MEDICAL NEGLIGENCE CASE pursue such claim, a patient must prove that a health care
provider in most cases a physician, either failed to do
Li vs Spouses Soliman
GR No. 165279 June 7, 2011
Facts: On July 7, 1993, respondents 11 year old daughter,
Angelica Soliman underwent a biopsy of the mass located in
her lower extremity at the St. Lukes Medical Center (SLMC).
Results showed that Angelica was suffering from
osteosaucoma, ostiobiostic type, a high-grade (highly
malignant) cancer of the bone which usually affects teenage
children. Following this diagnosis, Angelica’s right leg was
amputated by Dr. Tamayo in order to remove the tumor. As
a adjuvant treatment to eliminate any remaining cancer cells,
and hence minimizing the chances of recurrence and
prevent the decease from spreading to other parts of the
patient’s body, chemotherapy was suggested by Dr. Tamayo
and referred Angelica to another doctor at SLMC, herein
petitioner Dr. Rubi Li, a medical oncologist.
On July 23, 1993, petitioner saw the respondents at the
hospital after Angelica’s surgery and discussed with them
Angelica’s condition. Petitioner told respondents that
Angelica should be given 2-3 weeks to recover from the
operation before starting the chemotherapy. Respondents
were apprehensive due to financial constraints as Reynaldo
earns only from P70,000-150,000 a year from his jewelry
and watching repair business. Petitioner, however, assured
them not to worry about her professional fee and told them
to just save up for medicines to be used.
As the chemotherapy session started, day by day, Angelica
experience worsening condition and other physical effect on
the body such as discoloration, nausea, and vomiting.
Petitioner claimed, that she explained to respondents that
even when a tumor is removed, there are still small lesions
undetectable to the naked eye and that adjuvant
chemotherapy is needed to clean out the small lesions in
order to lessen the chance of cancer to recur. She did not
give the respondents any assurance that chemotherapy will
cure Angelica’s cancer. During these consultations with
respondents, she explained the following side effects of
chemotherapy treatment to respondents: 1.) Falling hair; 2.)
nausea and vomiting; 3.) loss of appetite; 4.) low count of
WBC, RBC, and platelets; 5.) possible sterility due to the
effects on Angelica’s ovary; 6.) Damage to kidney and heart;
7.) darkening of the skin especially when exposed to
sunlight. She actually talked to the respondents four times,
once at the hospital after the surgery, twice at her clinic and
fourth when Angelica’s mother called her through long
distance. This was disputed by respondents who countered
that petitioner gave them assurance that there is 95%
chance of healing for Angelica if she undergoes
chemotherapy and that the only side effects were nausea,
vomiting and hair loss. Those were the only side effects of
chemotherapy mentioned by petitioner.
Issue: Whether or not petitioner committed medical
malpractice.
Held: No. The type of lawsuit which has been called medical
malpractice or more appropriately, medical negligence, is
that type of claim which a victim has available to him or her
to redress a wrong committed by a medical professional
which has caused bodily harm. In order to successfully
something which a reasonably prudent health care provider
would have done or that he or she did something that a
reasonably health care provider would not have done; and
that failure or action caused injury to the patient.
Medical negligence cases are best proved by opinions of
expert witnesses belonging in the same general
neighborhood and in the same general line of practice as
defendant physician or surgeon. The deference of courts to
the expert opinion of qualified physicians stems from the
former’s realization that the latter possess unusual technical
skills which layman in most instances are incapable of
intelligently evaluating, hence the indispensability of expert
testimonies.
The doctrine of informed consent within the context of
physician-patient relationships goes as far back into english
common law. As early as 1767, doctors were charged with
the tort of battery if they have not gained the consent of their
patients prior to performing a surgery or procedure. In the
United States, the seminal case was Schoendorff vs Society
of New York Hospital which involved unwanted treatment
performed by a doctor. Justice Bejamin Cardozo oft-quoted
opinion upheld the basic right of a patient to give consent to
any medical procedure or treatment; every human being of
adult year and sound mind has a right to determine what
shall be done with his own body; and a surgeon who
performs an operation without his patient’s consent commits
an assault, for which he is liable in damages. From a purely
ethical norm, informed consent evolved into a general
principle of law that a physician has a duty to disclose what a
reasonably prudent physician in the medical community in
the exercise of reasonable care would disclose to his patient
as to whatever grave risk of injury might be incurred from a
proposed course of treatment, so that a patient, exercising
ordinary care for her own welfare and faced with a choice of
undergoing the proposed treatment, as alternative treatment,
or none at all, may intelligently exercise his judgement by
reasonably balancing the probable risk against the probable
benefits.
There are four essential elements a plaintiff must proved in a
malpractice action based upon the doctrine of informed
consent: 1.) the physician had a duty to disclose material
risks; 2.) he failed to disclose or inadequately disclosed
those risks; 3.) as a direct and proximate result of the failure
to disclose, the patient consented to treatment she otherwise
would not have consented to; and 4.) plaintiff was injured by
the proposed treatment. The gravamen in an informed
consent requires the plaintiff to point to significant
undisclosed information relating to the treatment which could
have altered her decision to undergo it.
Examining the evidence, we hold that there was adequate
disclosure of material risks inherent in chemotherapy
procedure performed with the consent of Angelica’s parents.
Respondents could not have been unaware in the course of
initial treatment and amputation of Angelica’s lower extremity
that her immune system was already weak on account of
the malignant tumor in her knee. When petitioner informed
the respondents beforehand of the side effects of
chemotherapy which includes lowered counts of white and
red blood cells, decrease in blood platelets, possible kidney
or heart damage and skin darkening, there is reasonable
expectation on the part of the doctor that the respondents
understood very well that the severity of these side effects
will not be the same for all patients undergoing the
procedure. In other words, by the nature of the disease itself,
each patients reaction to the chemical agents even with pre-
treatment laboratory tests cannot be precisely determined by
the physician. That death can possibly result from
complications of the treatment or the underlying cancer itself,
immediately or sometime after the administration of
chemotherapy drugs, is a risk that cannot be ruled out, as
with most other major medical procedures, but such
conclusion can be reasonably drawn from the general side
effects of chemotherapy already disclosed.
Professional Services Inc. vs Agana
GR No. 126297 January 31, 2007
Facts: On April 4, 1984, Natividad Agana was rushed to the
Medical City General Hospital because of difficulty of bowel
movement and bloody anal discharge. After a series of
medical examinations, Dr. Miguel Ampil diagnosed her to be
suffering from Cancer of the sigmoid. On April 11, 1984, Dr.
Ampil assisted by the medical staff of the Medical City
Hospital performed an Anterior resection surgery on
Natividad. He found that the malignancy on her sigmoid area
had spread on her left ovary, necessitating the removal of
certain portions of it. Thus, Dr. Ampil obtained the consent of
Natividad’s husband, Enrique Agana, to permit Dr. Juan
Fuentes to perform hysterectomy on her. After Dr. Fuentes
had completed the hysterectomy, Dr. Ampil took over,
completed the operation and closed the incision after
searching for the missing 2 gauzes as indicated by the
assisting nurses but failed to locate it. After a couple of days,
Natividad complained of excruciating pains in her anal region
but Dr. Ampil said it is a natural consequence of the
operation/surgery and recommended that she consult an
oncologist to examine the cancerous nodes which were not
removed during the operation. Natividad and her husband
went to the US to seek further treatment and she was
declared free from cancer. A piece of gauze portruding from
Natividad’s vagina was found by her daughter which was
then removed by hand by Dr. Ampil and assured that the
pains will vanished. However, it didn’t. The pains intensified
prompting Natividad to seek treatment at the Polymedic
General Hospital. While confined there, Dr. Ramon Guttierez
detected the presence of another foreign object in her vagina
– a foul smelling gauze measuring 1.5 inches in width which
badly infected her vagina. A recto-vaginal fistula had forced
stool to excrete through her vagina. Another surgical
operation was needed to remedy the damage.
Issue: Whether or not Dr. Ampil and Fuentes are liable for
medical malpractice and the PSI for damages due to the
negligence of the said doctors.
Held: Yes. No. Yes. An operation requiring the placing of
sponges in the incision is not complete until the sponges are
properly removed and it is settled that the leaving of sponges
or other foreign substances in the wound after the incision
has been closed is at least prima facie negligence by the
operating surgeon. To put it simply, such act is considered
so inconsistent with due care as to raise inference of
negligence. There are even legions of authorities to the
effect that such act is negligence per se.
This is a clear case of medical malpractice or more
appropriately, medical negligence. To successfully pursue
this kind of case, a patient must only prove that a health care
provider either failed to do something which a reasonably
prudent health care provider would have done, or that he did
something that a reasonably prudent provider would not
have done; and that failure or action caused injury to the
patient. Simply puts the elements are duty, breach, injury,
and proximate causation. Dr. Ampil, as the lead surgeon,
had the duty to remove all foreign objects, such as gauzes,
from Natividad’s body before closure of the incision. When
he failed to do so, it was his duty to inform Natividad about it.
Dr. Ampil breached both duties. Such breach caused injury
to Natividad, necessitating her further examination by
American doctors and another surgery. That Dr. Ampil’s
negligence is the proximate cause of Natividad’s injury could
be traced from his act of closing the incision despite the
information given by the attending nurses that 2 pieces of
gauze were still missing. That they were later on extracted
from Natividad’s vagina established the causal link between
Dr. Ampil’s negligence and the injury. And what further
aggravated such injury was his deliberate concealment of
this missing gauzes from the knowledge of Natividad and her
family.
The requisites for the applicability of the doctrine of res ipsa
liquitor are:
1. Occurrence of an injury;
2. The thing which caused the injury was under the
control and management of the defendant;
3. The occurrence was such that in the ordinary
course of things would not have happened if those
who had control or management used proper care,
and;
4. The absence of explanation by the defendant
Of the foregoing, the most instrumental is the “Control and
management of the thing which caused the injury.”
Under the “Captain of the ship” rule, the operating surgeon is
the person in complete charge of the surgery room and all
personnel connected with the operation.
The knowledge of any of the staff of Medical City constitutes
knowledge of PSI.
The doctrine of corporate responsibility, has the duty to see
that it meets the standards of responsibilities for the care of
patients. Such duty includes the proper supervision of the
members of its medical staff. The hospital accordingly has
the duty to make a reasonable effort to monitor and over see
the treatment prescribed and administered by the physician
practicing in its premises.
Cruz vs Court of Appeals
GR No. 122445 November 18, 1997
Facts: On March 22, 1991, prosecution witness, Rowena
Umali de Ocampo, accompanied her mother to the Perpetual
Help Clinic and General Hospital situated in Balagtas Street,
San Pablo City, Laguna. They arrived at the said hospital at
around 4:30 in the afternoon of the same day. Prior to March
22, 1991, Lydia was examined by the petitioner who found a
“Myoma” in her uterus, and scheduled her for a
hysterectomy operation on March 23, 1991. Rowena and her
mother slept in the clinic on the evening of March 22, 1991
as the latter was to be operated on the next day at 1pm.
According to Rowena, she noticed that the clinic was untidy
and the windows and the floor were very dusty prompting
her to ask the attendant fora rag to wipe the window and
floor with. Prior to the operation, Rowena tried to convince
her mother to not proceed with the operation and even
asked petitioner for it to be postponed, however it still
pushed through after the petitioner told Lydia that operation
must be done as scheduled. During the operation, the
assisting doctor of the petitioner, Dr. Ercillo went out of the
operating room and asked that tagmet ampules be bought
which was followed by another instruction to buy a bag of
blood. After the operation, when Lydia came out of the OR,
another bag of blood was requested to be bought, however,
the same was not bought due to unavailability of type A from
the blood bank. Thereafter a person arrived to donate blood
which was later transferred to Lydia. Rowena then noticed
her mother, who was attached to an oxygen tank, gasping
for breathe apparently, the oxygen tank is empty, so her
husband and petitioner’s driver bought an oxygen. Later,
without the knowledge of Lydia’s relatives,she was decided
by the doctors to be transferred to San Pablo District
Hospital were she was supposed to be re-operated. After
Lydia experienced shocks, she died.
Issue: Whether or not petitioner has been negligent which
caused the death of Lydia Umali.
Held: Yes. Whether or not a physician has committed an
“inexcusable lack of precaution” in the treatment of his
patient to be determined according to the standard of care
observed by other members of the profession in good
standing under similar circumstances bearing in mind the
advanced state of the profession at the time of treatment or
the present state of medical science. A doctor in effect
represents that, having the needed training and skill
possessed by physicians and surgeons practicing in the
same field, he will employ such training, care and skill in the
treatment of his patients. He therefore has a duty to use at
least the same level of care that any other reasonably
competent doctor would use to treat a condition under the
same circumstances. It is in this aspect of medical
malpractice that expert testimony is essential to establish not
only the standard of care of the profession but also that the
physician’s conduct in the treatment and care falls below
such standard. Further, in as much as the causes of the
injuries involved in malpractice actions are determinable only
in the light of scientific knowledge, it has been recognized
that expert testimony is usually necessary to the conclusion
as to causation.
In litigations involving medical negligence, the plaintiff has
the burden of establishing appellant’s negligence and for a
reasonable conclusion of negligence, there must be proof of
breach of duty on the part of the surgeon as well as causal
connection of such breach and the resulting death of his
patient.
In order that there may be recovery for an injury, however, it
must be shown that the injury for which recovery is sought
must be legitimate consequence of the wrong done; the
connection between the negligence and the injury must be a
direct and natural reference of events, unbroken by
intervening efficient causes. In other words, the negligence
must be the proximate cause of the injury. For negligence,
no matter what it consists, cannot create a right of action
unless it is the proximate cause of the injury complained of
and the proximate cause of an injury is that cause, which in
natural and continuous sequence, unbroken by any efficient
intervening cause, produces the injury and without which the
result would have occurred.
The elements of reckless imprudence are:
1. That the offender does or fails to do an act;
2. That the doing or the failure to do that act is
voluntary;
3. That it be without malice;
4. That material damage results from the reckless
imprudence; and
5. That there is inexcusable lack of precaution on the
part of the offender, taking into consideration his
employment or occupation, degree of intelligence,
physical condition, and other circumstances
regarding persons, time, and place.
The possible causes of hemorrhage during an operation are:
1.) the failure of the surgeon to tie or suture a cut blood
vessel; 2.) allowing a cut blood vessel to get out of control;
3.) the subsequent loosening of the tie or suture applied to a
cut blood vessel; and 4.)and a clotting defect known as DIC.
Spouses Flores vs Spouses Pineda
GR No. 158996 November 14, 2008
Facts: Teresita Pineda consulted her townmate Dr.
Fredelicto Flores regarding her medical condition,
complaining about general body weakness, loss of appetite,
frequent urination and thirst, and on-and-off vaginal
bleeding. After interviewing Teresita, Dr. Fredelicto advised
her to go to United Doctors Medical Center (UDMC) in
Quezon City for a general check-up the following week but
the former did not. As for her other symptoms, he suspected
that Teresita might be suffering from diabetes and told her to
continue her medications. When her conditions persisted,
she went to UDMC where Dr. Fredelictor check-up her and
ordered her admission and further indicate on call D&C
operation to be performed by his wife, Dra. Felicisima Flores,
an Ob-Gyne. Laboratory tests were done on Teresita
including internal vaginal examination, however, only the
blood sugar and CBC results came out prior to operation
which indicated of diabetes. D&C operations were still done
and thereafter, Dra. Felicisima advised her that she can go
home and continue to rest at home but Teresita opted
otherwise. Two days after the operation, her condition
worsened prompting further test to be done which resulted
that Teresita have diabetes melitus type II. Insulin was
administered but it might arrived late, she died.
Issue: Whether or not spouses petitioners are liable for
medical negligence.
Held: Yes. A medical negligence case is a type of claim to
redress a wrong committed by a medical professional, that
caused a bodily harm to or the death of a patient. There are
four elements involved in a medical negligence case,
namely: duty, breach, injury, and proximate cause.
Duty refers to the standard of behavior which imposes
restrictions on one’s conduct. The standard in turn refers to
the amount of competence associated with the proper
discharge of the profession. A physician is expected to use
at least the same level of case that any other reasonably
competent doctor would use under the same circumstances.
Breach of duty occurs when the physician fails to comply
with those professional standards. If injury results to the
patient as a result of this breach, the physician is answerable
for negligence.
If a patient suffers from some disability that increases the
magnitude of risk to him, that disability must be taken into
account as long as it is or should have been known to the
physician.
Stress, whether physical or emotional, is a factor that can
aggravate diabetes; a D&C operation is a form of physical
stress. Dr. Mendoza explained how surgical stress can
aggravate the patient’s hyperglycemia: when stress occurs,
the diabetic’s body, especially the autonomic system, reacts
by secreting hormones which are counter-regulatory; she
can have prolonged hyperglycemia which, if unchecked,
could lead to death. Medical lecture further explains that if
the blood sugar has become very high, the patient becomes
comatose (diabetic coma). When this happens over several
days, the body uses its own fats to produce energy, and the
result is high level of waste products in the blood and urine.
These findings leads us to the conclusion that the decision to
proceed with the D&C operation notwithstanding Teresita’s
hyperglycemia and without adequately preparing her for the
procedure, was contrary to the standards observed by the
medical profession. Deviation from this standard amounted
to a breach of duty which resulted in the patient’s death. Due
to this negligent conduct, liability must attach to the petitioner
spouses.
Solidum vs People of the Philippines
GR No. 192123 March 10, 2014
Facts: Gerald Albert Gercayo was born on June 2, 1992
with an imperforate anus. Two days after his birth, Gerald
under went colostomy, a surgical procedure to bring one end
of the large intestine out through the abdominal walls,
enabling him to excrete through a colostomy bag attached to
the side of his body. On May 17, 1995, Gerald was admitted
at the Ospital ng Maynila for a pull-through operation. Dr.
Leandro Resurreccionheaded the surgical team, and was
assisted by Dr. Joselito Lucerio, Dr.Donatella Valeria and Dr.
Joseph Tibio. The anesthesiologist included Drs. Abella,
Razon and Solidum. During the operation, Gerald
experienced bradycardia and went into a coma. His coma
lasted for two weeks , but he regained consciousness only
after a month. He could no longer see, hear, or move. A
complaint for reckless imprudence resulting in serious
physical injuries were filed by Gerald’s parents against the
team of doctors alleging that there was failure in monitoring
the anesthesia administered to Gerald.
Issues: Whether or not petitioner is liable for medical
negligence.
Whether or not res ipsa liquitor can be resorted to in medical
negligence cases.
Held: No. Negligence is defined as the failure to observe for
the protection of the interests of another person that degree
of care, precaution, and vigilance that the circumstances
justly demand, whereby such other person suffers injury.
Reckless imprudence, on the other hand, consists of
voluntarily doing or failing to do, without malice, an act from
which material damage results by reason of an inexcusable
lack of precaution on the part of the person to perform or
failing to perform such act.
The negligence must be the proximate cause of the injury.
For, negligence no matter in what it consists, cannot create a
right of action unless it is the proximate cause of the injury
complained of. And the proximate cause of an injury is that
cause, which, in natural and continuous sequence and
unbroken by any efficient intervening cause, produces the
injury, and without which the result would not have occurred.
An action upon medical negligence – whether criminal, civil
or administrative – calls for the plaintiff to prove by
competent evidence each of the following four elements
namely: a.) the duty owed by the physician to the patient, as
created by the physician-patient relationship, to act in
accordance with the specific norms or standards established
by his profession; b.) the breach of the duty by the
physician’s failing to act in accordance with the applicable
standard of care; c.) the causation, is, there must be a
reasonably close and casual connection between the
negligent act or omission and the resulting injury; and d.) the
damages suffered by the patient.
In the medical profession, specific norms on standard of care
to protect the patient against unreasonable risk, commonly
referred to as standards of care, set the duty of the physician
in respect of the patient. The standard of care is an objective
standard which conduct of a physician sued for negligence
or malpractice may be measured, and it does not depend
therefore, on any individual’s physician’s own knowledge
either. In attempting to fix a standard by which a court may
determine whether the physician has properly performed the
requisite duty toward the patient, expert medical testimony
from both plaintiff and defense experts is required.
The doctrine of res ipsa liquitor means that where the thing
which causes injury is shown to be under the management
of the defendant, and the accident is such as in ordinary
course of things does not happen if those who have
management use proper care, it affords reasonable
evidence, in the absence of an explanation by defendant that
the accident arose from want of care.
Nevertheless, despite the fact that the scope of res ipsa
liquitor has been measurably enlarged, it does not
automatically apply to all cases of medical negligence as to
mechanically shift the burden of proof to the defendant to
show that he is not guilty of the ascribed negligence. Res
ipsa liquitor is not a rigid or ordinary doctrine to be
perfunctorily used but a rule to be cautiously applied,
depending upon the circumstances of each case. It is
generally restricted to situations in malpractice cases where
a layman is able to say, as a matter of common knowledge
and observation, that the consequences of professional care
were not as such as would ordinarily have followed if due
care had been exercised. A distinction must be made
between the failure to secure results, and the occurrence of
something more unusual and not ordinarily found if the
service or treatment rendered followed the usual procedure
of those skilled in that particular practice. It must be
conceded that the doctrine of res ipsa liquitor can have no
application in a suit against a physician or surgeon which
involves the merits of a diagnosis or of a scientific treatment.
The physician or surgeon is not required at his peril to
explain why any particular diagnosis was not correct, or why
any particular scientific treatment did not produce the
desired results. Thus, res ipsa liquitor is not available in a
malpractice suit if the only showing is that the desired result
of an operation or treatment was not accomplished. The real
question, therefore, is whether or not in the process of the
operation any extraordinary incident or unusual event
outside the routine performance occurred which is beyond
the regular scope of customary professional activity in such
operations, which if unexplained would themselves
reasonably speak to the average man as the negligent case
or causes of the untoward consequence. If there was such
extraneous intervention, the doctrine of res ipsa liquitor may
be utilized and the dependent is called upon to explain the
matter, by evidence of exculpation, if he could.
Cayao-Lasam vs Spouses Ramolete
GR No. 159132 December 18, 2002
Facts: On July 28, 1994, respondent 3 months pregnant
Editha Ramolete was brought to Lorma Medical Center
(LMC) in San Fernando, La Union due to vaginal bleeding
upon advise of petitioner related via telephone, Editha was
admitted to the LMC on the same day. A pelvic sonogram
was then conducted on Editha revealing the fetus weak
cardiac pulsation. The following day, Editha repeat pelvic
sonogram showed that aside from the fetus weak cardiac
pulsation, no fetal movement was also appreciated. Due to
persistent and profuse vaginal bleeding, petitioner advised
her to undergo a D&C procedure. She was discharged the
following day. On September 16, 1994, Editha was once
gain brought at the LMC, as she was suffering from vomiting
ans severe abdominal pains. Editha was attended by Drs.
Dela Cruz, Mayo and Komiya. Dr. Mayo allegedly informed
Editha that there was a dead fetus in the latter’s womb, after
Editha went laparectomy, she was found to have massive
intra abdominal hemorrhage and ruptured uterus. Thus, she
had to go hysterectomy and as a result no more chance to
bear a child.
Issue: Whether or not petitioner is liable for medical
malpractice.
Held: No. Medical malpractice is a particular form of
negligence which consists in the failure of a physician or
surgeon to apply to his practice of medicine that degree of
care and skill which is ordinarily employed by the profession
generally under similar conditions, and in like surrounding
circumstances. In order to successfully pursue such a
claim, a patient must prove that the physician or surgeon
either failed to do something which a reasonably prudent
physician or surgeon would not have done, and that the
failure or action caused injury to the patient.
There are four elements involved in medical negligence
cases: duty, breach, injury, and proximate cause..
A physician-patient relationship was created when Editha
employed the services of the petitioner. As Editha’s
physician, petitioner was duty-bound to use at least the
same level of care that any reasonably competent doctor
would use to treat a condition under the same
circumstances. The breach of these professional duties of
skill and care, or their improper performance by a physician
surgeon, whereby the patient’s injured in body or in health,
constitutes actionable malpractice, as to this aspect of
medical malpractice, the determination of the reasonable
level of care and the breach thereof, expert testimony is
essential. Further, in as much as the causes of the injuries
involved in malpractice actions are determinable only in the
light of scientific knowledge, it has been recognized that
expert testimony is usually necessary to suspect the
conclusion as to causation.
It is undisputed that Editha did not return for follow-up
evaluation, in defiance of the petitioners advice. This is as
found out is the proximate cause of the injury she sustained.
Nogales vs Capitol Medical Center
GR No. 142625 December 19, 2006
Facts: Pregnant with her fourth child, Corazon Nogales, who
was then 37 y/o was under the exclusive prenatal care of Dr.
Oscar Estrada beginning on her fourth month of pregnancy
or as early as December 1975. While Corazon was on her
last trimester of pregnancy, Dr. Estrada noted an increase in
her blood pressure and development of leg edemas
indicating preeclampsia which is a dangerous complication
of pregnancy. Around midnight of May 26, 1976, Corazon
started to experience mild labor pains prompting Corazon
and Rogelio Nogales to see Dr. Estrada at his home. After
examining Corazon, Dr. Estrada advised her immediate
admission to Capitol Medical Center (CMC). Upon her
admission, an internal examination was conducted upon her
by a resident-physician. Based on the doctor’s sheet, around
3am, Dr. Estrada advised for 10mg valium to be
administered immediately by intramuscular injection, he later
ordered the start of intravenous administration of syntociron
admixed with dextrose, 5% in lactated ringer’s solution, at
the rate of 8-10 micro-drops per minute. When asked if he
needed the services of anesthesiologist, he refused.
Corazon’s bag of water ruptured spontaneously and her
cervix was fully dilated and she experienced convulsions. Dr.
Estrada ordered the injection of 10g of magnesium sulfate
but his assisting Doctor, Dr. Villaflor, only administered 2.5g.
She also applied low forceps to extract Corazon’s baby. In
the process, a 10 x 2.5cm piece of cervical tissue was
allegedly torn. The baby came out in an apric, cyanatic weak
and injured condition. Consequently the baby had to be
intubated and resuscitated. Corazon had professed vaginal
bleeding where a blood typing was ordered and she was
supposed to undergo hysterectomy, however, upon the
arrival of the doctor, she was already pronounced dead due
to hemorrhage.
Issue: Whether or not in the conduct of child delivery, the
doctors and the respondent hospital is liable for negligence.
Held: Yes. In general, a hospital is not liable for the
negligence of an independent contractor-physician. There is,
however an exception to this principle. The hospital may be
liable if the physician is the ostensible agent of the hospital.
This exception is also known as the doctrine of apparent
authority.
