Blue Cross Healthcare Inc. v.
Olivares
(GR 169737, February 12, 2008)
FACTS: Neomi Olivares applied for a health care program with petitioner Blue
Cross Health Care, Inc., a health maintenance firm. The application was
approved after Neomi paid the amount in full and in the health care agreement,
ailments due to "pre-existing conditions" were excluded from the coverage.
38 days from the effectivity of her health insurance, Neomi suffered a stroke and
underwent several laboratory tests. Consequently, she requested from the
representative of petitioner at Medical City a letter of authorization in order to
settle her medical bills. But petitioner refused to issue the letter and suspended
payment pending the submission of a certification from her attending physician
that the stroke she suffered was not caused by a pre-existing condition. After she
was discharged, it was her husband, Danilo Olivarez, who paid the medical bill.
Neomi and Danilo filed a complaint for collection of sum of money against
petitioner. The petitioner maintained that it had not yet denied respondents'
claim as it was still awaiting Dr. Saniel's report.
MeTC dismissed the complaint and ruled in favor of the petitioner, on the ground
that it was Neomi herself who prevented her attending physician from issuing the
required certification, petitioner cannot be faulted from suspending payment of
her claim. On appeal, RTC reversed the ruling of the MeTC and ordered
petitioner to pay the medical bill of respondents with legal interest, damages and
held that it was the burden of petitioner to prove that the stroke of respondent
Neomi was excluded from the coverage of the health care program for being
caused by a pre-existing condition. The CA affirmed the decision of RTC.
ISSUE: whether Neomi should be excluded from the coverage of the health care
agreement
RULING: No, petitioner failed to prove that respondent Neomi's stroke was
caused by a pre-existing condition and therefore, Neomi should not be excluded
from the coverage of the health care agreement.
Under the "pre-existing condition" in the health care agreement, petitioner is not
liable for pre-existing conditions if they occur within one year from the time the
agreement takes effect.
In Philamcare Health Systems, Inc. v. CA, 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.
Petitioner never presented any evidence to prove that respondent Neomi's stroke
was due to a pre-existing condition. It merely speculated that Dr. Saniel's report
would be adverse to Neomi, based on her invocation of the doctor-patient
privilege. This was a disputable presumption at best.
Furthermore, limitations of liability on the part of the insurer or health care
provider must be construed in such a way as to preclude it from evading its
obligations. Accordingly, they should be scrutinized by the courts with "extreme
jealousy" and "care" and with a "jaundiced eye." Since petitioner had the burden
of proving exception to liability, it should have made its own assessment of
whether respondent Neomi had a pre-existing condition when it failed to obtain
the attending physician's report. It could not just passively wait for Dr. Saniel's
report to bail it out. The mere reliance on a disputable presumption does not
meet the strict standard required under our jurisprudence.
DOCTIRNE: 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.
