced because Section 3(A) dealt with emergency care in accredited hospitals, a distinct scenario from emergency care in non-accredited hospitals abroad.
Main Doctrine
Health care agreements are contracts of adhesion and are liberally construed in favor of the subscriber. Ambiguities in the terms, especially exclusionary clauses, are strictly construed against the provider. In cases of emergency confinement in a foreign territory, the phrase 'approved standard charges' refers to the actual hospitalization costs and professional fees incurred, not necessarily the Philippine standard, unless clearly specified.