Under the doctrine of apparent authority a hospital can be
held vicariously liable for the negligent acts of a physician
providing care at the hospital, regardless of whether the
physician is an independent contractor, unless the patient
knows, or should have known, that the physician is an
independent contractor.
For a hospital to be liable under the doctrine of apparent
authority, a plaintiff must show that 1.) the hospital, or its
agent, acted in a manner that would lead a reasonable
person to conclude that the individual who was alleged to be
negligent was an employee or agent of the hospital; 2.)
Where the acts of the agent create the appearance of
authority, the plaintiff must also prove that the hospital had
knowledge of and acquired in them; and 3.) the plaintiff
acted in reliance upon the conduct of the hospital or its
agent, consistent with ordinary care and prudence.
Borrowed servant doctrine provides that once a surgeon
enters the operating room and takes charge of the acts or
omissions of operating room personnel and any negligence
associated with each acts or omissions are imputable to the
surgeon, while the assisting physicians and nurses may be
employed by the hospital, or engaged by the patient, they
normally become the temporary servants or agents of the
surgeon in charge while the operation is in progress, and
liability may be imposed upon the surgeon for their negligent
acts under the doctrine of respondeat superior.
Cantre vs Go
GR No. 160889 April 27, 2007
Facts: Petitioner Dr. Milagros L. Cantre is a specialist in
obstetrics and gynecology at the Dr. Jesus Delgado
memorial Hospital. She was the attending physician of
respondent Nora Go, who was admitted at the said hospital
on April 19, 1992. At 1:30am of April 20, 1992, Nora gave
birth to her fourth child, a baby boy. However, at around
3:30am Nora suffered profuse bleeding insider her womb
due to some parts of the placenta were not completely
expelled from her womb after delivery consequently, Nora
suffered hypovolemic shock, resulting in a drop in her blood
pressure to 40/0. Petitioner said the assisting resident
physician performed various medical procedures to stop the
bleeding and to restore Nora’s blood pressure. Her blood
pressure was frequently monitored with the use of a
sphygmamometer. While petitioner was massaging Nora’s
uterus for it to contract and stop bleeding, she ordered a
drop light to warm Nora and her baby. Nora remained
unconscious until she recovered. While in the recovery
room, her husband, respondent John David Z. Go noticed a
fresh gasping wound 2 1/2″ x 3 1/2″ in the inner portion of
her left arm, close to the armpit. He asked the nurses what
caused the injury. He was informed, it was a burn. An
investigation was filed by Nora’s husband and found out
from the petitioner that it was caused by the blood pressure
cuff, however, this was contrary to the findings from a
medico-legal report which stated that it was indeed a burn
and that a drop light when placed near a skin for about
10mins could cause such burn. Nora was referred to a
plastic surgeon from the hospital and skin grafting was done
on her and scar revision but both still left a mark on Nora’s
arm compelling the respondent spouse to file a complaint for
damages against petitioner.
Issue: Whether or not petitioner is liable for the injury
referred by Nora.
Held: Yes. The Hippocratic oath mandates physicians to
give primordial consideration to the well-being of their
patients. If a doctor fails to live up to his precept, he is
accountable for his acts. This is notwithstanding, courts face
a unique restraint in adjudicating medical negligence cases
because physicians are not guardians of care and they
never set out to intentionally cause injury to their patients.
However, intent is immaterial in negligence cases because
where negligence exist and is proven, it automatically gives
the injured a right to reparation for the damage caused.
In cases, involving medical negligence, the doctrine of res
ipsa liquitor allows the mere existence of an injury to justify a
presumption of negligence on the part of the person who
controls the instrument causing the injury, provided that the
following requisites concur:
1. The accident is of a kind which ordinarily does not
occur in the absence of someone’s negligence;
2. It is caused by an instrumentality within the
exclusive control of the defendant or defendants;
3. The possibility of contributing conduct which would
make the plaintiff responsible is eliminated.
All of these three requisites were present in the case at bar.
Under the the captain of the ship doctrine, the surgeon in
charge of the operation is liable for the negligence of his
assistants during the time when those are under the
surgeons control.
Ramos vs Court of Appeals
GR No. 124354 December 29, 1999
Facts: Plaintiff Erlinda Ramos was, until the afternoon of
June 17, 1985 a 47-year old robust woman. Except for
occasional complaints of discomfort due to pains allegedly
caused by presence of a stone in her gall bladder, she was
as normal as any other woman. Married to Rogelio Ramos,
an executive of Philippine Long Distance Telephone
Company (PLDT), she has three children whose names are
Rommel, Roy Roderick, and Ron Raymond. Because of the
discomforts somehow interfered with her normal ways, she
sough professional advice. She was told to undergo an
operation for the removal of a stone in her gall bladder. She
underwent series of examination which revealed that she
was fit for the said surgery. Through the intercession of a
mutual friend, she and her husband met Dr. Osaka for the
first time and she was advised by Dr. Osaka to go under the
operation called cholecystectomy and the same was agreed
to be scheduled on June 17,1985 at 9:00am at the Delos
Santos Medical Center. Rogelio asked Dr. Osaka to look for
a good anesthesiologist to which the latter agreed to. A day
before the scheduled operation, she was admitted at the
hospital and on the day of the operation, Erlinda’s sister was
with her insider the operating room. Dr. Osaka arrived at the
hospital late, Dr. Guttierez, the anesthesiologist, started to
intubate Erlina when Herminda heard her say that intubating
Erlinda is quite difficult and there were complications. This
prompt Dr. Osaka to order a call to another anesthesiologist,
Dr. Caldron who successfully intubated Erlina. The patient’s
nails became bluish and the patient was placed in a
trendelenburg position. After the operation, Erlina was
diagnosed to be suffering from diffuse cerebral parenchymal
damage and that the petitioner alleged that this was due to
lack of oxygen supply to Erlinda’s brain which resulted from
the intubation.
Issue: Whether or not the doctors and the hospital are liable
for damages against petitioner for the result to Erlinda of the
said operation.
Held: Yes. The private respondents were unable to disprove
the presumption of negligence on their part in the care of
Erlinda and their negligence was the proximate case of her
piteous condition.
Nevertheless, despite the fact that the scope of res ipsa
liquitor has been measurably enlarged, it does not
automatically follow that it apply to all cases of medical
negligence as to mechanically shift the burden of proof to the
defendant to show that he is not guilty of the ascribed
negligence. Res ipsa liquitor is not a rigid or ordinary
doctrine to be perfunctorily used but a rule to be cautiously
applied, depending upon the circumstances of each case. It
is generally restricted to situations in malpractice cases
where a layman is able to say, as a matter of common
knowledge and observation, that the consequences of
professional care were not as such as would ordinarily have
followed if due care had been exercised. A distinction must
be made between the failure to secure results, and the
occurrence of something more unusual and not ordinarily
found if the service or treatment rendered followed the usual
procedure of those skilled in that particular practice. It must
be conceded that the doctrine of res ipsa liquitor can have
no application in a suit against a physician or surgeon which
involves the merits of a diagnosis or of a scientific treatment.
Scientific studies point out that intubation problems are
responsible for 1/3 of deaths and serious injuries associated
with anesthesia. Nevertheless, 98% or the vast majority of
difficult intubation may be anticipated by performing a
thorough evaluation of the patient’s airway prior to the
operation. As stated beforehand, respondent, Dra. Guttierez
failed to observe the proper pre-operative protocol which
could have prevented this unfortunate incident. Had
appropriate diligence and reasonable care been used in the
pre-operative evaluation, respondent physician could have
been more prepared to meet the contingency brought about
by the perceived atomic variations in the patient’s neck and
oral area; defects which could have been easily overcome
by a prior knowledge of those variations together with a
change in technique. In other words, an experienced
anesthesiologist, adequately alerted by a thorough pre-
operative evaluation, would have had little difficulty going
around the short neck and potruding teeth. Having failed to
observe common medical standards in pre-operative
management and intubation, respondent Dra. Guttierez
negligence resulted in cerebral anoxia and eventual coma of
Erlinda.
Jarcia vs People of the Philippines
GR No. 187926 February 15, 2012
Facts: Belinda Santiago lodged a complaint with the
National Bureau of Investigation (NBI) against the
petitioners, Dr. Emanuel Jarcia and Dr. Marilou Bastan, for
their alleged neglect of professional duty which caused her
son, Roy Alfonso Santiago, to suffer physical injuries. Upon
investigation, the NBI found that Roy Jr. was hit by a taxicab;
that he was rushed to the Manila Doctors Hospital for an
emergency medical treatment; that an X-ray of the victim’s
ankle was ordered; that the X-ray result showed no fracture
as read by Dr. Jarcia; that Dr. Bastan entered the
emergency room and, after conducting her own examination
of the victim, informed Mrs. Santiago that since it was only
the ankle that was hit there was no need to examine the
upper leg; that 11 days later, Roy developed fever, swelling
of the right leg and misalignment of the right foot; that Mrs.
Santiago brought him back to the hospital; and that the x-ray
revealed a right mid-tibial fracture and a linear hairline
fracture in the shaft of the bone. A complaint for reckless
imprudence resulting physical injuries was filed against the
petitioners for the alleged misconduct in the handling of the
illness of Roy.
Issue: Whether or not the petitioners failed to exercise the
degree of care expected of them as doctors and are liable
for negligence to the private respondent.
Held: Yes. The doctrine of res ipsa liquitor as a rule of
evidence is unusual to the law of negligence which
recognizes that prima facie negligencce may be established
without direct proof and furnishes a substitute for specific
proof of negligence. The doctrine however, is not a rule of
substantive law, but merely a mode of proof or a mere
procedural convenience the rule when applicable to the facts
and circumstances of a given case, is not meant to and does
not dispense with the requirement of proof of culpable
negligence on the party charged. It merely determines and
regulates what shall be prima facie evidence thereof and
helps the plaintiff in proving a breach of duty. The doctrine
can be invoked when and only when, under the
circumstances involved, direct evidence is absolute and not
readily available.
The requisites for the application of the doctrine of res ipsa
liquitor are:
1. The accident was of a kind which does not
ordinarily occur unless someone is negligent;
2. The instrumentality or agency which caused the
injury was under the exclusive control of the
person in charge; and
3. The injury suffered must not have been due to any
voluntary action or contribution of the person
injured.
Negligence is defined as the failure to observe for the
protection of the interests of another person that degree of
care, precaution and vigilance which the circumstances
justly demand whereby such other person suffers injury.
Reckless imprudence consists of voluntarily doing or failing
to do, without malice, an act from which material damage
results by reason of an inexcusable lack of precaution on the
part of the person performing or failing to perform such act.
In failing to perform an extensive medical examination to
determine the extent of Roy’s injuries, Dr. Jarcia and Dr.
Bastan were remiss of their duties as members of the
medical profession. Assuming for the sake of argument that
they did not have the capacity to make such thorough
evaluation at that stage they should have referred the patient
to another doctor with sufficient training and experience
instead of assuring him and his mother that everything was
all right.
Atienza vs Board of Medicine
GR No. 177407 February 9, 2011
Facts: Due to her Lumbar parts, private respondent Editha
Sioson went to Rizal Medical Center (RMC) for check-up on
February 4, 1995. Sometime in 1999, due to the same
problem, she was referred to Dr. Pedro Lantin III of RMC
who, accordingly, ordered several diagnostic laboratory
tests. The tests revealed that her right kidney is normal. It
was ascertained, however, that her left kidney is non-
functioning and non-visualizing. This, she underwent kidney
operation in 1999, September. On February 18, 2000,
private respondents husband Romeo Sioson, filed a
complaint for gross negligence and/or incompetence before
the board of medicine against the doctors who allegedly
participated in the fateful kidney operation. It was alleged in
the complaint that the gross negligence and/or
incompetence committed by the said doctors, including
petitioner, consists of the removal of private respondents
fully functional right kidney, instead of the left non-
functioning and non-visualizing kidney. Among the evidence
presented are certified photocopy of the results of the
ultrasound and X-ray conducted to Editha with the
interpretation that both of her kidneys are in their proper
anatomical location.
Issue: Whether or not the doctors who conducted the kidney
operation are liable for gross negligence despite the
evidence presented were mere photocopies.
Held: Yes. To begin with, it is a well settled rule that the
rules of evidence are not strictly applied in proceedings
before administrative bodies such as the Board of Medicine.
It is the safest policy to be liberal, not rejecting them on
doubtful or technical grounds, but admitting them unless
plainly irrelevant, immaterial or incompetent, for the reason
that their rejection places them beyond the consideration of
the court, if they are thereafter found relevant or competent;
on the other hand, their admission, if they turn out later to be
irrelevant or incompetent, can easily be remedied by
completely discarding them or ignoring them.
Unquestionably, the rules of evidence are merely the means
for ascertaining the truth respecting a matter of fact. This,
they likewise provide for some facts which are established
and need not be proved, such as those covered by judicial
notice, both mandatory and discretionary. Laws of nature
involving the physical sciences, specifically biology include
the structural make-up and composition of living things such
as human beings. In this case, we may take judicial notice
that Editha’s kidneys before, and after the time of her
operation, as with most human beings, were in their proper
anatomical locations.
Dela Torre vs Imbuido
GR No. 192973 September 29, 2014
Facts: At around 3:00pm of February 3, 1992, Carmen was
brought to Divine Spirit General Hospital’s operating room
for her caesarian section operation, which was to be
performed by Dr. Nestor. By 5:30pm, of the same day,
Pedrito was informed by his wife’s delivery of a baby boy. In
the early morning of February 4, 1992, Carmen experienced
abdominal pains and difficulty in urinating. She was
diagnosed to be suffering from urinary tract infection (UTI),
and was prescribed medication by Dr. Norma. On February
10, 1992, Pedrito noticed that Carmen’s stomach was
getting bigger, but Dr. Norma dismissed the patient’s
condition as mere fratulence. When Carmen’s stomach still
grow bigger despite medications, Dr. Norma advised Pedrito
of the possibility of a second operation on Carmen. Dr.
Norma, however, provided no details on its purpose and the
doctor who would perform it. At around 3:00pm on February
12, 1992 Carmen had her second operation. Later in the
evening, Dr. Norma informed Pedrito that “everything was
going on fine with his wife.” The condition of Carmen,
however, did not improve. It instead worsened that on
February 13, 1992, she vomited dark red blood. At 9:30pm
of the same day, Carmen died. Per her death certificate
upon information provided by the hospital, the immediate
cause of Carmen’s death was cardio-respiratory arrest
secondary to cerebro vascular accident, hypertension and
chronic nephritis induced by pregnancy. An autopsy report
prepared by Dr. Partilano, medico-legal officer designate of
Olongapo City, however, provided that the cause of
Carmen’s death was shock due to peritonitis severe with
multiple intestinal adhesions; status post caesarian section
and exploratory laparotomy. Pedrito claimed in his complaint
that the respondents failed to exercise the degree of
diligence required of them as members of the medical
profession, and were negligent for practicing surgery on
Carmen in the most unskilled, ignorant, and cruel manner.
Issue: Whether or not respondents were liable for medical
malpractice that resulted to Carmen’s death.
Held: No. Medical malpractice or, more appropriately,
medical negligence, is that type of claim which a victim has
available to him or her to redress a wrong committed by a
medical professional which has caused bodily harm. In order
to successfully pursue such a claim, a patient, or his or her
family as in this case, must prove that healthcare provider, in
most cases, a physician, either failed to do something which
a reasonably prudent health care provider would have done,
or that he or she did something that a reasonably prudent
provider would not have done; and that failure or action
caused injury to the patient.
Four essential elements must be established namely: 1.)
duty; 2.) breach; 3.) injury and 4.) proximate causation. All
four elements must be present in order to find the physician
negligent and thus, liable for damages.
For the trial court to give weight to Dr. Partilano’s report, it
was necessary to show first Dr. Partilano’s specialization
and competence to testify on the degree of care, skill and
diligence needed for the treatment of Carmen’s case.
Considering that it was not duly established that Dr.
Partilano practiced and was an expert on the fields that
involved Carmen’s condition, he could not have accurately
identified the said degree of care, skill and diligence and the
medical procedure, that should have been applied.
Alano vs Magud-Logmao
GR No. 1755540 April 7, 2014
Facts: At around 9:50pm of March 1, 1988, Arnelito Logmao
then 18 y/o, was brought to the East Avenue Medical Center
(EAMC) in Quezon City by two sidewalk vendors, who
allegedly saw the former fall from the overpass near the
Farmer’s Market in Cubao, Quezon City. The patient’s data
sheet identified the patient as Angelito Lugmoso of Boni
Ave., Mandaluyong. However, the clinical abstract prepared
by Dr. Paterno F. Cabrera, the surgical resident on-duty at
the emergency room of EAMC, stated the patient is Angelito
Logmao. Dr. Cabrera reported that Logmao was drowsy with
alcoholic breath, was conscious and coherent; that the skull
x-ray showed no fracture; that at around 4:30am of March 2,
1988, Logmao developed generalized seizures and was
managed by the neuro-surgeon resident on-duty; that the
condition of Logmao progressively deteriorated and he was
intubated and ambu-bagging support was provided; that
admission to the ICU and mechanical ventilation support
became necessary, but there was no vacancy at the ICU
and all the ventilation units were being used by other
patients; that a resident physician of NKTI, who was rotating
at EAMC, suggested that Logmao be transferred to NKTI;
and that after arrangements were made, Logamo was
transferred to NKTI at 10:10am. At the NKTI, the name
Angelito Logmao was recorded as Angelito Lugmoso.
Lugmoso was immediately attended to and given the
necessary medical treatment. As Lugmoso had no relatives
around, Jennifer Misa, transplant coordinator was asked to
locate his family by enlisting police and media assistance.
Dr. Enrique Ona, chairman of the Department of Surgery,
observed that severity of the brain injury of Lugmoso
manifested symptoms of brain death. He requested the
laboratory section to conduct tissue typing and tissue cross-
matching examination, so that should Lugmoso expire
despite the necessary care and medical management and
he would be found to be a suitable organ donor and his
family would consent to organ donation, the organs thus
donated could be detached and transplanted promptly to any
compatible beneficiary. The identity of Lugmoso was verified
by Misa from EAMC and she was furnished the patient’s
data sheet. She then contacted several radio and television
stations to request for air time for the purpose of locating the
family of Angelito Lugmoso of Boni Ave., Mandaluyong who
was confined at NKTI with severe head injury after allegedly
falling from the Cubao overpass, as well as police station no.
5 Eastern Police District. Lugmoso was pronounced brain
dead on March 3, 1988 7:00am. Two hours later, Dr. Ona
was informed that EEG recording exhibited a flat tracing
thereby confirming his brain death. He was found to be a
suitable donor of the heart, kidneys, pancreas, and liver, and
after the extensive search, no relatives were found. Dr. Ona
then requested the removal of the specific organs of
Lugmoso from the herein petitioners, Dr. Alano, the director
of NKTI who thereafter issued a memorandum stating that
only after the requirements of RA 349 as amended by PD
856 was complied, they can remove the specified organs of
Lugmoso. Lugmoso’s remains was brought at La Funeraria
Oro. A press release made by NKTI announcing a double
organ transplant led to the findings of the relatives of
Lugmoso.
Issue: Whether or not the removal of Lugmoso’s organs
were valid.
Held: Yes. The internal organs of the deceased were
removed only after he had been declared brain dead; thus
the emotional pain suffered by respondent due to the death
of her son cannot be in any way be attributed to petitioner.
Neither can the court find evidence or second to show that
respondent’s emotional suffering at the sight of the pitful
state in which she found her son’s lifeless body be
categorically attributed to petitioner’s conduct.
Thus, there can be no cavil that petitioners employed
reasonable means to disseminate notifications intended to
reach the relatives of the deceased. The only question that
remains pertains to the sufficiency of time allotted for notices
to reach the relatives of the deceased.
If respondent failed to immediately receive notice of her
son’s death because the notices did not properly state the
name or identity of the deceased, fault cannot be laid at
petitioner’s door. The trial and appellate courts found that it
was the EAMC, who recorded the wrong information
regarding the deceased’s identity to NKTI. The NKTI could
not have obtained the information about his name from the
patient, because as found by the lower courts, the deceased
was already unconscious by the time he was brought to
NKTI.
Bondoc vs Mantala
GR No. 203080 November 12, 2014
Facts: Respondent was admitted at the Oriental Mindoro
Provincial Hospital (OMPH) on April 3, 2009, at around
11:00am, with referral from the Bansud Municipal Health
Office. She was due to deliver her 5th child and was advised
for a caesarian section because her baby was big and there
was excessive amniotic fluid in her womb. She started to
labor at 7:00am and was initially brought to the Bongabon
Health Center. However, said health center also told her to
proceed directly to the hospital. In her complaint-affidavit,
respondent alleged that inside the delivery room of OMPH,
she was attended to by petitioner who instructed the midwife
and two younger assistants to press down on respondent’s
abdomen and even demonstrated to them how to insert their
fingers into her vagina. Thereafter, petitioner went out of the
delivery room and later, his assistants also left. After hours
of being in labor, respondent pleaded for a caesarian
section. The midwife and the younger assistants pressed
down on her abdomen causing excruciating pains on her ribs
and made her very weak. They repeatedly did this pressing
until the bay and placenta came out. When she regained
consciousness, she was already at the recovery room, she
learned that an operation was performed on her by petitioner
to removed her ruptured uterus but what depressed her most
was her stillborn baby and the loss of her reproductive
capacity. The respondent noticed that her vulva swollen and
there is an open wound which widened later on and was re-
stitched by petitioner. Petitioner was heard uttering words
unbecoming of his profession pertaining to the respondent’s
states while in labor. Respondent filed then a complaint for
grave misconduct against the petitioner before the
ombudsman. The petitioner resigned as medical officer of
OMPH, alleging that the complaint against him is now moot
and academic.
Issue: Whether or not petitioner’s conduct during the
delivery of respondent’s baby constitute grave misconduct.
Held: Yes. Misconduct is defined as a transgression of some
established and definite rule of action, more particularly
unlawful behavior or gross negligence by a public officer, a
forbidden act, a dereliction of duty, willful in character, and
implies wrongful intent and not mere error in judgement. It
generally means wrongful, improper or unlawful conduct
motivated by a premeditated, obstinate or intentional
purpose. The term, however does not necessarily imply
corruption or criminal intent. To constitute an administrative
offense, misconduct should relate to or be connected with
the performance of the official functions and duties of a
public officer. On the other hand, when the elements of
corruption, clear intent to violate the law or flagrant disregard
of established rule are manifest, the public officer shall be
liable for grave misconduct.
In deliberately leaving the respondent to a midwife and two
inexperienced assistants despite knowing that she was
under prolonged painful labor and about to give birth to a
macrosomic baby by vaginal delivery, petitioner clearly
committed a dereliction of duty and a breach of his
professional obligations. The gravity of respondent’s
conditions is highlighted by the expected complications she
suffered – her stillborn baby, a ruptured uterus that
necessitated the immediate surgery and blood transfusion
and vulvar hematomas.
Article II section 1 of the code of medical ethics of the
medical profession in the Philippines states: A physician,
should attend to his patients faithfully and conscientiously.
He should secure fore them all possible benefits that may
depend upon his professional skill and care. As the sole
tribunal to adjudge the physician’s failure to fulfill his
obligation to his patient is, in most cases, his own
conscience, violation of this rule on his part is discreditable
and inexcusable.
A doctor’s duty to his patient is not required to be
extraordinary. The standard contemplated for doctors is
simply the reasonable coverage merit among ordinarily good
physicians i.e. reasonable skill and competence. Even by
this standard, petitioner fill short when he routinely delegated
an important task that requires his professional skill and
competence to his subordinates who have no requisite
training and capability to make crucial decisions in difficult
child births.
A physician should be dedicated to provide competent
medical care with full professional skill and accordance with
the current standards of care, compassion, independence,
and respect for human dignity.
Bontilao vs Gerona
GR No. 176675 September 15, 2010
Facts: On December 28, 1991, respondent Dr. Carlos
Gerona, an orthopedic surgeon at the Vicente Gullas
Memorial Hospital, treated petitioner’s son, 8 y/o Allen Roy
Bontilao, for a fractured right wrist. Respondent administered
a “U-spint” and immobilized Allen’s wrist with a cast, then
sent Allen home. On June 4, 1992, Alen re-fractured the
same wrist and was brought back to the hospital. The x-ray
examination showed a complete fractured and displacement
bone, with the fragments overlapping each other.
Respondent performed a closed reduction procedure, with
Dr. Vicente Jabagat as the anesthesiologist. Then he placed
Allen’s arm in a plaster cast to immobilize it. He allowed
Allen to go home after the post reduction x-ray showed that
the bones were properly aligned, but advised Allen’s mother,
petitioner Sherlina Bontilao, to bring Allen back for re-
tightening of the cast not later than June 15, 1992. Allen was
however, only brought back after the said date. By then,
because the cast had not be re-tightened, a rotational
deformity had developed in Allen’s arm. The x-ray
examination showed that the deformity was caused by a re-
displacement of the bone fragments, so it was agreed that
an open reduction surgery will be conducted on June 24,
1992 by the respondent, again with Dr. Jabagat as the
anesthesiologist. On the said date, Sherlina was allowed to
observe the operation behind a glass panel. Dr. Jabagat
failed to intubate the patient after 5 attempts so anesthesia
was administered through a gas mask. Respondent asked
Dr. Jabagat if the operation should be postponed given the
failure to intubate, but Dr. Jabagat said that it was alright to
proceed. Respondent verified that Allen was breathing
properly before proceeding with the surgery. As respondent
was about to finish the suturing, Sherlina decided to go out
of the operating room to make a telephone call and wait for
her son. Later, she was informed that her son died on the
operating table. The cause of death was asphyxia due to the
congestion and edema of the epiglottis. Hence, a criminal,
administrative and civil case was filed by the parents of Allen
against the doctors for the negligence that caused Allen’s
death.
Issue: Whether or not respondent is liable for medical
negligence due to the death of Allen.
Held: No. The trial court erred in applying the doctrine of res
ipsa liquitor to pin liability on respondent for Allen’s
death. Res ipsa liquitor is a rebuttable presumption or
influence that the defendant was negligent. The presumption
only arises upon proof that the instrumentality causing injury
was in the defendant’s exclusive control, and that the
accident was one which ordinarily does not happen in the
absence of negligence. It is a rule of evidence whereby
negligence of the alleged wrong does may be inferred from
the mere fact that the accident happened, provided that the
character of the accident and circumstances attending it lead
reasonably to the belief that in the absence of negligence it
would not have occurred and that the thing which caused
injury is shown to have been under the management and
control of the alleged wrong doer.
Res ipsa liquitor is not a rigid or ordinary doctrine to be
perfunctorily used but a rule to be cautiously applied
defending upon the circumstances of each case. In
malpractice case, the doctrine is generally restricted to
situations where a layman is able to say, as a matter of
common knowledge and observation, that the consequence
of professional care were not as such as would ordinarily
have followed if due care had been exercised.
Moreover, we note that in the instant case, the instrument
which caused the injury or damage was not even within
respondent’s exclusive control and management as Dr.
Jabagat was exclusively in control and management of the
anesthesia and endotracheal tube. The doctrine of res ipsa
liquitorallows the mere existence of an injury to justify a
presumption of negligence or the part of the person who

