By: Roel B. Araña

In Fortune Medicare, Inc. vs. David Robert U. Amorin (G.R. No. 195872, March 12, 2014), the Supreme Court ruled that the term “standard charges” in a health care contract refers to the actual hospitalization costs and professional fees which were cited as compensable even when incurred in a foreign country.

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 his medical coverage were provided in a Corporate Health Program Contract (Health Care Contract) executed between Fortune Care and the Philippine House of Representatives where he was a permanent employee.

While on vacation in Hawaii, Amorin underwent an emergency appendectomy, causing him to incur professional and hospitalization expenses of US$7,242.35 and US$1,777.79, respectively. When he attempted to recover from Fortune Care, the latter merely approved a reimbursement of Php12,151.36 (about US$ 275) which is the amount based on the average cost of appendectomy if the procedure were to be performed in an accredited hospital in Metro Manila.

Amorin received the approved amount under protest and asked for its adjustment to cover the entire amount of professional fees and at least eighty (80%) of the approved standard charges based on US standard considering that the surgery was performed in the United States. To justify his claim, he cited Section 3, Article V of the Health Care Contract, to wit:

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 Fortune Care 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.

B. EMERGENCY CARE IN NON-ACCREDITED HOSPITAL 1. Whether as an in-patient or out-patient, Fortune Care shall reimburse 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. The above coverage applies only to emergency confinement within Philippine territory. However, if the emergency confinement occurs in foreign territory, Fortune Care will be obligated to reimburse or pay eighty (80%) percent of the approved standard charges which shall cover the hospitalization costs and professional fees.

Fortune Care denied Amorin’s request which prompted the latter to file a complaint for breach of contract with damages. In denying the request, Fortune Care argued that the Health Care Contract did not cover hospitalization costs and professional fees incurred in foreign countries and that its liability to Amorin had already been extinguished when the latter accepted the P12,151.36 payout.

The trial court dismissed Amorin’s complaint finding that the parties intended to use the Philippine standard as basis for the computation of the amount of reimbursement. The Court of Appeals, however, reversed the trial court’s decision and pointed out that, like insurance contracts, Fortune Care’s Health Care Contract must be liberally construed in favor of the subscriber and that doubtful provisions of the contract should be strictly construed against the provider.

The Supreme Court affirmed the CA’s finding that Fortune Care’s liability to Amorin should be based on the actual expenses he incurred for hospital and professional fees, which should not be limited to the amount that he would have incurred had the procedure been performed in an accredited hospital in the Philippines.

Instead of determining Philippine or American standards, the High Court interpreted “standard charges” in Section 3 to mean 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. For treatments in foreign territories, Fortune Care should only reimburse the subscriber 80% of the cost.

The High Tribunal reiterated the principle that ambiguities in a contract are interpreted against the party who caused the ambiguity. In this case, Fortune Care cannot raise the argument that the premium and other charges in the Health Care Contract were merely computed based on assumption and risk under Philippine cost and not under any foreign standard since such limitation should have been specified and reflected in the extent of coverage which the company voluntarily assumed. LF©


(April 25, 2014)


 

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