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Philamcare Insurance Contract Ruling

Philamcare refused to pay Ernani Trinos' hospitalization costs after he suffered a heart attack, claiming he failed to disclose pre-existing medical conditions in his health insurance application. Ernani's wife Julita sued Philamcare for damages. The Supreme Court ruled that Philamcare could not avoid the health coverage agreement. It determined the agreement was a non-life insurance contract covered by insurance law. The Court also found that Ernani answered the medical questions on his application in good faith without intent to conceal, as he was not a medical expert. Philamcare did not properly void the agreement before Julita filed suit.

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49 views1 page

Philamcare Insurance Contract Ruling

Philamcare refused to pay Ernani Trinos' hospitalization costs after he suffered a heart attack, claiming he failed to disclose pre-existing medical conditions in his health insurance application. Ernani's wife Julita sued Philamcare for damages. The Supreme Court ruled that Philamcare could not avoid the health coverage agreement. It determined the agreement was a non-life insurance contract covered by insurance law. The Court also found that Ernani answered the medical questions on his application in good faith without intent to conceal, as he was not a medical expert. Philamcare did not properly void the agreement before Julita filed suit.

Uploaded by

James William
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Philamcare v CA G.R. No. 125678.

March 18, 2002

379 SCRA 356 Mercantile Law Insurance Law Representation Concealment


Rescission of an Insurance Contract Health Care Agreement is an Insurance Contract
In 1988, Ernani Trinos applied for a health care insurance under the Philamcare Health
Systems, Inc. He was asked if he was ever treated for high blood, heart trouble, diabetes,
cancer, liver disease, asthma, or peptic ulcer; he answered no. His application was
approved and it was effective for one year. His coverage was subsequently renewed twice
for one year each. While the coverage was still in force in 1990, Ernani suffered a heart
attack for which he was hospitalized. The cost of the hospitalization amounted to
P76,000.00. Julita Trinos, wife of Ernani, filed a claim before Philamcare for the latter to pay
the hospitalization cost. Philamcare refused to pay as it alleged that Ernani failed to disclose
the fact that he was diabetic, hypertensive, and asthmatic. Julita ended up paying the
hospital expenses. Ernani eventually died. In July 1990, Julita sued Philamcare for
damages. Philamcare alleged that the health coverage is not an insurance contract; that the
concealment made by Ernani voided the agreement.
ISSUE: Whether or not Philamcare can avoid the health coverage agreement.
HELD: No. The health coverage agreement (health care agreement) entered upon by
Ernani with Philamcare is a non-life insurance contract and is covered by the Insurance
Law. It 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. There is no
concealment on the part of Ernani. He answered the question with good faith. He was not a
medical doctor hence his statement in answering the question asked of him when he was
applying is an opinion rather than a fact. Answers made in good faith will not void the policy.
Further, Philamcare, in believing there was concealment, should have taken the necessary
steps to void the health coverage agreement prior to the filing of the suit by Julita.
Philamcare never gave notice to Julita of the fact that they are voiding the agreement.
Therefore, Philamcare should pay the expenses paid by Julita.

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