controls the instrument causing the injury, provided that the

following requisites concur:

1. The accident is of a kind which ordinarily does not

occur in the absence of someone’s negligence;
2. It is caused by an instrumentality within the
exclusive control of the defendant or co-
defendants;
3. The possibility of contributing conduct which would
make the plaintiff responsible is eliminated.
 MEDICO LEGAL ASPECT OF DEATH
INVESTIGATION OF DEATH
PHYSICAL INJURIES
Industrial Textile Manufacturing Company of the
Philippines vs Flonzo
GR No. L-21969 August 31, 1966
Facts: Respondent Sofia Reyes Flonzo is the mother of the
deceased Ricardo Flonzo, an employee of petitioner
ITEMCOP for a little less than four years up to March 20,
1950 when he died after becoming paralyzed at the age of
25. His job was to replace empty loom beams attached to a
weaving machines with fully loaded ones. An empty beam
weighs from 15-30 kilos. During an 8-hour period, about 20
t0 30 beams are substituted on a total of 406 machines.
Ricardo worked 8 hours a day, 6 days a week. Ricardo fell ill
and was diagnosed by the ITEMCOP’s physician, Dr.
Alfonso Ayesa to be thrombocytopenic purpura, idipathic
which was later on discovered as cerebral hemorrhage,
secondary to blood deporia. When he died, his autopsy
findings by Dr. Pedro Solis was anemia, severe, secondary
to hemorrhagic gastric ulcer. A claim for Ricardo’s benefits
was filed by his mother, Sofia at the Worker’s Compensation
Commission.
Issue: Whether or not the death of Ricardo is compensable.
Held: Yes. Flonzo suffered bleeding in the stomach. Dr.
Pedro Solis explained that even if the stomach is not empty,
the frequent stress brought about by lifting heavy objects
might produce an ulcer in the stomach, and this is known in
medicine as “stress ulcer.” Further, the effect of continuous
work on a person with stomach ulcer, Dr. Solis added is that
will aggravate the deceased condition of the stomach, and
most likely, it may produce hemorrhage which could be
uncontrollable or controllable. There is then reason to
believe, as the commission observes, that the continuous
exertion of carrying beams during his employment gradually,
if imperceptibly, resulted to his illness causing paralyzation
of half of his body and ultimately his death.
People of the Philippines vs Colinares
GR No. 72025 June 30, 1988
Facts: Respondent Carlos Colinares Y Solmerano is the
accused for the murder (alleged) of Armando Cardinas Y
Luberiano. There are two sides of the story – the
prosecution’s and the defense’s. The version of the
prosecution states that the victim Armando Cardinas just
recently arrived from the Visayas, was the nephew of the
spouses Roberto and Trinidad Lopez, residents of Don
Fabian Subdivision, Fairview, Quezon City, two of the five
testimonial witnesses. That at about 10:00am of Novenmer
29, 1981, a quarrel between the spouses neighbours De
Leon and Martinez family ensued in front of their house and
some thirty armed persons arrived at their house and
mauled and kicked them, that Armando was taken to the
barangay service jeep and was later brought to Quirino
Memorial Hospital in Quezon City where he was pronounced
dead on arrival. On the other hand, the defense’s side was
that Colinares was doing his usual job on the said day and
don’t even know the identity of the victim. The medico legal
report by Col. Gregorio Blanco states that Colinares when
the autopsy was done on November 29, 1981 at the funeral
parlor, Armando has been dead for an estimate 12 hours
already.
Issue: Whether or not the medico legal report could be the
basis of the acquittal of conviction of Colinares absent other
evidence.
Held: Yes. Aside from the fact that there is no evidence
presented to show where the crime took place and who
inflicted the fatal wounds sustained, the record is not clear
as to the time of the mauling incident and the death of the
victim. Roberto Lopez testified that the mauling incident
happened on November 28, 1981 between 10-11:00am,
Trinidad Lopez testified that it happened on the same day
but at 7:30am and Rowena Lopez that it happened at 10am.
Another witness for the prosecution Col. Gregorio C. Blanco
after qualifying himself as a medico-legal expert testified that
the cadaver of the victim was already in rigor mortis (more
than 12 hours dead) when he autopsied it at high noon of
November 29, 1981. Taking into consideration this
unimpeachable testimony of the doctor and the necropsy
report which substantially support the doctor’s oral
testimony, the death of the victim could be calculated to
have occurred at least 12 hours before time of necropsy
which is about November 28, 1981 at 12 midnight. Thus, the
mauling incident of the victim did not happen or could not
have happened because the victim was already dead at that
time of the alleged mauling incident. There is no
inconsistency between the doctor’s oral testimony and the
necropsy report because the time and date of death of the
victim appearing on the necropsy report as a/1040H 29
November 1981 pertains to the time and date as reported to
the doctor by the authorities concerned since the victim was
dead on arrival at 10:40am November 29, 1981 at the
Quirino Memorial Hospital, Quezon City.
People of the Philippines vs Tolentino
GR No. 70836 October 18, 1988
Facts: On or about July 26, 198, in Quezon City, Philippines,
and within the jurisdiction of this honorable court, the above
named accused, conspiring together with and aiding one
another, did, then and there willfully, unlawfully, and
feloniously with intent to kill, qualified by evident
premeditation and treachery attack, assault and employ
personal violence upon the person of Alfredo Quitoriano Y
Bayot by then and there throwing at him stones hitting him
on the head and stabbing the said victim thereby inflicting
upon him serious and mortal wounds which were the direct
and immediate cause of his untimely death, to the damage
and prejudice of his heirs. In order to determine the identity
of the other accused, the fiscal conducted a reinvestigation
and thereafter submitted his resolution to the trial court
wherein he noted the failure of the complainant during the
investigation to present any witness to establish the identity
of said John Doe. Hence, the reinvistigation was terminated
with the identity of said Jon Doe still undetermined.
Accordingly, only the herein accused was arraigned and
tried. A plea of not guilty was entered by the accused. His
application for bail was denied. A medico-legal officer, Dr.
Gregorio Blanco was presented, who also performed the
autopsy on the victim. The necropsy report states that the
fatal injuries in the head caused by a sharp object was the
reason or cause of death.
Issue: Whether or not the testimony by the medico-legal
officer could be accepted as evidence.
Held: Yes. In this jurisdiction, expert opinion constitutes one
of the few exceptions to the general rule that a mere opinion
of a witness regarding a particular matter is not admissible.
In this correction, Rule 130, section 43 provides “The opinion
of a witness regarding a question of science, art or trade,
when he is entitled therein, may be received in evidence.”
In the field of medicine, opinions of doctors qualified by
training and experience us to causation are competent and
in many cases controlling and binding upon the court. In this
case, Dr. Blanco’s opinion as to the cause of the victim’s
injuries should be accorded great respect, it being peculiarly
within the expertise of medical practitioners.
A careful examination of the findings of the medico legal
officer on his necropsy report, particularly on the wounds
found on the victim’s head, bolsters the appellant’s claim that
his guilt has not been proved beyond reasonable doubt.
Wound no. 1, an abrasion was located above the victim’s
eyebrow and therefore, could not have been inflicted by the
appellant as Ferrer plainly testified that the appellant was
behind the victim when he threw the stones. The same can
be said of wound no. 3, a contusion locate near the right
cheek of the victim. The infliction of the fatal wound, wound
no. 2, a lacerated wound measuring only 2.5 by .3cm,
located at the back of the victim’s head cannot likewise be
attributed to appellant, as according to the expert opinion of
the doctor who examined the wound, it was caused by a
sharp instrument like a balisong. While the doctor’s
testimony on record does not preclude the possibility that the
wound could have also been caused by a stone, it was
incumbent upon the prosecution, for in case against the
accused to succeed to elicit a positive statement that effect
from the doctor.
Asetre vs Asetre
GR No. 171536 April 7, 2009
Facts: On December 27, 2000, Hanz Dietrich Asetre was
found dead on his residence, which also housed his printing
press business. He was 26 years old. Petitioner, April Joy
Asetre, Hanz’s wife, alleged that her husband committed
suicide by hanging himself using bed covers. She said Hanz
was deppressed, suicidal, a drug dependent, an alcoholic
and evident even before they got married. She also claimed
that when Hanz got high on drugs and alcohol, he would
break things. When his mother had cancer, he became
desperate, losing his concentration in work as well as lacking
sleep at night then, after her mother died of cancer, he
started writing letters expressing his desire to follow his
mother. He also became depressed because they were left
with huge debts and he had to assume payments. It was
recommended that Hanz under rehabilitation in Cebu City,
but he stayed there for only two weeks. However,
respondent Junel Astre, Hanz’s brother claimed that the
marks on Hanz’s neck was not that of bed spreads but of
rope. He claimed that petitioner Buenaventura Gamboa
know who killed Hanz but was reluctant to divulge it lest he
be charged on harmed by April’s father. In a resolution dated
October 3, 2001, the office of the city prosecutor of Bacolod
found probable cause against April, Hanz’s first cousin,
Galinzehel and Buenaventura Gamboa, and printing press
worker Benjie Ebcas. The investigating prosecutor held that
from the evidence adduced by the parties, herein petitioner
were physically and actively moreover from actuations of
petitioners and the events that took place, it can be gleaned
that they connived in killing Hanz and later tried to cover up
the crime. Further the prosecutor rejected petitioner suicide
theory because it is inconsistent with the medico legal
findings that while Hanz might have wanted to end his life,
the circumstances of his death proved he could not have
done it himself. The prosecutor explained that the possibility
of murder is not negated even if Hanz sustained no wounds
or injuries, since he had been drinking shortly before his
death which could have rendered him too drunk to be aware
that he was being strangled. Thus, prosecutor recommended
that murder charges under article 248 of the revised penal
code be filed against Ebcas and the Gamboa and parricide
against April.
Issue: Whether or not the prosecution’s reliance on the
testimonies of the medico-legal officer is proper.
Held: No. Dr. Samson Gonzaga, the private physician who
signed the death certificate, and Dr. Luis Gamboa, the
medico-legal officer of Bacolod City who conducted the post
mortem autopsy on Hanz’s body, are not expert witnesses,
nor were they offered to testify as medico-legal experts. Dr.
Nicasio Botin, medico-legal officer, NBI Iloilo City, who
prepared the exumeration report is also not a forensic
expert. They never opined that it was improbable for the
deceased to have committed suicide. The death certificate
signed by Dr. Gonzaga indicated asphyxia secondary to
strangulation as the cause of death, without explaining
whether it was suicide or not. It pointed to depression as
antecedent cause, implying that Hanz committed suicide.
Thus, the appellate court lacks sufficient basis to conclude
that it was improbable for Hanz to commit suicide based on
the opinions of of the three doctors.
All circumstances considered, we find that DOC secretary
correctly held that circumstantial evidence presented by
private respondents to prove probable cause against
petitioner, does not support the theory of conspiracy to
commit murder. Such circumstantial evidence in our view,
would not sufficiently warrant a conclusion that private
respondents are responsible for the death of Hanz.
Petitioners mere presence at the death scene, without more,
does not suffice to establish probable cause against them. It
is noteworthy that complainants failed to establish
conclusively that April, Hanz cousin and his workers had an
ax to grind against Hanz. The alleged quarrel of the couple
the night before the incident is a hearsay and could not
establish enough credible motive on the part of April;
contrary to the opinion of the investigating prosecutor,
because the same witness who testified about the alleged
fight also stated that the couple had a good relationship and
that it was unusual for the couple to have verbal altercations
occasionally. Equally worth stressing is the positive proof
that the accused were not the only person present inside the
couple’s house; and that the door of the gate of the house,
including the door of the room where the victim was found
hanging were not so well observed as to exclude the
possibility that the act was committed by other person who
were then also present in the house or even intruders. April
was not attempting to reduce the number of possible witness
as stated by the investigating prosecutor when she sent her
children to Iloilo as it was then victim’s decision to send their
children to Iloilo upon his cousin’s invitation.
Visayan Stevedore and Transportation Company vs
Workmen’s Compensation Commission
GR No. L-26657 September 12, 1974
Facts: The deceased, employed as engineer by Visayan
Stevedore and Transportation Company with a monthly
salary of P235 was part of a 3-man over of the tugboat
M/TDILIS. His main duty consisted in his starting the engine
and seeing to it that it functioned properly during the voyage,
with the actual navigation of the tugboat being the
responsibility of his 2 other companions the “patron” who
controlled the wheel and a helper who operated the rudder.
According to Federico Sespene “Patron” of the tugboat when
the deceased died, from February 10-17, 1964, they were
given to tow barges to the ship and load it with cargoes.
They also had to shift or bring barges to dry dock at the
company’s compound in Iloilo. Aside from that, their work
was to bring the barges from Jordan to Iloilo City, from
terminal to the middle of Guimaras and back. As a
consequence of this work, they were compelled to stay in the
tugboat. On that fatal day of February 17, 1964, they had
received various orders and at about 4am of the same day,
they were towing barges from the shell wharf to Tabangao,
and while they were navigating, Eduardo Libiyo, visibly tired
and in active duty asked for permission to take a rest. When
the tugboat reach Tabangao, witness Sespene was ordered
by Orleans to start towing the barge but when Sespene
called Libiyo to start the engine, there was no answer from
Libiyo. The quartermaster was the one who responded
instead and was the one who ordered to wake up Libiyo,
who at the time was already dead. It was about 6:30am of
February 17, 1964. A subsequent autopsy report of the
deceased’s remains conducted by Dr. Raymund L. Torres,
the assistant medico-legal officer of the Iloilo City police
department, traced the cause of death of Eduardo as
“bangungot.”
Issue: Whether or not the death of Eduardo Libiyo is
compensable and is supported by the autopsy report.
Held: Yes. We do not think that the main point pressed by
petitioner, namely that death caused by bangungot is not
compensable, is at all decisive in the case at bar, what is not
denied, and this is crucial in so far as the compensability of
Eduardo Libiyo’s death is concerned, is that when death
came to the deceased he was in active duty, of as an
engineer-employee of the petitioner. This being the case, the
need to pinpoint the cause of his death as work-connected in
order to render it compensable assumes very little
importance. It is to be presumed, under section 44 of the
Workmen’s Compensation Act, as amended that the
employee’s death, supervening at the time of his
employment, either arose out of, or was at least aggravated
by said employment. With this legal presumption, the burden
of proof shifts to the employer, and the employee is relieved
of the burden to show causation. The mere opinion of
doctors presented by petitioner as evidence cannot prevail
over the presumption established by law.
Seven-Up Bottling Company Inc. Iloilo vs Workmen’s
Compensation Commission
GR No. L-31284 June 11, 1975
Facts: On October 2, 1962, at about 5:30pm, a hand
grenade exploded inside the office of the seven-up bottling
company, Iloilo plant, in Iloilo City, instantly killing William
Peñaflorida, a stock clerk of the company, and Felixberto
Herrera, the branch cashier. Another employee, Victorino
trespeces, was wounded seriously. When the case was
heard, the employer presented Victorina Trespeces, who
testified that the late William Peñaflorida was intoxicated at
the time of the fatal incident and was himself the one who
exploded the hand grenade. It also submitted the police
investigation report tending to corroborate the testimony of
said witnesses. In view of the extended stay in Manila of the
claimant’s rebuttal witness Dr. Teodoro Centeno, the
medico-legal officer of the Iloilo police department at the time
of the incident, the case was submitted for decision without
his testimony. On October 2, 1964, the case was moved to
be reopen and the testimony of Dr. Centeno was received –
that he did not find any trace of liquor in the body of the late
William Peñaflorida and that the hand grenade could have
been thrown from somewhere.
Issue: Whether or not Dr. Centeno’s testimony may be
considered as substantial evidence.
Held: No. Evidently the medico-legal officer arrived at the
conclusion that there was no trace of liquor in the body of the
late William Peñaflorida because of the absence of alcoholic
odor in his breathe. There is no showing that the deceased’s
stomach or intestines were opened and their contents
analyzed for possible alcohol contents. Since he was already
dead it was impossible to detect the presence of alcohol in
his breathe. The means employed by the doctor in arriving at
his conclusion was inherently unreliable, and his testimony
does not meet the test of substantiality of the evidence, let
alone its sufficiency to contradict the police investigation
report and the positive testimony of Victorino Trespeces.
At best, Dr. Centeno’s testimony on this point is merely
conjecture, an inference without legal basis. Again, it cannot
be given any weight in the face of the testimony of
Trespeces, even in itself alone cannot be considered
substantial evidence.
People of the Philippines vs De Vera
GR No. 11316 October 30, 1996
Facts: In the afternoon of September 30, 1990, Irma
Aspurias De Vera, the young housewife of the accused, was
at home with household helper Francisca Eugenio, their
tenant Lorna Anteola, the accused sister Rowena De Vera-
Jesuitas and the latter’s husband Arnel Jesuitas. At about
3:00pm, Irma’s husband accused Ronald De Vera arrived.
Ronald asked Irma, who was then at the kitchen with
Francing and Lorna, to join him in the bedroom upstairs in
order to discuss an important matter. Within minutes, Lorna
heard a commotion in the couple’s bedroom. She could hear
that the two were engaged in a shouting match. Then, there
was a complete silence. After awhile, sensing that all is well
again, Lorna went upstairs. To her surprise, she saw Ronald,
assisted by Arnel carrying a disabled Irma out of the room.
The latter was brought to the Quezon City Medical Center
where she was pronounced dead on arrival. Looking over at
the couple’s bedroom, Lorna and Francing saw that the
place was in disarray. In the medico-legal examination
conducted on October 4, 1990, by the police, the cause of
death was said to be asphyxia by hanging. The National
Bureau of Investigation (NBI), at the request of the
commission on Human Rights (CHR) undertook its own
investigation of the case. Irma’s body was exhausted, and a
second autopsy was conducted. This time the cause of
death was found to be asphyxia compatible with
strangulation. The defense sought to convince that Irma took
her own life.
Issue: Whether or not the autopsy report is binding as
evidence for the crime charged to the respondent.
Held: Yes. It might be stressed that Dr. Bautista, in making
his examination and in identifying the cause of death, did not
fail to take into account the wounds which were apparently
inflicted after Irma’s death, such as the incise wound on the
other right side of the neck and the wound on the wrist of the
left side or antero-lateral aspect.
The corpus delicti indications that the victim was strangled to
death, exemplified by contuse-abrasions on the victim’s neck
and other parts of the body characterized by marked
congestions on the superior part of the first portion of the
trachea and the thyroid cartilage which was even detected
by the NBI medico-legal officer Dr. Bautista at the time he
conducted an autopsy on the victim’s body.
G.R. No. 176389 January 18, 2011
ANTONIO LEJANO, Petitioner,
vs.
PEOPLE OF THE PHILIPPINES, Respondent.
x - - - - - - - - - - - - - - - - - - - - - - -x
G.R. No. 176864
PEOPLE OF THE PHILIPPINES, Appellee,
vs.
HUBERT JEFFREY P. WEBB, ANTONIO LEJANO,
MICHAEL A. GATCHALIAN, HOSPICIO FERNANDEZ,
MIGUEL RODRIGUEZ, PETER ESTRADA and GERARDO
BIONG, Appellants.
On December 14, 2010 the Court reversed the judgment of
the Court of Appeals (CA) and acquitted the accused in this
case, Hubert Jeffrey P. Webb, Antonio Lejano, Michael A.
Gatchalian, Hospicio Fernandez, Miguel Rodriguez, Peter
Estrada, and Gerardo Biong of the charges against them on
the ground of lack of proof of their guilt beyond reasonable
doubt.
On December 28, 2010 complainant Lauro G. Vizconde, an
immediate relative of the victims, asked the Court to
reconsider its decision, claiming that it "denied the
prosecution due process of law; seriously misappreciated
the facts; unreasonably regarded Alfaro as lacking credibility;
issued a tainted and erroneous decision; decided the case in
a manner that resulted in the miscarriage of justice; or
committed grave abuse in its treatment of the evidence and
1
prosecution witnesses."
But, as a rule, a judgment of acquittal cannot be
reconsidered because it places the accused under double
jeopardy. The Constitution provides in Section 21, Article III,
that:
Section 21. No person shall be twice put in jeopardy of
punishment for the same offense. x x x
To reconsider a judgment of acquittal places the accused
twice in jeopardy of being punished for the crime of which he
has already been absolved. There is reason for this
provision of the Constitution. In criminal cases, the full power
of the State is ranged against the accused. If there is no limit
to attempts to prosecute the accused for the same offense
after he has been acquitted, the infinite power and capacity
of the State for a sustained and repeated litigation would
eventually overwhelm the accused in terms of resources,
stamina, and the will to fight.
As the Court said in People of the Philippines v.
2
Sandiganbayan:
[A]t the heart of this policy is the concern that permitting the
sovereign freely to subject the citizen to a second judgment
for the same offense would arm the government with a
potent instrument of oppression. The provision therefore
guarantees that the State shall not be permitted to make
repeated attempts to convict an individual for an alleged
offense, thereby subjecting him to embarrassment, expense,
and ordeal and compelling him to live in a continuing state of
anxiety and insecurity, as well as enhancing the possibility
that even though innocent he may be found guilty. Society’s
awareness of the heavy personal strain which a criminal trial
represents for the individual defendant is manifested in the
willingness to limit the government to a single criminal
proceeding to vindicate its very vital interest in the
3
enforcement of criminal laws.
Of course, on occasions, a motion for reconsideration after
an acquittal is possible. But the grounds are exceptional and
narrow as when the court that absolved the accused gravely
abused its discretion, resulting in loss of jurisdiction, or when
a mistrial has occurred. In any of such cases, the State may
assail the decision by special civil action of certiorari under
Rule 65.
4
Here, although complainant Vizconde invoked the
exceptions, he has been unable to bring his pleas for
reconsideration under such exceptions. For instance, he
avers that the Court "must ensure that due process is
afforded to all parties and there is no grave abuse of
discretion in the treatment of witnesses and the
5
evidence." But he has not specified the violations of due
process or acts constituting grave abuse of discretion that
the Court supposedly committed. His claim that "the highly
questionable and suspicious evidence for the defense taints
 6
with serious doubts the validity of the decision" is, without
more, a mere conclusion drawn from personal perception.
Complainant Vizconde cites the decision in Galman v.
7 acquitted solely because there was lingering doubt as to
Sandiganbayan as authority that the Court can set aside the
acquittal of the accused in the present case. But the
government proved in Galman that the prosecution was
deprived of due process since the judgment of acquittal in
8 the case of Hubert Webb, the evidence tends to establish his
that case was "dictated, coerced and scripted." It was a
sham trial. Here, however, Vizconde does not allege that the
Court held a sham review of the decision of the CA. He has
made out no case that the Court held a phony deliberation in
this case such that the seven Justices who voted to acquit
the accused, the four who dissented, and the four who
inhibited themselves did not really go through the process.
Ultimately, what the complainant actually questions is the
Court’s appreciation of the evidence and assessment of the
prosecution witnesses’ credibility. He ascribes grave error on
the Court’s finding that Alfaro was not a credible witness and
assails the value assigned by the Court to the evidence of
the defense. In other words, private complainant wants the
Court to review the evidence anew and render another
judgment based on such a re-evaluation. This is not
constitutionally allowed as it is merely a repeated attempt to
secure Webb, et al’s conviction. The judgment acquitting
Webb, et al is final and can no longer be disturbed.
WHEREFORE, the Court DENIES for lack of merit
complainant Lauro G. Vizconde’s motion for reconsideration
dated December 28, 2010.
For essentially the same reason, the Court DENIES the
motions for leave to intervene of Fr. Robert P. Reyes, Sister
Mary John R. Mananzan, Bishop Evangelio L. Mercado, and
Dante L.A. Jimenez, representing the Volunteers Against
Crime and Corruption and of former Vice President Teofisto
Guingona, Jr.
No further pleadings shall be entertained in this case.
CONCURRING OPINION
SERENO, J.:
The Motion for Reconsideration assails the majority for
failing to uphold the trial court’s conclusions. The simple fact
is that the evidence tends to demonstrate that Hubert Webb
is innocent. The simple fact also is that the evidence
demonstrates that not only had Jessica Alfaro failed to
substantiate her testimony, she had contradicted herself and
had been contradicted by other more believable evidence.
The other main prosecution witnesses fare no better. This is
the gist of the Decision sought to be reconsidered. While this
Court does not make a dispositive ruling other than a
pronouncement of "guilt" or "non-guilt" on the part of the
accused, the legal presumption of innocence must be
applied in operative fact. It is unfortunate that statements
were made that sought to dilute the legal import of the
majority Decision. A pronouncement of this Court that the
accused has not been proven to be guilty beyond
reasonable doubt cannot be twisted to mean that this Court
does not believe in the innocence of the accused when the
reasoning of the Court demonstrates such belief. A careful
reading of the majority Decision, as well as the concurring
opinions, is required to determine whether the accused were
their guilt of the crime charged or whether the accused were
acquitted not only because of doubt as to their guilt but also
because the evidence tends to establish their innocence. In
innocence. On the other hand, the testimony of Jessica
Alfaro was wholly rejected by the majority as not believable.
In his Motion for Reconsideration, private complainant
asserts that this Court should have respected the trial court’s
resolve to give full credence to the testimony of Jessica
Alfaro. While as a general rule, a trial judge’s findings as to
the credibility of a witness are entitled to utmost respect as
he has had the opportunity to observe their demeanor on the
witness stand, this holds true only in the absence of bias,
partiality, and grave abuse of discretion on the part of the
1
judge. The succeeding discussion demonstrates why this
Court has no choice but to reject the trial court’s findings.
The mistaken impression that Alfaro was a credible witness
was, in significant measure, perpetrated by the trial court’s
inappropriate and mismatched attribution of rights to and
duties of the accused vis-a-vis the principal witness in a
criminal proceeding. As discussed in the promulgated
Decision of the Court in this case, the trial court failed to
recognize the accused’s right to be presumed innocent.
Instead, the trial court’s Decision indicated a preconceived
belief in the accused’s guilt, and as a corollary, that witness
Alfaro was telling the truth when she testified to the
accused’s guilt. In excessively protecting Alfaro, the trial
court improperly ascribed to her the right reserved for an
accused. It also unreasonably imposed severe limitations on
the extent of the right of the defense to cross-examine her.
During Alfaro’s cross examination, the defense counsel tried
to impeach her credibility by asking her about her 28 April
1995 Affidavit, which markedly differs from her 22 May 1995
Affidavit. The prosecution objected and moved that the
questions be expunged from the records on the basis of the
inadmissibility of the evidence obtained allegedly without the
assistance of counsel, pursuant to Article III Section 12(1)
2
and (3) of the 1987 Constitution. This constitutional right,
however, is a right reserved solely for the accused or a
"person under investigation for the commission of an
offense." The prosecution’s objection had no legal basis
because Alfaro was clearly not the accused in the case.
Alfaro was a witness who had a legal duty to "answer
questions, although his (her) answer may tend to establish a
3
claim against him (her)." Notwithstanding this, the lower
court sustained the prosecution’s objection.
The law does not confer any favorable presumption on
behalf of a witness. It is precisely due to the absence of any
legal presumption that the witness is telling the truth that
he/she is subjected to cross-examination to "test his
accuracy and truthfulness and freedom from interest or bias,
or the reverse, and to elicit all important facts bearing upon
4
the issue." The Rules provide that "the witness may be
cross-examined by the adverse party as to any matters
stated in the direct examination, or connected
therewith, with sufficient fullness and freedom." A
5]
witness may be impeached "by contradictory evidence, by
evidence that his general reputation for truth, honesty, or
integrity is bad, or by evidence that he has made at other
6
times statements inconsistent with his present testimony."
The right to cross-examine a witness is a matter of
procedural due process such that the testimony or
deposition of a witness given in a former case "involving the
same parties and subject matter, may be given in evidence
against the adverse party" provided the adverse party "had
7
the opportunity to cross-examine him."
Notwithstanding the right of the accused to fully and freely
conduct a thorough cross examination, the trial court set
undue restrictions on the defense counsel’s cross
examination of Alfaro, effectively denying the accused such
right. The length of the cross-examination is not as material
in the determination of the credibility of the witness as much
as whether such witness was fully tested by the defense
when demanded to be tested on cross-examination – for
honesty by contradictory evidence of a reputation for
dishonesty, for inconsistency, or for possible bias or
improper motive.
To establish Alfaro’s bias and motive for testifying in the
case, the defense counsel sought to ask Alfaro about her
brother, Patrick. Alfaro admitted that Patrick was a drug
addict and had been arrested once by the NBI for illegal
possession of drugs, but that he was presently in the United
States. The theory of the defense was that Patrick’s liberty
was part of a deal that Alfaro had struck with the NBI in
exchange for her services. When defense counsel inquired
about the circumstances of Patrick’s departure for the United
States, the prosecution objected to the questions on the
ground of irrelevance. Respondent judge sustained the
objection, thus foreclosing a significant avenue for testing
Alfaro’s "freedom from interest or bias."
The defense counsel tried to cross-examine Alfaro regarding
her educational attainment as stated in her sworn
statements. The defense presented her college transcript of
records to prove that she only enrolled for a year and earned
nine (9) academic units, contrary to her claim that she
finished second year college. Notably, Alfaro misrepresented
her educational attainment in both of her affidavits – her 28
April 1995 Affidavit which she claimed was executed without
assistance of counsel, and her subsequent 22 May 1995
Affidavit which was admittedly executed with the assistance
of counsel. Apparently, Alfaro’s lie under oath about her
educational attainment persisted even after being given
counsel’s assistance in the execution of the second affidavit,
as well as more time to contemplate the matter.
Unfortunately, the lower court sustained the prosecution’s
objection to the question on the ground of irrelevance when
the line of testing could have tested Alfaro's penchant for
"accuracy and truthfulness."
Ironically, notwithstanding the trial court’s disallowance of
the defense’s attempts to impeach Alfaro's character, and
the rule that "(e)vidence of the good character of a witness is
not admissible until such character has been
8
impeached," the trial court allowed the prosecution to
9
present Atty. Pedro Rivera to testify positively on Alfaro’s
character. Worse yet, the trial court disallowed the defense
from presenting Atty. Rivera’s earlier statement to impeach
the latter’s credibility; again, this was disallowed on the
ground of immateriality. When a proffer of evidence was
10
made by the defense following such disallowance, the trial
court struck the proffer from the record on the ground that it
was allegedly improper on cross-examination.
The notion that witness Alfaro was able to withstand her
cross examination appears sustainable in large part because
her cross examination was so emasculated by the trial
court’s inordinate protection of her, which went so far as to
improperly accord her the right reserved for an accused.
Taken together with repeated instances of unwarranted
exertion of effort to wipe the record clean of some entries
that cast doubt on Alfaro’s credibility, the trial court’s actions
show that it had a bias towards upholding the truthfulness of
Alfaro’s testimony.
The trial court’s treatment of documentary evidence also
suffered from mismatched ascription – discarding legal
presumptions without evidence to the contrary while giving
evidentiary weight to unsubstantiated speculation. For
instance, in rejecting Webb’s alibi defense, the trial court
used mere speculation that the accused’s family influenced
the production of false entries in official documents to defeat
the legal presumption of said documents’ accuracy and
regularity of issuance. Notably, the United States
Immigration and Naturalization Service (US INS)
Certification, which confirmed that Webb was in the United
States from March 1991 until October 1992, was
authenticated by no less than the Office of the U.S. Attorney
General and the U.S. State Department. Furthermore, this
official certification of a sovereign state. having passed
through formal diplomatic channels, was authenticated by
the Department of Foreign Affairs. As discussed in the main
decision, such official documents as the authenticated U.S.
INS Certification enjoy the presumption of accuracy of the
11
entries therein. Official documents are not infallible, but the
presumption that they are accurate can only be overcome
with evidence. Unfortunately, in the mind of the trial court,
pure conjecture and not hard evidence was allowed to defeat
a legal presumption.
Clearly, the trial court’s decision in this case was, in
significant measure, the product of switched attributions as
to who should enjoy certain rights and what should be
presumed under the law. This behavior on the part of the
trial court and the effect it had on the factual conclusions on
the credibility of Jessica Alfaro and on the presence of
Hubert Webb in the Philippines at the time of the
commission of the crime cannot be upheld.
Lejano vs People of the Philippines
GR No. 176389 December 14, 2010
Facts: On June 30, 1991, Estrelita Vizconde and her
daughter Carmela nineteen and Jennifer seven were brutally
slain at their home in Parañaque City. Following an intense
investigation, the police arrested a group of suspects, some
of whom gave detailed confessions. But the trial court
smelled a frame-up and eventually ordered them discharged.
Thus, the identities of the real perpetrators remained a
mystery especially to the public whose interest were aroused
by the gripping details of what everybody referred to as the
Vizconde massacre. Four years later in 1995, the National
Bureau of Investigation (NBI) announced that it had solved
the crime. It presented star witness Jessica Alfaro, one of its
informers, who claimed ghat she witnessed the crime. She
pointed to the accused Herbert Jeffrey Webb, Antonio “Tony
Boy” Lejano, Artemio Dong Ventura, Michael Gatchalian, and there inflict physical injuries and threw Marijoy into a
Hospicio Pyke Fernandez, Peter Estrada, Miguel Ging deep ravine which caused her death.
Rodriguez, and Joey Filart as the culprits. She also tagged
police officer Gerardo Biong as an accessory after the fact.
Issue: Whether or not witness who is also one of the
Relying primarily on Alfaro’s testimony, on August 10, 1995,
perpetrators is a credible witness for the crime charged.
the public prosecutors filed an information for rape with
homicide against Webb etal. The prosecution presented
Alfaro as its main witness with the others corroborating her Held: Yes. Rustia positively identified the appellants. The
testimony. These included the medico-legal officer who settled rule is that positive identification of an accused by a
autopsied the bodies of the victims, the security guard of credible as the perpetrator of the crime demolishes alibi, the
Pitong Daan subdivision, the former laundry-woman of the much abused sanctuary of felons. Rusia’s testimony was
Webb’s household, police officer Biong’s former girlfriend, corroborated by several disinterested witnesses who also
and Lauro Vizconde, Estrelita’s husband. identified the appellants. Most of them are neither friends,
relatives nor acquaintances of the victim’s family. As we
received closely the transcript of stenographic notes, we
Issue: Whether or not failure to conduct a DNA test on the
could not discern any motive on their part why they should
semen specimen found on Carmela is a ground for Webb’s
testified falsely against the appellants. In the same vein, it is
acquittal.
improbable that the prosecution would tirelessly go through
the rigors of litigation just to destroy innocent lives.
Held: No. The medical evidence clearly established that
Carmela was raped and, consistent with this, semen
Meanwhile, appellants argue that the prosecution failed to
specimen was found in her. It is true that Alfaro identified
prove that the body found at the foot of a deep ravine in Tan-
Webb in her testimony, as Carmela’s rapist and killer but
awan, Carcar was that of Marijoy. We are not convinced,
serious questions had been raised about her credibility. At
Rusia testified that Josman instructed Rowen “to get Rid” of
the very least, there exist a possibility that Alfaro had lied.
Marijoy, and following such instruction, Rowen and Ariel
On the other hand, the semen specimen was taken from
pushed her into the deep ravine. Furthermore, inspector
Carmela cannot possibly lie. It cannot be coached or allured
Edgardo Lenizo, a fingerprint expert, testified that the
by a promise of reward or financial support. No two persons
fingerprints of the corpse matched those of Marijoy. The
have the same DNA finger print, with the exception of
packaging tape and the handcuff found on the dead body
identical twins. If, on examination, the DNA of the subject
were the same items placed on Marijoy and Jacqueline while
specimen does not belong to Webb, then he did not rape
they were being detained. The body had the same clothes
Carmela. It is that simple. Thus, the court would have been
worn by Marijoy on the day she was abducted. The
able to determine that Alfaro committed perjury in saying that
members of the Chiong family personally identified the
he did. Still, Webb is not entitled to acquittal for failure of the
corpse to be that of Marijoy which they eventually buried.
state to produce the semen specimen at this late stage. For
They erected commemorative at the ravine, cemetery, and
one thing, the ruling in Brady vs Maryland that he cites his
every place which mattered to Marijoy. Indeed, there is
no longer long been overtaken by the decision in Arizona vs
overwhelming and convincing evidence that it was the body
Youngblood, where the US Supreme Court held that due
of Marijoy that was found in the ravine.
process does not require the State to preserve the semen
specimen although it might be useful to the accused unless
the latter is able to show bad faith on the part of the
prosecution or the police. Here, the state presented a
medical expert who testified on the existence of the
specimen and Webb in fact, sought to have the same People of the Philippines vs Whisenhunt
subjected to DNA test. GR No. 123819 November 14, 2001

For another, when Webb raised the DNA issue, the rule
governing DNA evidence did not yet exist, the country did
not yet have the technology for conducting the test and no
Philippine precedent had as yet recognized its admissibility
as evidence.
People of the Philippines vs Larrañaga
GR No. 138874-75 February 3, 2004
Facts: On July 16, 1997 at about 10 o’clock more or less in
the evening, in the City of Cebu, Philippines and within the
jurisdiction of this honorable court, the said accused all
private individuals, conniving, confederating and mutually
helping each other, with deliberate intent, did then and there
willfully and feloniously kidnap or deprive Marijoy Chiong and
Jacqueline Chiong, of their liberty and on the occasion
thereof, and in connection, accused, with deliberate intent,
did then and there have carnal knowledge against them with
the use of force and intimidation and subsequent thereto and
on the occasion thereof, accused with intent to kill did then
Facts: That on or about September 24, 1993, in the
municipality of San Juan, Metro Manila, Philippines, and
within the jurisdiction of this honorable court, the above
named accused did then and there willfully, unlawfully and
feloniously, with intent to kill and taking advantage of
superior strength, attack, assault and use personal violence
upon the person of one Elsa Santos-Castillo by then and
there stabbing her with a bladed weapon in different parts of
her body, thereby inflicting upon her mortal wounds which
were the direct and immediate cause of her death and
thereafter outraged or scofted her corpse by then and there
chopping off her head and different parts of her body. The
medico-legal officer, found contusions on accused-
appellant’s left periumbilical region, right elbow, left and right
forearms and right leg. Dr. Ronaldo Mendez, the medico-
legal officer who conducted the autopsy, concluded that the
cause of death of Elsa were stabbed wounds. Respondent,
Whisenhunt as his witness his lawyer who is also a medico-
legal officer.
Issue: Whether or not the testimony of respondent’s
presented witness as a lawyer-witness will be given.
Held: No. Accused-appellant makes capital of the fact that
the medico-legal officer, Dr. Mendez, did not examine the
pancreas of the deceased notwithstanding Demetrio’s
statement that according to accused-appellant, Elsa died of
“bangungot”, hemorrhage of the pancreas, because of this
accused-appellant insist that the cause of death was not
adequately established. Then, he relied on the controverting
testimony of his witness, lawyer-doctor, Ernesto Brion, who
was himself a medico-legal officer of the NBI for several
years, to the effect that the autopsy report prepared by Dr.
Mendez was unreliable and inconclusive. The trial court,
however, noted that Dr. Brion was a biased witness whose
testimony cannot be relied upon because he entered his
appearance as one of the counsel for the accused-appellant
and, in such capacity, extensively cross-examined Dr.
Mendez accused-appellant counters that there’s no
prohibition against lawyers giving testimony. Moreover, the
trial court’s ruling would imply that lawyers who testify on
behalf of their clients are presumed to be lying.

By rejecting the testimony of Dr. Brion, the trial court did not
mean that he perjured himself on the witness stand. Notably,
Dr. Brion was presented as expert witness. His testimony
and the questions propounded on him dealt with his opinion
on the probable cause of death of the victim. Indeed the
presentation of expert testimony is one of the well-known
exceptions to the rule against admissibility of opinions in
evidence. In like manner, Dr. Mendez was presented on the
stand to give his own opinion on the same subject. His
opinion differed from that of Brion, which is not at all
unusual. What the trial court simply did was to choose which
— between two conflicting medico-legal opinions – was the
more plausible. The trial court correctly lent more credence
to Dr. Mendez’s testimony not only because Dr. Brion was a
biased witness, but more importantly, because it was Dr.
Mendez who conducted the autopsy and personally
examined Elsa’s corpse up close.

Physical evidence is a mute but eloquent manifestation of

truth, and it ranks high in the hierarchy of our trustworthy
evidence.
 MEDICO LEGAL ASPECT OF DANGEROUS DRUGS
People of the Philippines vs Hatani
GR No. 78813-14 November 8, 1993
Facts: On or about July 6, 1979, in Quezon City, Philippines
the above named accused, knowing fully well that he has not
satisfactorily passed the corresponding board examination,
neither is he a holder of a valid certificate of registration duly
issued by the board of medical examiners, as in fact he does
not even appear to have taken or completed the course
leading to a medical degree, did then and there, willfully,
unlawfully, and feloniously for compensation, fee and salary,
paid to him directly, physically examined Priscila Borja and
Wilma Borja, diagnosed, treated and administer injections on
their person in violation of section 10 in relation to section 28
of RA 2382. On or about the same day, accused with lewd
designs, and while she was deprived of reason or
unconscious after having been drugged or administered
medicine, did then and there, willfully, unlawfully and
feloniously have sexual intercourse with Priscila without her
consent and against her will, to her damage and prejudice.
Issue: Whether or not the accused is liable for the crime
charged.
Held: Yes. The evidence is overwhelming that appellant
actually treated and diagnosed Priscila and Wilma Borja.
The positive testimony of Agustina, Priscila, Wilma, and
Josefina Borja; the medico-legal report, which attests to the
needle marks, the handwriting identification report; the
photographs showing assorted drugs and medical
equipment in appellants room; and the chemistry reports
proved that appellant was engaged in the practice of
medicine. And as to his allegation that there was no proof of
payment, the law specificallt punishes said act whether or
not done for a fee.
Suffice it to say, the medico-legal report indicates swellings
and lacerations and concludes that Priscila was no longer a
virgin. Although the records fail to show any sworn statement
by Priscila, such is not fatal where the sworn affidavits of her
mother, her twi sisters and the medico-legal report are
sufficient to show probable cause of rape.
The absence of injuries does not negate the commission of
rape, for rape may be committed after rendering a woman
unconscious.
It is settled jurisprudence that virginity is not an essential
element of rape.
People of the Philippines vs Mendoza
GR No. 186387 August 31, 2011
Facts: An information was received that a certain Juan
Mendoza is selling illegal drugs, shabu specifically in the City
of Baguio. A buy-bust operation to entrap the accused was
set, Police officer Antolin was the buyer to meet the accused
at the stairs of the Cresencia Barangay hall along Bokaw
Kan Road at around 2:00 pm when the signal was given by
Antolin upon the end of the transaction, the accused was
searched and was take under custody where other sachets
of shabu were seized from him. The said items were then
tested positive of menthamphetamine hydrochloride. The
same pieces of evidence were transmitted to the crime
laboratory and was later on presented to the court.
Issue: Whether or not the items seized were admissible as
evidence to convict the accused for violations of the
Dangerous Drugs Act of 2002.
Held: Yes. In crimes involving sale of illegal drugs, two
essential elements must be satisfied:
1. Identities of the Buyer, the Seller, the object and
the consideration; and
2. The delivery of the thing sold and the payment for
it.
In the prosecution for illegal possession of dangerous drugs,
on the other hand, it must be shown that:
1. The accused is in possession of an item or an
object identified to be prohibited or a regulated
drug;
2. Such possession is not authorized by law;
3. The accused freely and consciously possessed
the said drug.
In this case, all these elements were satisfactorily proven by
the prosecution beyond reasonable doubt through
testimonial, documentary and object evidence presented
during the trialm PO2 Antolin, the designated poseur-buyer,
testified as the circumstances surrounding the apprehension
of the accused, and the seizure and marking of the illegal
drugs recovered from the accused. Then, SPO4 Sison
corroborated PO2 Antolin’s testimony and confirmed that all
the confiscated items recovered from the accused were
turned over to him as team leader.
The compliance with the chain of custody rule was
sufficiently established.
In the chain of custody in a buy-bust situation, the following
links must be established: first, the seizure and marking, if
practicable, of the illegal drug received from the accused by
the apprehending officer; second, the turnover of the illegal
drug seized by the apprehending officer to the investigating
officer; third, the turnover by the investigating officer of the
illegal drug to the forensic chemist for laboratory
examination; and fourth, the turnover and submission of the
marked illegal drug seized from the forensic chemist to the
court.
People of the Philippines vs Amarillo
GR No. 194721 August 15, 2012
Facts: Accused-appellant identified himself as John Brian
Amarillo 25 years old, a resident of Laperal Compound,
Guadalupe Viego, Makati City, single, a washing boy. On or
about April 8, 2006, in the City of Makati, Philippines, and
within the jurisdiction of this honorable court, Amarillo,
without the corresponding license or prescription did then
and there willfully, unlawfully and feloniously sell, give away,
distribute and deliver 0.03g of methylamphetamine
hydrochloride (shabu), which is a dangerous drug. On the
same day, after the arrest of the accused, a search was
made upon his person and in his possession was found 17
small heat-sealed plastic which contains shabu, with a total
of 0.33g.
Issue: Whether or not failure to perform the regular
inventory of the drugs seized would render the evidence
inadmissible and accused not liable for the crime charged.
Held: No. To prove illegal sale of shabu, the following
elements must be present: a.) the identities of the buyer and
the seller, the object of the sale, and the consideration; and
b.) the delivery of the thing sold and the payment for the
thing. And, to secure conviction, it is immaterial to establish
that the transaction or sale actually took place, and to bring
to the court the corpus delicti as evidence.
As to the crime of illegal possession of shabu, the
prosecution clearly proved the presence of the following
essential elements of the crime: a.) the accused was in
possession of an item or object that is identified to be a
prohibited as dangerous drugs; b.) such possession was not
authorized by law; and c.) the accused freely and
consciously possessed the drug. After the arrest, accused-
appellant, 17 heat-sealed sachets of white substance were
found in his possession. The chemistry report showed that
the white substamce in the plastic sachets tested for shabu.
And, there was no showing that such possession was
authorized by law.
The failure of the prosecution to show that the police officers
conducted the required physical inventory and photograph of
the evidence confiscated pursuant to said guidelines is not
fatal and does not automatically render accused-appellant’s
arrest illegal or the items seized/confiscated from him
inadmissible.
The court has long settled that an accused may still be found
guilty despite the failure to faithfully observe the
requirements provided under section 21 of RA 9165, for as
long as the chain of custody remains unbroken.
The doctrine of presumption of regularity in the performance
of official duty is likewise applicable in the instant case, there
being no showing of any ill motive on the part of the arresting
officers to falsely accuse accused-appellant of the crimes
charged. In fact, he himself testified that he did not know any
of the persons who arrested him and that he did not also
have any misunderstanding with any one of them. And, in
the absence of proof of any intent on the part of the police
authorities to falsely impute such a serious crime against
appellant as in this case, the presumption of regularity in the
performance of official duty must prevail.
People of the Philippines vs Sabardon
GR No. 132135 May 21, 2004
Facts: Sometime in 1990, the Banluta Family transferred
their residence at No. 5 Linaluz Street, San Carlos
subdivision, Tayuman, Binangonan, Rizal. Opposite their
house was that of Elizabeth de Lima. Another neighbour of
the Banluta family was the appellant, then 5 y/o, Domingo
Sabardon, a cathecist who resided in a two-storey apartment
about 15m away from the Banluta residence. The appellant
came to meet Richelle as he frequented the Banluta house
and befriended Rico Banluta, Nimfa’s 21 y/o son. At about
10pm on September 15, 1991, Nimfa berated Richelle for
playing with the diaper of her niece. Richelle who was then a
little more than 12 y/o, placed some underwear, shorts, long
pants, and four shirts in her school bag and surreptitiously
left the house. She passed by the appellant’s apartment
while the latter was on his way out to throw garbage. The
appellant inquired where she was going, and Richelle replied
that she was earlier berated by her mother and was leaving
the house. The appellant invited Richelle to his apartment,
and to spend the night therein. Richelle agreed. She felt
happy, thinking that she was in good hands. Besides, she
had nowhere to go. During Richelle’s stay at the accused’s
apartment, there were instances when she was forced to
drink beer or juice after which she fell unconscious and upon
waking up, she will find herself naked with his body in pain
especially her vagina and that the same is bleeding. She
also find the accused beside her also naked. She would ask
the accused of what happened but the latter will just leave
her in the in the room. After days of staying in the accused’s
apartment, when Elizabeth, the neighbour saw Richelle in
there, they rescued her while the accused is away.
Issue: Whether or not the finding of the presence of drugs in
the drinks of Richelle was necessary to make liable the
accused of the crime charged.
Held: No. The drug or substance in question is only
corroborative to Richelle’s testimony that she became dizzy
and unconscious when the appellant forced her to drink beer
and juice. There can be no other conclusion that the
appellant mixer a sedative in the beverage which he forced
Richelle to drink. It must be stressed that Richelle was then
barely 12 y/o. The alcoholic content of the beer must have
caused her to feel dizzy and lose consciousness. She was
rendered to such steeper, weakness of the body and mind
as to prevent effectual resistance and preclude the
possibility of consent.
A tests to determine the presence of any sedative on drug in
the drinks given to a victim is not an indispensable element
in the prosecution for rape.
True, there was no test conducted to determine the
presence of any sedative or drug in the drinks given to the
victims which caused them to lose momentary control of
their faculties. But this is of little consequence as the same is
not an indispensable element in the prosecution for rape.
Under the circumstances, it suffices that the victim was
found to have been unconscious at the time the offender had
carnal knowledge of her.
In rape cases, carnal knowledge of the victim by the accused
may be proven not only by direct evidence but also by
circumstantial evidence, provided that there is more than
one circumstances; the facts from which the inferences are
derived are proven; the combination of all the circumstances
is such as to produce a conviction beyond reasonable doub
 People of the Philippines vs Alejandro
GR No. 205227 April 7, 2014
Facts: On or about July 12, 2006, in the City of Muntinlupa
and within the jurisdiction of this Honorable court, accused
Marco Alejandro along with Imelda Solema and Jerry del
Rosario, conspiring and confederating together and mutually
helping and aiding one another, not being authorized by law
did then and there willfully, unlawfully and feloniously sell,
trade, deliver and give away to another, methamphethamine
hydrochloride, a dangerous drug weighing 98.51g contains
in 1 heat-sealed transparent plastic sachet in violation of
section 5, article II of Republic Act No. 9165. It was alleged
that when the marking of the said illegal drugs was done. It
was done not in accordance with the rules whereby the
inventory and said marking was done in the absence of the
local officials of the place.
Issue: Whether or not the failure to comply with the
guidelines renders the evidence for the violation of RA 9165
inadmissible.
Held: No. Firmly established in our jurisprudence is the rule
that in the prosecution for illegal sale of drugs, the following
essential elements must be proven: 1.) That the transaction
or sale took place; 2.) The corpus delicti or the illicit drug
was presented as evidence; and 3.) That the buyer and
seller were identified. Implicit in all these is the need for
proof that the transaction or sale actually took place, coupled
with the presentation in court of the confiscated prohibited or
regulated drug as evidence.
What determines if there was, indeed, a sale of dangerous
drugs in a buy-bust operation is proof of the concurrence of
all the elements of the offense, to wit: 1.) The identity of the
Buyer and the seller, the object, and the consideration; and
2.) The delivery of the thing sold and the payment therefore.
Clearly all the elements of the crime were established by
both the oral and object evidence presented in court. It is
settled that in cases involving violation of the dangerous
drugs act, credence is given to prosecution witnesses who
are police officers for they enjoy the presumption of having
performed their duties in a regular manner, unless, of
course, there is evidence to the contrary suggesting ill
motive on their part or deviation from the regular
performance of their duties. Since no proof of such ill-motive
on the part of the PDEA buy-bust team was adduced by
appellant, the RTC and CA did not err in giving full faith and
credence to the prosecution’s account of the buy-bust
operation. This court has repeatedly stressed that a buy-
busy operation is a valid means arresting violators of RA
9165.
Under section 1(b) of dangerous drugs board resolution no.
1 series of 2002, which implements RA 9165 “Chain of
Custody” is defined as the duly recorded authorized
movements and custody of seized drugs or controlled
chemicals or plant sources of dangerous drugs or laboratory
equipment of each stage, from the time of
seizure/confiscation to receipt in the forensic laboratory to
safekeeping to presentation in court for destruction. Such
record of movements and custody of seized items shall
include the identity and signature of the person who held
temporary custody of the seized items, the date and time
when such transfer of custody were made in the course of
safekeeping and use in court as evidence, and the final
disposition.
The failure of the prosecution to show that the police officers
conducted the required physical inventory and photography
of the evidence confiscated pursuant to the guidelines, is not
fatal.
The links that the prosecution must establish in the chain of
custody in a buy-bust situation to be are: first, the seizure
and marking, if practicable, of the illegal drug recovered from
the accused by the apprehending officer; second, the
turnover of the illegal drugs seized by the apprehending
officer to the investigating officer; third, the turnover by the
investigating officer; third, the turnover by the investigating
officer of the illegal drug to the forensic chemist for
laboratory examination; and fourth, the turnover and
submission of the marked illegal drug seized from the
forensic chemist to the court.
The non-presentation as witnesses of other persons such as
the investigation and the receiving clerk of the PNP regional
crime laboratory is not crucial point against the prosecution.
The matter of presentation as witnesses by the prosecution
is not for the cour to decide. The prosecution had the
discretion as to how to present its case and it has the right to
choose whom it wishes to present as witnesses. Further,
there is nothing in RA 9165 or in it implementing rules, which
requires each and every one who came into contact with the
seized drugs to testify in court. As long as the chain of
custody of the seized drug was clearly established to have
not been broken and the prosecution did not fail to identify
properly the drugs seized, it is not indispensable that each
and every person who came into possession of the drugs
should take the witness stand.
People of the Philippines vs Oriza
GR No. 202709 July 3, 2013
Facts: On June 21, 2004 the public prosecutor’s office filed
(of Rizal) separate charges of possession of dangerous
drugs before the RTC of Rizal Branch 2, against accused
spouses, Romeo in criminal case no. 7598 and Mercy in
criminal case no. 7599. The prosecution further charged the
spouses with selling dangerous drugs in criminal case no.
7600, all allegedly in violation of dangerous drugs act. The
prosecution’s version is that they received an information
from their asset that a certain Mercy Oriza is engaged in the
selling of dangerous drugs, and a buy-bust operation was
planted in order to capture said Mercy in their home in
Phase 1-D of Kasiglahan Village, Rizal. On the day of the
buy-bust, upon the giving of the signal, the police headed to
the home of Mercy and Romeo, however, the accused ran
into their house when they saw the police officers but the
latter rammed the door until they were able to get in and
found from the accused 4 heat-sealed sachet containing
white crystalline. On the other hand, the defense’s version is
that Mercy was caught by the police and was invited to the
police station when she went out of their house due to one of
her neighbour’s call that her brother, Valentino were being
arrested in an accusation he did not do. The prosecution and
the defense stipulated that the specimens that PO1 Annalie
Forro, a PNP forensic chemical officer, examined were
methamphethamine hydrochloride. They further stipulated,
however, that officer Forro could not testify on the source
and origin of the subject specimens that she had examined.
As a result, PO1 Forro did not testify and only her report was
adduced by the prosecution as evidence.
Issue: Whether or not the prosecution proved beyond
reasonable doubt that Romeo and Mercy were in possession
of and were selling dangerous drugs when the team of police
officers arrested them on June 16, 2004.
Held: No. Compliance with section 21, RA 9165, especially
the required physical inventory and photograph of the seized
drugs in the presence of the accused, the media and
responsible government functionaries, would be clear
evidence that the police had carried out a legitimate buy-bust
operation. Here, the prosecution was enable to adduce such
evidence, indicating that the police officers did not at all
comply with the prescribed procedure. Worse, they offered
no excuse or explanation at the hearing of the case for their
blatant commission of what the law required of them.
Apart from the above, the prosecution carried the burden of
proving and establishing the chain of custody of the
dangerous drugs that the police allegedly seized from the
accused in the night of June 16, 2004. It should establish the
following links in that chain of custody of the confiscated
item: first, the seizure and marking, if practicable, of the
illegal drug recovered from the accused by the apprehending
officer; second, the turnover of the illegal drug seized by the
apprehending to the investigating officer; third, the turnover
by the investigating officer of the illegal drug to the forensic
chemist for laboratory examination; fourth, the turnover and
submission of the marked illegal drug seized from the
forensic chemist to the court.
Still, jurisprudence has established a rare exception with
respect to the first link – immediate seizure and marking of
the seized items in the presence of the accused and others
namely, that a.) There must be justifiable grounds for non-
compliance with procedures; and b.) The integrity and
evidentiary value of the seized items are properly preserved.
Yet, the police officers did not bother to offer any sort of
reason or justification for their failure to make an inventory
and take pictures of the drugs immediately after their seizure
in the presence of the accused and the other persons
designated by law. Both the RTC and CA misapprehended
the significance of such omission. It is imperative for the
prosecution to establish a justifiable cause for non-
compliance with the procedural requirements set by law. The
procedures outlined in section 21 of RA 9165 are not merely
empty formalities – these are safeguards against abuse, the
most notorious of which is its use as a tool for extortion.
transfer of custody of the illegal, there were inconsistencies
– as to gender of the informant, who marked the exhibit.
Issue: Whether or not the inconsistencies in the testimonies
is material to the crime charged.
Held: Yes. Inconsistencies and discrepancies referring to
minor details and not upon the basic aspect of the crime do
not diminish the witnesses’ credibility. If the cited
inconsistency has nothing to do with the elements of the
crime, it does not stand as a ground to reverse conviction.
However, in this case, the material inconsistencies are
furthered by inconsistencies of the police officers on minor
details. Referring back to the narration of circumstances of
the buy-bust operation. SPO2 Nagera was asked about the
gender of the informant who went to their office to report
about the illegal activities committed by Ningning. He readily
answered that the informant was a female.PO3 Ramos in
turn, when asked to describe what happened in the
afternoon before the buy-bust operation, testified that a male
informant came to their office to report about a person selling
illegal drugs. These conflicting statements of the prosecution
effectively broke the chain of custody of evidence of the sale
of dangerous drug.
Proof beyond reasonable doubt does not mean such a
degree of proof as, excluding possibility of error, produces
absolute certainty. Moral certainty only is required, or that
degree of proof which produces conviction in an
unprejudiced mind. It must rest on its own merits and must
not only rely on the weakness of the defense. If the
prosecution fails to meet the required amount of evidence,
the defense may logically not even present evidence on its
own behalf, in which case, the presumption prevails and the
accused should separately be acquitted.
It was explained that the chain of custody rule includes
testimony about every link in the chain, from the moment the
item was picked up to the time it was offered in evidence, in
such a way that every person who touched the exhibit would
describe how and from it was received where it was and
what happened to it while in the witnesses’ possession, the
condition in which it was received and the condition in which
it was derived to the next link in the chain.

People of the Philippines vs Clara

GR No. 195528 July 24, 2013

Facts: On September 12, 2005, at about 4pm, an informant

came at the district anti-illegal drug special task group office
to give an information that a certain Ningning is selling illegal
drugs. A buy-bust operation was conducted whereby
accused Joel was arrested and no Ningning was found.
During the investigations, the testimony of the witnesses
police officers regarding the conduct of the buy-bust and the
 ADDITIONAL CASES
G.R. No. 191225 October 13, 2014
ZARSONA MEDICAL CLINIC vs. PHILIPPINE HEALTH
INSURANCE CORPORATION
Before the Court is a petition for review on certiorari under
Ruic 45 of the Rules of Court, questioning the 28 January
1 2
2009 and 7 December 2009 Resolutions of the Court of
Appeals in CA-G.R. SP No. 02489-MIN.
A complaint was filed against petitioner Zarsona Medical
Clinic (ZMC) for violation of Section 149 of the Revised
Implementing Rules and Regulations of Republic Act No.
7875 or the National Health Insurance Act of 1995. Section
149 penalizes any health care provider that increases the
period of actual confinement of any patient with revocation of
accreditation.
ZMC filed a claim withthe Philippine Health Insurance
Corporation (Philhealth) on the confinement of National
Health Insurance Program (NHIP) member Lorna M. Alestre
(Alestre) on 10-12 August 2003. Said claim was denied on
the ground of "extended confinement." It was stated on the
claim form that Alestre was admitted to ZMC on 6 August
2003 and was discharged on 12 August 2003. Itwas also
3
revealed in her Salaysay dated 12 January 2004 that
Alestre’s actual confinement at ZMC was on 10-11 August
2003. Alestre, who is a teacher at Rizal Elementary School,
was found to have reported for work on 12 August 2003.
In defense of ZMC, Dr. Sylvia Bragat (Dr. Bragat), its
Medical Director, stated that ZMC’s Midwife/Clerk Jennifer
R. Acuram (Acuram) committed an honest mistake when she
wrote 6-12 August 2003 as the confinement period in the
claim form. Dr. Bragat asserted that the hospital had in fact
claimed only for two (2) days. Acuram acknowledged her
mistake in her Affidavit of Explanation.
4 retraction rang true because she was willing to incriminate
5
ZMC also presented an Affidavit of Explanation dated 21
January 2005 from Alestre recanting her previous Salaysay.
Alestre explained that the previous statement she gave does
not reflect the truth because she was protecting herself when
she logged-in at the school’s time record on 12 August 2003
when she was supposedly still confined at ZMC. Alestre
narrated that she and her son were admitted at ZMC on 10
August 2003 at around 1:30 p.m. and was discharged on 12
August 2003. In the morning of 12 August 2003, after her
attending physician went to check on her, she managed to
slip out of the hospital. She proceeded to the school, which
was a mere ten minute drive away from ZMC.She reported
for work and came back to the hospital at noon to take her
medicines and look after her child. Thereafter, she again
wentback to the school and at about 1:30 p.m., she asked
permission from the school principal that she needed to go
back to the hospital. She then went back to ZMC to attend to
her child and process her discharge papers. At around 2:00
p.m., she finally came back to the school.
Dr. Ariel dela Cruz, attending physician of Alestre, confirmed
that he ordered Alestre’s discharge inthe morning of 12
6
August 2003.
On 12 December 2007, ZMC was found liable for the charge
of "Extending Period of Confinement" in violation of Section
149 of the Revised Rules and Regulations of Republic Act
No. 7875 and was meted the penalty of suspension from
participating in the NHIP for a period of three (3) months and
a fine of ₱10,000.00.
While Health Insurance Arbiter Michael Troy Polintan
considered the admission date of 6 August 2003 reflected in
Alestre’s clinical record as a mere clerical error, he refused
to believe Alestre’s claim that she was discharged only on 12
August 2003 but onthat day, she was travelling back and
forth from hospital tothe school where she teaches. The
Philhealth Arbiter gave more evidentiary weight to the
signature ofAlestre in the school’s attendance logbook which
established the fact that she reported for work on 12 August
2003.
ZMC appealed but on 24 July 2008, the Philhealth Board of
Directors (the Board) issued Philhealth Board Resolution No.
1151, Series of 2008 dismissing the appeal and affirming the
12 December 2007 Decision of the Philhealth Arbiter.
The Board ruled that the contentsof the Affidavit of
Explanation dated 3 May 2005executed by Alestre is "too
good to be true" because "in the first place, she has stated in
detail all her acts from 7:17 a.m. to 8:15 [a.m.], 9:30 [a.m.],
9:50 [a.m.], 12:00 [noon]; 12:55 p.m., 1:30 p.m., 1:50 p.m.,
2:15 p.m. and 2:30 p.m. The recollection of all these times
after 22 months is not only fantastic but likewise
7
incredible." Moreover, the Board also noted that Alestre
could not possibly be in ZMC and in the school at the same
time on 12 August 2003 while her son was still confined at
the hospital.
ZMC filed a petition for review withthe Court of Appeals
putting in the forefront of its arguments Alestre’s Affidavit of
Explanation. ZMC admitted to Alestre’s recantation but inits
defense, ZMC emphasized that the Affidavit, being notarized
and executed under oath, should weigh more than the
Salaysay, which was not so. ZMC added that Alestre’s
herself in exchange for telling the truth.
Acting on the petition, the Court of Appeals issued the 4
September 2008 Resolution, which reads:
In the greater interest of substantial justice, petitioner is
directed to RECTIFY within five (5) days from notice, the
following deficiencies in its petition: (1) failure to attach the
Special Power of Attorney executed by the petitioner
Zarsona Medical Clinicin favor of Ma. Irene M. Hao,
authorizing the latter to execute the verification and
certification of nonforum shopping; (2) failure of the petitioner
to attach the certified true copy of the assailed decision of
the Board of Directors of the Philippine Health Insurance
Corporation as required under Rule 43, Section 6(c) of the
Revised Rules of Court; (3) failure of the petitioner’s counsel,
Atty. John Tracy F. Cagas, to indicate the dates and places
of issuance of his IBP and PTR Receipts as well as his Roll
of Attorneys Number.
Further action on the petition isheld in abeyance pending the
8
petitioner’s compliance on these matters.
On 30 October 2008, ZMC filed its Compliance, attaching
thereto the plain copies of the Official Receipts of Atty. John
Tracy F. Cagas’ Integrated Bar of the Philippines dues and
Professional Tax Receipts showing the dates and places of
issuance thereof, his roll number, a certified true copy of the
assailed Decision dated 24 July 2008, and a Special Power
of Attorney (SPA) dated 5 February 2001 executed by Dr.
Leandro Zarsona, Jr. (Dr. Zarsona) in favor of Dr. Bragat and
William Bragat.
On 28 January 2009, the Court of Appeals dismissed the
petition for failure on the part of ZMC to attach a valid SPA.
The appellate court found the SPA defective on the ground
that it does not explicitly authorize Dr. Bragat to sign and
execute the required verification and certification of
nonforum shopping in this case. The appellate court noted
that the powers granted to Dr. Bragat pertain only to her
administrative functions as Medical Director of ZMC.
ZMC moved for reconsideration but itwas denied for lack of
merit on 7 December 2009. In his Dissent, Court of Appeals
Associate Justice Ruben Ayson believed that ZMC should
be given the opportunity to rectify any defect or infirmity in
the petition pursuant to the preference on liberal construction
9
of the Rules of Court over strict construction.
Hence, this petition for review with the following assignment
of errors:
1. THE COURT OF APPEALS ERRED IN
RULING THAT THE SPECIAL POWER OF
ATTORNEY (SPA) EXECUTED IN FAVOR OF
DR. SYLVIA P. BRAGAT WAS INSUFFICIENT
TO COVER THE AUTHORITY GRANTED UPON
HER TO SIGN THE VERIFICATION AND
CERTIFICATION OF NON-FORUM SHOPPING
OF THIS INSTANT CASE.
2. THE COURT OF APPEALS ERRED IN
DISMISSING THIS INSTANT CASE BY
10
DISREGARDING THE MERITS THEREOF.
ZMC insists that the SPA provided that the Attorney-in-fact
can make, execute and sign any contract, documents or all
other writing of whatever kind and nature which are
necessary to the power granted to it which is to represent,
process, follow-up, transact and facilitate claims in
Philhealth. This also covers the execution of verification and
certification of non-forum shopping. ZMC then asserts that it
will not gain anything in extending the period of confinement
and reiterates that its clerk committed a mistake in entering
the exact period of confinement.
At the outset, the issues revolve on the sufficiency of the
SPA authorizing Dr. Bragat to sign the verification and
certification of non-forum shopping in the petition filed before
the Court of Appeals.
Verification of a pleading is a formal, not jurisdictional,
requirement intended to secure the assurance that the
matters alleged in a pleading are true and correct. Thus, the
court may simply order the correction of unverified pleadings
or act on them and waive strict compliance with the rules. It
is deemed substantially complied with when one who has
ample knowledge to swear to the truth of the allegations in
the complaint or petition signs the verification, and
whenmatters alleged inthe petition have been made in good
11
faith orare true and correct.
As to certification against forum shopping, non-compliance
therewith or a defect therein, unlike in verification, is
generally not curable by its subsequent submission or
correction thereof, unless there is a need to relax the Rule
on the ground of "substantial compliance" or presence of
12
"special circumstances or compelling reasons." Rule 7,
Section 5 of the Rules of the Court, requires that the
certification should be signed by the "petitioner or principal
party" himself. The rationalebehind this is "because only the
petitioner himself has actual knowledge of whether or not he
has initiated similar actions or proceedings indifferent courts
13
or agencies."
14
In Lim v. The Court of Appeals, Mindanao Station, we
reiterated that the requirements of verification and
certification against forum shopping are not jurisdictional.
Verification is required to secure an assurance that the
allegations in the petition have been made in good faith or
are true and correct, and not merely speculative. Non-
compliance with the verification requirement does not
necessarily render the pleading fatally defective, and is
substantially complied with when signed by one who has
ample knowledge of the truth of the allegations in the
complaint or petition, and when matters alleged in the
petition have been made in good faith orare true and correct.
On the other hand, the certification against forum shopping
is required based on the principle that a party-litigantshould
not be allowed to pursue simultaneous remedies in different
fora. While the certification requirement is obligatory, non-
compliance or a defect in the certificate could be cured by its
subsequent correction or submission under special
circumstances or compelling reasons, or on the ground of
15
"substantial compliance."
In both cases, the submission of an SPA authorizing an
attorney-infact to sign the verification and certification
against forum-shopping in behalf of the principal party is
considered as substantial compliance with the Rules.
In this case, Philhealth found the SPA defective.
The SPA granted by Dr. Zarsona tohis attorneys-in-fact, Dr.
Bragat and William Bragat, authorizes the latter to do the
following:
A) To represent(,) process, follow up, transact and
facilitate all claims, benefits and privileges
belonging to or owing to Zarsona Medical Clinic in
the Philippine Health Insurance Corporation,
Department of Health and in other agencies, may
it be private or government;
B) To receive, withdraw, and encash any check or
checks belonging to or in the name of Zarsona
Medical Clinic;
C) To make, execute, and sign any contract,
documents or all other writings of whatever kind
and nature which are necessary to the foregoing
16
powers.
Indeed, a reading of the SPA reveals that the powers
conferred by Dr. Zarsona to his attorneys-in-fact pertain to
administrative matters. The phrase "claims, benefits and
privileges belonging to or owing to Zarsona Medical Clinic"
clearly does not include the filing of cases before the courts
or any quasi-judicial agencies. The term"claims" in particular
refers to those claims for payment of services rendered by
the hospital during a Philhealth member’s confinement.
These claims are filed by the hospital with Philhealth.
Furthermore, the SPA makes no mention of any court,
judicial or quasi-judicial bodies. The enumeration of
agencies in the first paragraph of the SPA, such as
Philhealth and Department of Health, refers to those
agencies which are health-related. There is no explicit
authorization for Dr. Bragat to sign and execute the
requirement verification and certification in this case. At the
very least, the SPA should have granted the attorneys-in-fact
the power and authority to institute civil and criminal actions
which would necessarily include the signing of the
verification and certification against forum-shopping.
The defects in the SPA notwithstanding, we rule in favor of
ZMC. We agree with the Dissent registeredby Associate
Justice Ruben Ayson when he suggested that ZMC should
begiven the opportunity to rectify the defects in the petition.
We are aware that the Court of Appeals in its Resolution
dated 28 January 2009 had directed ZMC to submit an SPA.
ZMC had in good faith complied by submitting an SPA which
it thought was sufficient and encompasses the filing of the
instant suit. Time and again, we had espoused the doctrine
that provisions of the Rules of Court should be liberally
construed in order to promote their objective of securing a
just, speedy and inexpensive disposition of every action and
proceeding. Otherwise put, the rule requiring a certification
of forum shopping to accompany every initiatory pleading, or
the verification for that matter "should not be interpreted with
such absolute literalness as to subvert its own ultimate and
legitimate objective or the goal of all rules of procedure –
which is to achieve substantial justice as expeditiously as
17
possible." While it is true that the rules of procedure are
intended to promote rather than frustrate the ends of justice,
and the swift unclogging of court docket is a laudable
objective, it nevertheless mustnot be met at the expense of
substantial justice. This Court has time and again reiterated
the doctrine that the rules of procedure are mere tools aimed
at facilitating the attainment of justice, rather than its
frustration. A strict and rigid application of the rules must
always be eschewed when it would subvert the primary
objective of the rules, that is, to enhance fair trialsand
expedite justice. Technicalities should never be used to
defeat the substantive rights of the other party. Every party-
litigant must be affordedthe amplest opportunity for the
proper and just determination of his cause, free from the
constraints of technicalities.
18
We choose to apply liberality becauseof the substantial merit
of the petition.
The petition was dismissed by the Court of Appeals purely
on a procedural ground. Ordinarily, procedure dictates that
the Court of Appeals should be tasked with properly
disposing the petition, a second time around, on the merits.
However, when there is enough basis on which a proper
evaluation of the merits of petitioner’s case may be had, the
Court may dispense with the time-consuming procedure of
remand in order to prevent further delays in the disposition of
the case. Clearly, a remand of the instant case to the Court
of Appeals would only unnecessarily prolong its resolution
which had been pending for a decade. It is already an
accepted rule of procedure for us to strive to settlethe entire
controversy in a single proceeding, leaving no root or branch
tobear the seeds of future litigation. If, based on the records,
the pleadings, and other evidence, the dispute can be
resolved by us, we will do so to serve the ends of justice
instead of remanding the case to the lower court for further
19
proceedings.
Thus, we find the petition meritorious.
ZMC was charged with extending the period of confinement
punishable under Section 149 of the Revised Implementing
Rules and Regulations of Republic Act No. 7875, which
provides:
Section 149. Extending Period of Confinement. — This is
committed by any health care provider who, for the purpose
of claiming payment from the NHIP, files a claim with
extended period of confinement by:
a. Increasing the actual confinement of any
patient;
b. Continuously charting entries in the Doctor's
Order, Nurse's Notes and Observation despite
actual discharge or absence of the patients;
c. Using such other machinations that would result
in the unnecessary extension of confinement.
The foregoing offenses shall be penalized by revocation of
accreditation. In addition, a recommendation shall be
submitted to the DOH for cancellation of its license,
oraccreditation, orclearance to operate, as appropriate.
The Philhealth Arbiter and the Board did not give weight to
the Affidavit of Explanation submitted by the patient herself
recanting her previous statement and categorically stating
that she was discharged only on 12 August 2003.
It is an oft-repeated rule that findings of administrative
agencies are generally accorded not only respect but also
finality when the decision and order are not tainted with
unfairness or arbitrariness that would amount to abuse of
discretion or lack of jurisdiction. The findings of facts must be
respected, so long as they are supported by substantial
20
evidence even if not overwhelming or preponderant.
After an exhaustive review of the records, we find that this
case warrants a departure from said rule.1âwphi1
We are inclined to give more credence to Alestre’s Affidavit,
which is essentially a recantation of her previous Salaysay,
for the following reasons: First, Alestre has fully explained
toour satisfaction why she initially misdeclared her dates of
confinement in ZMC. In her desire to report and be
compensated for one day of work, Alestre hied back and
forth between school and the hospital. It is difficultto believe
that she would risk her reputation as a public schoolteacher,
as well as prosecution for violation of civil service rules, to be
an abettor ofZMC. Second, Alestre truly cannot be in two
places at the same time. But her narration clearly accounts
for her whereabouts on 12 August 2003. She travelled at
least 3 times to and from the hospital and school. She
admitted that the school was a mere ten-minute drive away
from the hospital so she can easily traverse between the two
locations. Third, ZMC had in fact admitted to its error in
indicating the dates of Alestre’s confinement so there is no
reason for ZMC to further conceal the actual days of
Alestre’s confinement. Fourth, the Salaysayis not notarized.
While recantation is frowned upon and hardly given much
weight in the determination of a case, the affidavit is still a
notarized document which carries in its favor the
presumption of regularity with respect to its due execution,
and thatthere must be clear, convincing and more than
21
merely preponderant evidence to contradict the same.
Based on the foregoing, we reverse the finding of Philhealth
and hold that ZMC is not guilty of extending the period of
confinement.
WHEREFORE, the petition is GRANTED. The Resolution of
the Court or Appeals in CA-G.R. SP No. 02489-MIN
dismissing the petition is REVERSED and SET ASIDE.
Philhcalth Board Resolution No. 1151, Series or 2008 is SET
ASIDE.
SO ORDERED.
G.R. No. 195909 September 26, 2012
COMMISSIONER OF INTERNAL
REVENUE, PETITIONER,
vs.
ST. LUKE'S MEDICAL CENTER, INC., RESPONDENT.
x-----------------------x
G.R. No. 195960
ST. LUKE'S MEDICAL CENTER, INC., PETITIONER,
vs.
COMMISSIONER OF INTERNAL
REVENUE, RESPONDENT.
1
These are consolidated petitions for review on certiorari
under Rule 45 of the Rules of Court assailing the Decision of
19 November 2010 of the Court of Tax Appeals (CTA) En
2
Banc and its Resolution of 1 March 2011 in CTA Case No.
6746. This Court resolves this case on a pure question of
law, which involves the interpretation of Section 27(B) vis-à-
vis Section 30(E) and (G) of the National Internal Revenue
Code of the Philippines (NIRC), on the income tax treatment
of proprietary non-profit hospitals.
The Facts
St. Luke's Medical Center, Inc. (St. Luke's) is a hospital
organized as a non-stock and non-profit corporation. Under
its articles of incorporation, among its corporate purposes
are:
(a) To establish, equip, operate and maintain a
non-stock, non-profit Christian, benevolent,
charitable and scientific hospital which shall give
curative, rehabilitative and spiritual care to the
sick, diseased and disabled persons; provided that
purely medical and surgical services shall be
performed by duly licensed physicians and
surgeons who may be freely and individually
contracted by patients;
(b) To provide a career of health science
education and provide medical services to the
community through organized clinics in such
specialties as the facilities and resources of the
corporation make possible;
(c) To carry on educational activities related to the
maintenance and promotion of health as well as
provide facilities for scientific and medical
researches which, in the opinion of the Board of
Trustees, may be justified by the facilities,
personnel, funds, or other requirements that are
available;
(d) To cooperate with organized medical societies,
agencies of both government and private sector;
establish rules and regulations consistent with the
highest professional ethics;
3
xxxx
On 16 December 2002, the Bureau of Internal Revenue
(BIR) assessed St. Luke's deficiency taxes amounting to
₱76,063,116.06 for 1998, comprised of deficiency income
tax, value-added tax, withholding tax on compensation and
expanded withholding tax. The BIR reduced the amount to
4
₱63,935,351.57 during trial in the First Division of the CTA.
On 14 January 2003, St. Luke's filed an administrative
protest with the BIR against the deficiency tax assessments.
The BIR did not act on the protest within the 180-day period
under Section 228 of the NIRC. Thus, St. Luke's appealed to
the CTA.
The BIR argued before the CTA that Section 27(B) of the
NIRC, which imposes a 10% preferential tax rate on the
income of proprietary non-profit hospitals, should be
applicable to St. Luke's. According to the BIR, Section 27(B),
introduced in 1997, "is a new provision intended to amend
the exemption on non-profit hospitals that were previously
categorized as non-stock, non-profit corporations under
5
Section 26 of the 1997 Tax Code x x x." It is a specific
provision which prevails over the general exemption on
income tax granted under Section 30(E) and (G) for non-
stock, non-profit charitable institutions and civic
organizations promoting social welfare.
6
The BIR claimed that St. Luke's was actually operating for
profit in 1998 because only 13% of its revenues came from
charitable purposes. Moreover, the hospital's board of
trustees, officers and employees directly benefit from its
profits and assets. St. Luke's had total revenues of
₱1,730,367,965 or approximately ₱1.73 billion from patient
7
services in 1998.
St. Luke's contended that the BIR should not consider its
total revenues, because its free services to patients was
₱218,187,498 or 65.20% of its 1998 operating income (i.e.,
total revenues less operating expenses) of
8
₱334,642,615. St. Luke's also claimed that its income does
not inure to the benefit of any individual.
St. Luke's maintained that it is a non-stock and non-profit
institution for charitable and social welfare purposes under
Section 30(E) and (G) of the NIRC. It argued that the making
of profit per se does not destroy its income tax exemption.
The petition of the BIR before this Court in G.R. No. 195909
reiterates its arguments before the CTA that Section 27(B)
applies to St. Luke's. The petition raises the sole issue of
whether the enactment of Section 27(B) takes proprietary
non-profit hospitals out of the income tax exemption under
Section 30 of the NIRC and instead, imposes a preferential
rate of 10% on their taxable income. The BIR prays that St.
Luke's be ordered to pay ₱57,659,981.19 as deficiency
income and expanded withholding tax for 1998 with
surcharges and interest for late payment.
The petition of St. Luke's in G.R. No. 195960 raises factual
matters on the treatment and withholding of a part of its
9 20
income, as well as the payment of surcharge and
delinquency interest. There is no ground for this Court to
undertake such a factual review. Under the
10 11
Constitution and the Rules of Court, this Court's review
power is generally limited to "cases in which only an error or
12
question of law is involved." This Court cannot depart from
this limitation if a party fails to invoke a recognized
exception.
The Ruling of the Court of Tax Appeals
The CTA En Banc Decision on 19 November 2010 affirmed
in toto the CTA First Division Decision dated 23 February
2009 which held:
WHEREFORE, the Amended Petition for Review [by St.
Luke's] is hereby PARTIALLY GRANTED. Accordingly, the
1998 deficiency VAT assessment issued by respondent
against petitioner in the amount of ₱110,000.00 is hereby
CANCELLED and WITHDRAWN. However, petitioner is
hereby ORDERED to PAY deficiency income tax and
deficiency expanded withholding tax for the taxable year
1998 in the respective amounts of ₱5,496,963.54 and
₱778,406.84 or in the sum of ₱6,275,370.38, x x x.
xxxx
In addition, petitioner is hereby ORDERED to PAY twenty
percent (20%) delinquency interest on the total amount of
₱6,275,370.38 counted from October 15, 2003 until full
payment thereof, pursuant to Section 249(C)(3) of the NIRC
of 1997.
13
SO ORDERED.
The deficiency income tax of ₱5,496,963.54, ordered by the
CTA En Banc to be paid, arose from the failure of St. Luke's
to prove that part of its income in 1998 (declared as "Other
14
Income-Net") came from charitable activities. The CTA
cancelled the remainder of the ₱63,113,952.79 deficiency
assessed by the BIR based on the 10% tax rate under
Section 27(B) of the NIRC, which the CTA En Banc held was
15
not applicable to St. Luke's.
The CTA ruled that St. Luke's is a non-stock and non-profit
charitable institution covered by Section 30(E) and (G) of the
NIRC. This ruling would exempt all income derived by St.
Luke's from services to its patients, whether paying or non-
paying. The CTA reiterated its earlier decision in St. Luke's
Medical Center, Inc. v. Commissioner of Internal
16
Revenue, which examined the primary purposes of St.
Luke's under its articles of incorporation and various
17
documents identifying St. Luke's as a charitable institution.
The CTA adopted the test in Hospital de San Juan de Dios,
18
Inc. v. Pasay City, which states that "a charitable institution
does not lose its charitable character and its consequent
exemption from taxation merely because recipients of its
benefits who are able to pay are required to do so, where
funds derived in this manner are devoted to the charitable
19
purposes of the institution x x x." The generation of income
from paying patients does not per se destroy the charitable
nature of St. Luke's.
Hospital de San Juan cited Jesus Sacred Heart College v.
Collector of Internal Revenue, which ruled that the old
NIRC (Commonwealth Act No. 466, as
21
amended) "positively exempts from taxation those
corporations or associations which, otherwise, would be
subject thereto, because of the existence of x x x net
22
income." The NIRC of 1997 substantially reproduces the
provision on charitable institutions of the old NIRC. Thus, in
rejecting the argument that tax exemption is lost whenever
there is net income, the Court in Jesus Sacred Heart College
declared: "[E]very responsible organization must be run to at
least insure its existence, by operating within the limits of its
own resources, especially its regular income. In other words,
it should always strive, whenever possible, to have a
23
surplus."
The CTA held that Section 27(B) of the present NIRC does
24
not apply to St. Luke's. The CTA explained that to apply
the 10% preferential rate, Section 27(B) requires a hospital
to be "non-profit." On the other hand, Congress specifically
used the word "non-stock" to qualify a charitable "corporation
or association" in Section 30(E) of the NIRC. According to
the CTA, this is unique in the present tax code, indicating an
intent to exempt this type of charitable organization from
income tax. Section 27(B) does not require that the hospital
be "non-stock." The CTA stated, "it is clear that non-stock,
non-profit hospitals operated exclusively for charitable
purpose are exempt from income tax on income received by
them as such, applying the provision of Section 30(E) of the
25
NIRC of 1997, as amended."
The Issue
The sole issue is whether St. Luke's is liable for deficiency
income tax in 1998 under Section 27(B) of the NIRC, which
imposes a preferential tax rate of 10% on the income of
proprietary non-profit hospitals.
The Ruling of the Court
St. Luke's Petition in G.R. No. 195960
As a preliminary matter, this Court denies the petition of St.
Luke's in G.R. No. 195960 because the petition raises
factual issues. Under Section 1, Rule 45 of the Rules of
Court, "[t]he petition shall raise only questions of law which
must be distinctly set forth." St. Luke's cites Martinez v.
26
Court of Appeals which permits factual review "when the
Court of Appeals [in this case, the CTA] manifestly
overlooked certain relevant facts not disputed by the parties
and which, if properly considered, would justify a different
27
conclusion."
This Court does not see how the CTA overlooked relevant
facts. St. Luke's itself stated that the CTA "disregarded the
testimony of [its] witness, Romeo B. Mary, being allegedly
self-serving, to show the nature of the 'Other Income-Net' x x
28
x." This is not a case of overlooking or failing to consider
relevant evidence. The CTA obviously considered the
evidence and concluded that it is self-serving. The CTA
declared that it has "gone through the records of this case
and found no other evidence aside from the self-serving
29
affidavit executed by [the] witnesses [of St. Luke's] x x x."
The deficiency tax on "Other Income-Net" stands. Thus, St.
Luke's is liable to pay the 25% surcharge under Section
248(A)(3) of the NIRC. There is "[f]ailure to pay the
deficiency tax within the time prescribed for its payment in
30
the notice of assessment[.]" St. Luke's is also liable to pay
20% delinquency interest under Section 249(C)(3) of the
31
NIRC. As explained by the CTA En Banc, the amount of
₱6,275,370.38 in the dispositive portion of the CTA First
Division Decision includes only deficiency interest under
Section 249(A) and (B) of the NIRC and not delinquency
32
interest.
The Main Issue
The issue raised by the BIR is a purely legal one. It involves
the effect of the introduction of Section 27(B) in the NIRC of
1997 vis-à-vis Section 30(E) and (G) on the income tax
exemption of charitable and social welfare institutions. The
10% income tax rate under Section 27(B) specifically
pertains to proprietary educational institutions and
proprietary non-profit hospitals. The BIR argues that
Congress intended to remove the exemption that non-profit
hospitals previously enjoyed under Section 27(E) of the
NIRC of 1977, which is now substantially reproduced in
33
Section 30(E) of the NIRC of 1997. Section 27(B) of the
present NIRC provides:
SEC. 27. Rates of Income Tax on Domestic Corporations. -
xxxx
(B) Proprietary Educational Institutions and Hospitals. -
Proprietary educational institutions and hospitals which are
non-profit shall pay a tax of ten percent (10%) on their
taxable income except those covered by Subsection (D)
hereof: Provided, That if the gross income from unrelated
trade, business or other activity exceeds fifty percent (50%)
of the total gross income derived by such educational
institutions or hospitals from all sources, the tax prescribed
in Subsection (A) hereof shall be imposed on the entire
taxable income. For purposes of this Subsection, the term
'unrelated trade, business or other activity' means any trade,
business or other activity, the conduct of which is not
substantially related to the exercise or performance by such
educational institution or hospital of its primary purpose or
function. A 'proprietary educational institution' is any private
school maintained and administered by private individuals or
groups with an issued permit to operate from the Department
of Education, Culture and Sports (DECS), or the
Commission on Higher Education (CHED), or the Technical
Education and Skills Development Authority (TESDA), as the
case may be, in accordance with existing laws and
regulations. (Emphasis supplied)
St. Luke's claims tax exemption under Section 30(E) and (G)
of the NIRC. It contends that it is a charitable institution and
an organization promoting social welfare. The arguments of
St. Luke's focus on the wording of Section 30(E) exempting
from income tax non-stock, non-profit charitable
34
institutions. St. Luke's asserts that the legislative intent of
introducing Section 27(B) was only to remove the exemption
35
for "proprietary non-profit" hospitals. The relevant
provisions of Section 30 state:
SEC. 30. Exemptions from Tax on Corporations. - The
following organizations shall not be taxed under this Title in
respect to income received by them as such:
xxxx
(E) Nonstock corporation or association organized and
operated exclusively for religious, charitable, scientific,
athletic, or cultural purposes, or for the rehabilitation of
veterans, no part of its net income or asset shall belong to or
inure to the benefit of any member, organizer, officer or any
specific person;
xxxx
(G) Civic league or organization not organized for profit but
operated exclusively for the promotion of social welfare;
xxxx
Notwithstanding the provisions in the preceding paragraphs,
the income of whatever kind and character of the foregoing
organizations from any of their properties, real or personal,
or from any of their activities conducted for profit regardless
of the disposition made of such income, shall be subject to
tax imposed under this Code. (Emphasis supplied)
The Court partly grants the petition of the BIR but on a
different ground. We hold that Section 27(B) of the NIRC
does not remove the income tax exemption of proprietary
non-profit hospitals under Section 30(E) and (G). Section
27(B) on one hand, and Section 30(E) and (G) on the other
hand, can be construed together without the removal of such
tax exemption. The effect of the introduction of Section 27(B)
is to subject the taxable income of two specific institutions,
36
namely, proprietary non-profit educational institutions and
proprietary non-profit hospitals, among the institutions
covered by Section 30, to the 10% preferential rate under
Section 27(B) instead of the ordinary 30% corporate rate
under the last paragraph of Section 30 in relation to Section
27(A)(1).
Section 27(B) of the NIRC imposes a 10% preferential tax
rate on the income of (1) proprietary non-profit educational
institutions and (2) proprietary non-profit hospitals. The only
qualifications for hospitals are that they must be proprietary
and non-profit. "Proprietary" means private, following the
definition of a "proprietary educational institution" as "any
private school maintained and administered by private
individuals or groups" with a government permit. "Non-profit"
means no net income or asset accrues to or benefits any
member or specific person, with all the net income or asset
devoted to the institution's purposes and all its activities
conducted not for profit.
"Non-profit" does not necessarily mean "charitable." In
Collector of Internal Revenue v. Club Filipino Inc. de
37
Cebu, this Court considered as non-profit a sports club
organized for recreation and entertainment of its
stockholders and members. The club was primarily funded
by membership fees and dues. If it had profits, they were
used for overhead expenses and improving its golf
38
course. The club was non-profit because of its purpose
and there was no evidence that it was engaged in a profit-
39
making enterprise.
The sports club in Club Filipino Inc. de Cebu may be non-
profit, but it was not charitable. The Court defined "charity" in
40
Lung Center of the Philippines v. Quezon City as "a gift, to
be applied consistently with existing laws, for the benefit of
an indefinite number of persons, either by bringing their
minds and hearts under the influence of education or
religion, by assisting them to establish themselves in life or
41
[by] otherwise lessening the burden of government." A non-
profit club for the benefit of its members fails this test. An
organization may be considered as non-profit if it does not
distribute any part of its income to stockholders or members.
However, despite its being a tax exempt institution, any
income such institution earns from activities conducted for
profit is taxable, as expressly provided in the last paragraph
of Section 30.
To be a charitable institution, however, an organization must
meet the substantive test of charity in Lung Center. The
issue in Lung Center concerns exemption from real property
tax and not income tax. However, it provides for the test of
charity in our jurisdiction. Charity is essentially a gift to an
indefinite number of persons which lessens the burden of
government. In other words, charitable institutions provide
for free goods and services to the public which would
otherwise fall on the shoulders of government. Thus, as a
matter of efficiency, the government forgoes taxes which
should have been spent to address public needs, because
certain private entities already assume a part of the burden.
This is the rationale for the tax exemption of charitable
institutions. The loss of taxes by the government is
compensated by its relief from doing public works which
would have been funded by appropriations from the
42
Treasury.
Charitable institutions, however, are not ipso facto entitled to
a tax exemption. The requirements for a tax exemption are
specified by the law granting it. The power of Congress to
tax implies the power to exempt from tax. Congress can
create tax exemptions, subject to the constitutional provision
that "[n]o law granting any tax exemption shall be passed
without the concurrence of a majority of all the Members of
43
Congress." The requirements for a tax exemption are
44
strictly construed against the taxpayer because an
exemption restricts the collection of taxes necessary for the
existence of the government.
The Court in Lung Center declared that the Lung Center of
the Philippines is a charitable institution for the purpose of
exemption from real property taxes. This ruling uses the
45
same premise as Hospital de San Juan and Jesus Sacred
46
Heart College which says that receiving income from
paying patients does not destroy the charitable nature of a
hospital.
As a general principle, a charitable institution does not lose
its character as such and its exemption from taxes simply
because it derives income from paying patients, whether out-
patient, or confined in the hospital, or receives subsidies
from the government, so long as the money received is
devoted or used altogether to the charitable object which it is
intended to achieve; and no money inures to the private
benefit of the persons managing or operating the
47
institution.
For real property taxes, the incidental generation of income
is permissible because the test of exemption is the use of
the property. The Constitution provides that "[c]haritable
institutions, churches and personages or convents
appurtenant thereto, mosques, non-profit cemeteries, and all
lands, buildings, and improvements, actually, directly, and
exclusively used for religious, charitable, or educational
48
purposes shall be exempt from taxation." The test of
exemption is not strictly a requirement on the intrinsic nature
or character of the institution. The test requires that the
institution use the property in a certain way, i.e. for a
charitable purpose. Thus, the Court held that the Lung
Center of the Philippines did not lose its charitable character
when it used a portion of its lot for commercial purposes.
The effect of failing to meet the use requirement is simply to
remove from the tax exemption that portion of the property
not devoted to charity.
The Constitution exempts charitable institutions only from
real property taxes. In the NIRC, Congress decided to
extend the exemption to income taxes. However, the way
Congress crafted Section 30(E) of the NIRC is materially
different from Section 28(3), Article VI of the Constitution.
Section 30(E) of the NIRC defines the corporation or
association that is exempt from income tax. On the other
hand, Section 28(3), Article VI of the Constitution does not
define a charitable institution, but requires that the institution
"actually, directly and exclusively" use the property for a
charitable purpose.
Section 30(E) of the NIRC provides that a charitable
institution must be:
(1) A non-stock corporation or association;
(2) Organized exclusively for charitable purposes;
(3) Operated exclusively for charitable purposes;
and
(4) No part of its net income or asset shall belong
to or inure to the benefit of any member,
organizer, officer or any specific person.
Thus, both the organization and operations of the charitable
institution must be devoted "exclusively" for charitable
purposes. The organization of the institution refers to its
corporate form, as shown by its articles of incorporation, by- any of its activities conducted for profit, regardless of the
laws and other constitutive documents. Section 30(E) of the disposition made of such income, shall be subject to tax."
NIRC specifically requires that the corporation or association Prior to the introduction of Section 27(B), the tax rate on
be non-stock, which is defined by the Corporation Code as such income from for-profit activities was the ordinary
"one where no part of its income is distributable as dividends corporate rate under Section 27(A). With the introduction of
49
to its members, trustees, or officers" and that any profit Section 27(B), the tax rate is now 10%.
"obtain[ed] as an incident to its operations shall, whenever
necessary or proper, be used for the furtherance of the
In 1998, St. Luke's had total revenues of ₱1,730,367,965
purpose or purposes for which the corporation was
50 from services to paying patients. It cannot be disputed that a
organized." However, under Lung Center, any profit by a
hospital which receives approximately ₱1.73 billion from
charitable institution must not only be plowed back
paying patients is not an institution "operated exclusively" for
"whenever necessary or proper," but must be "devoted or
charitable purposes. Clearly, revenues from paying patients
used altogether to the charitable object which it is intended
51 are income received from "activities conducted for
to achieve." 52
profit." Indeed, St. Luke's admits that it derived profits from
its paying patients. St. Luke's declared ₱1,730,367,965 as
The operations of the charitable institution generally refer to "Revenues from Services to Patients" in contrast to its "Free
its regular activities. Section 30(E) of the NIRC requires that Services" expenditure of ₱218,187,498. In its Comment in
these operations be exclusive to charity. There is also a G.R. No. 195909, St. Luke's showed the following
specific requirement that "no part of [the] net income or asset "calculation" to support its claim that 65.20% of its "income
shall belong to or inure to the benefit of any member, after expenses was allocated to free or charitable services"
53
organizer, officer or any specific person." The use of lands, in 1998.
buildings and improvements of the institution is but a part of
its operations.
REVENUES FROM ₱1,730,367,965.00
SERVICES TO PATIENTS
There is no dispute that St. Luke's is organized as a non-
stock and non-profit charitable institution. However, this does
not automatically exempt St. Luke's from paying taxes. This
OPERATING EXPENSES
only refers to the organization of St. Luke's. Even if St.
Luke's meets the test of charity, a charitable institution is not
Professional care of patients ₱1,016,608,394.00
ipso facto tax exempt. To be exempt from real property
taxes, Section 28(3), Article VI of the Constitution requires
Administrative 287,319,334.00
that a charitable institution use the property "actually, directly
and exclusively" for charitable purposes. To be exempt from
Household and Property 91,797,622.00
income taxes, Section 30(E) of the NIRC requires that a
charitable institution must be "organized and operated
₱1,395,725,350.00
exclusively" for charitable purposes. Likewise, to be exempt
from income taxes, Section 30(G) of the NIRC requires that
the institution be "operated exclusively" for social welfare. INCOME FROM ₱334,642,615.00 100%
OPERATIONS
However, the last paragraph of Section 30 of the NIRC
qualifies the words "organized and operated exclusively" by Free Services -218,187,498.00 -
providing that: 65.20%

INCOME FROM ₱116,455,117.00 34.80%

Notwithstanding the provisions in the preceding paragraphs, OPERATIONS, Net of FREE
the income of whatever kind and character of the foregoing SERVICES
organizations from any of their properties, real or personal,
or from any of their activities conducted for profit regardless
of the disposition made of such income, shall be subject to OTHER INCOME 17,482,304.00
tax imposed under this Code. (Emphasis supplied)

In short, the last paragraph of Section 30 provides that if a
tax exempt charitable institution conducts "any" activity for
profit, such activity is not tax exempt even as its not-for-profit
activities remain tax exempt. This paragraph qualifies the
requirements in Section 30(E) that the "[n]on-stock
corporation or association [must be] organized and operated
exclusively for x x x charitable x x x purposes x x x." It
likewise qualifies the requirement in Section 30(G) that the
civic organization must be "operated exclusively" for the
promotion of social welfare.
Thus, even if the charitable institution must be "organized
and operated exclusively" for charitable purposes, it is
nevertheless allowed to engage in "activities conducted for
profit" without losing its tax exempt status for its not-for-profit
activities. The only consequence is that the "income of
whatever kind and character" of a charitable institution "from
EXCESS OF REVENUES ₱133,937,421.00
OVER EXPENSES
In Lung Center, this Court declared:
"[e]xclusive" is defined as possessed and enjoyed to the
exclusion of others; debarred from participation or
enjoyment; and "exclusively" is defined, "in a manner to
exclude; as enjoying a privilege exclusively." x x x The words
"dominant use" or "principal use" cannot be substituted for
the words "used exclusively" without doing violence to the
Constitution and the law. Solely is synonymous with
54
exclusively.
The Court cannot expand the meaning of the words
"operated exclusively" without violating the NIRC. Services
to paying patients are activities conducted for profit. They
cannot be considered any other way. There is a "purpose to
55
make profit over and above the cost" of services. The
₱1.73 billion total revenues from paying patients is not even
incidental to St. Luke's charity expenditure of ₱218,187,498
for non-paying patients.
St. Luke's claims that its charity expenditure of
₱218,187,498 is 65.20% of its operating income in 1998.
However, if a part of the remaining 34.80% of the operating
income is reinvested in property, equipment or facilities used
for services to paying and non-paying patients, then it cannot
be said that the income is "devoted or used altogether to the
56
charitable object which it is intended to achieve." The
income is plowed back to the corporation not entirely for
charitable purposes, but for profit as well. In any case, the
last paragraph of Section 30 of the NIRC expressly qualifies
that income from activities for profit is taxable "regardless of
the disposition made of such income."
Jesus Sacred Heart College declared that there is no official
legislative record explaining the phrase "any activity
conducted for profit." However, it quoted a deposition of
Senator Mariano Jesus Cuenco, who was a member of the
Committee of Conference for the Senate, which introduced
the phrase "or from any activity conducted for profit."
P. Cuando ha hablado de la Universidad de Santo Tomás
que tiene un hospital, no cree Vd. que es una actividad
esencial dicho hospital para el funcionamiento del colegio de
medicina de dicha universidad?
xxxx
R. Si el hospital se limita a recibir enformos pobres, mi
contestación seria afirmativa; pero considerando que el
hospital tiene cuartos de pago, y a los mismos generalmente
van enfermos de buena posición social económica, lo que
se paga por estos enfermos debe estar sujeto a 'income tax',
y es una de las razones que hemos tenido para insertar las
57
palabras o frase 'or from any activity conducted for profit.'
The question was whether having a hospital is essential to
an educational institution like the College of Medicine of the
University of Santo Tomas. Senator Cuenco answered that if
the hospital has paid rooms generally occupied by people of
good economic standing, then it should be subject to income
tax. He said that this was one of the reasons Congress
inserted the phrase "or any activity conducted for profit."
The question in Jesus Sacred Heart College involves an
58
educational institution. However, it is applicable to
charitable institutions because Senator Cuenco's response
shows an intent to focus on the activities of charitable
institutions. Activities for profit should not escape the reach
of taxation. Being a non-stock and non-profit corporation
does not, by this reason alone, completely exempt an
institution from tax. An institution cannot use its corporate
form to prevent its profitable activities from being taxed.
The Court finds that St. Luke's is a corporation that is not
"operated exclusively" for charitable or social welfare
purposes insofar as its revenues from paying patients are
concerned. This ruling is based not only on a strict
interpretation of a provision granting tax exemption, but also
on the clear and plain text of Section 30(E) and (G). Section
30(E) and (G) of the NIRC requires that an institution be
"operated exclusively" for charitable or social welfare
purposes to be completely exempt from income tax. An
institution under Section 30(E) or (G) does not lose its tax
exemption if it earns income from its for-profit activities. Such
income from for-profit activities, under the last paragraph of
Section 30, is merely subject to income tax, previously at the
ordinary corporate rate but now at the preferential 10% rate
pursuant to Section 27(B).
A tax exemption is effectively a social subsidy granted by the
State because an exempt institution is spared from sharing
in the expenses of government and yet benefits from them.
Tax exemptions for charitable institutions should therefore
be limited to institutions beneficial to the public and those
which improve social welfare. A profit-making entity should
not be allowed to exploit this subsidy to the detriment of the
government and other taxpayers.1âwphi1
St. Luke's fails to meet the requirements under Section 30(E)
and (G) of the NIRC to be completely tax exempt from all its
income. However, it remains a proprietary non-profit hospital
under Section 27(B) of the NIRC as long as it does not
distribute any of its profits to its members and such profits
are reinvested pursuant to its corporate purposes. St. Luke's,
as a proprietary non-profit hospital, is entitled to the
preferential tax rate of 10% on its net income from its for-
profit activities.
St. Luke's is therefore liable for deficiency income tax in
1998 under Section 27(B) of the NIRC. However, St. Luke's
has good reasons to rely on the letter dated 6 June 1990 by
the BIR, which opined that St. Luke's is "a corporation for
purely charitable and social welfare purposes"59 and thus
60
exempt from income tax. In Michael J. Lhuillier, Inc. v.
61
Commissioner of Internal Revenue, the Court said that
"good faith and honest belief that one is not subject to tax on
the basis of previous interpretation of government agencies
tasked to implement the tax law, are sufficient justification to
62
delete the imposition of surcharges and interest."
WHEREFORE, the petition of the Commissioner of Internal
Revenue in G.R. No. 195909 is PARTLY GRANTED. The
Decision of the Court of Tax Appeals En Banc dated 19
November 2010 and its Resolution dated 1 March 2011 in
CTA Case No. 6746 are MODIFIED. St. Luke's Medical
Center, Inc. is ORDERED TO PAY the deficiency income tax
in 1998 based on the 10% preferential income tax rate under
Section 27(B) of the National Internal Revenue Code.
However, it is not liable for surcharges and interest on such
deficiency income tax under Sections 248 and 249 of the
National Internal Revenue Code. All other parts of the
Decision and Resolution of the Court of Tax Appeals are
AFFIRMED.
The petition of St. Luke's Medical Center, Inc. in G.R. No.
195960 is DENIED for violating Section 1, Rule 45 of the
Rules of Court.
SO ORDERED
G.R. No. 150355 July 31, 2006
MANILA DOCTORS HOSPITAL vs. SO UN CHUA and
VICKY TY
Before this Court is a Petition for Review on Certiorari under
1
Rule 45 questioning the Decision dated October 2, 2001
promulgated by the Court of Appeals (CA) in CA-G.R. CV
No. 61581, which affirmed the Decision dated September
30, 1997 of the Regional Trial Court (RTC), Branch 159,
Pasig City, but which reduced the award of damages.
This case originated from an action for damages filed with
the RTC by respondents So Un Chua and Vicky Ty against
2 same were resorted to as cost-cutting measures and to
petitioner Manila Doctors Hospital. The complaint is
premised on the alleged unwarranted actuations of the
petitioner towards its patient, respondent So Un Chua
(Chua), who was confined for hypertension, diabetes, and
related illnesses.
The antecedents of the case follow:
On December 13, 1993, respondents filed a Complaint
averring that on October 30, 1990, respondent Chua, the
mother of respondent Vicky Ty, was admitted in petitioner's
hospital for hypertension and diabetes; that while respondent
Chua was confined, Judith Chua, the sister of respondent
Ty, had been likewise confined for injuries suffered in a
vehicular accident; that partial payments of the hospital bills
were made, totaling P435,800.00; that after the discharge of
Judith Chua, respondent Chua remained in confinement and
the hospital bills for both patients accumulated; that
respondent Chua was pressured by the petitioner, through
its Credit and Collection Department, to settle the unpaid
bills; that respondent Ty represented that she will settle the
bills as soon as the funds become available; that respondent
Ty pleaded to the management that in view of the physical
condition of her mother, respondent Chua, the
correspondences relating to the settlement of the unpaid
hospital bills should be relayed to the former; that these
pleas were unheeded by the petitioner; that petitioner
threatened to implement unpleasant measures unless
respondent Ty undertakes her mother's obligation as well as
the obligation of her sister, Judith Chua, to pay the
hospitalization expenses; that petitioner made good its threat
and employed unethical, unpleasant and unlawful methods
which allegedly worsened the condition of respondent Chua,
particularly, by (i) cutting off the telephone line in her room
and removing the air-conditioning unit, television set, and
refrigerator, (ii) refusing to render medical attendance and to
change the hospital gown and bed sheets, and (iii) barring
the private nurses or midwives from assisting the patient.
Respondents thus prayed for the award of moral damages,
exemplary damages, and attorney's fees.
In its Answer, Amended Answer, and Rejoinder, petitioner
specifically denied the material averments of the Complaint
and Reply, and interposed its counterclaims arguing that as
early as one week after respondent Chua had been admitted
to its hospital, Dr. Rody Sy, her attending physician, had
already given instructions for her to be discharged, but
respondents insisted that Chua remain in confinement; that,
through its staff, petitioner accordingly administered medical
examinations, all of which yielded negative results; that
respondent Ty voluntarily undertook, jointly and severally, to
pay the hospital bills for both patients; that although
respondent Ty paid up to P435,000.00, more or less, she
reneged on her commitment to pay the balance in violation
of the Contract for Admission and Acknowledgment of
Responsibility for Payment dated October 30, 1990 which
she voluntarily executed; that she signed a Promissory Note
on June 5, 1992 for the unpaid balance of P1,075,592.95
and issued postdated checks to cover the same; that no
such undue pressure had been imposed upon respondent
Chua to settle the bills, the truth being that, as a matter of
standard procedure, the reminders to settle the bills were
transmitted not to the patients but to their relatives who
usually undertook to pay the same; that respondent Ty
deliberately evaded the staff of the Credit and Collection
Department; that the cutting-off of the telephone line and
removal of the air-conditioning unit, television set, and
refrigerator cannot constitute unwarranted actuations, for the
minimize respondents' charges that were already piling up,
especially after respondent Ty refused to settle the balance
notwithstanding frequent demands; that respondent Ty
evaded the staff when the latter attempted to inform her that
the room facilities will be cut off to minimize the rising
charges; and that respondents instituted the present civil
case purposely as leverage against the petitioner after the
latter had filed criminal charges for violation of Batas
Pambansa (B.P.) Blg. 22 against respondent Ty for issuing
checks, later dishonored, totaling P1,075,592.95, the amount
referring to the unpaid hospital bills. In its compulsory
counterclaim, petitioner prayed, among other items, for the
award of no less than P1,000,000.00 as compensatory
damages due to the filing of a malicious and unfounded suit,
and, in its permissive counterclaim, petitioner prayed for
respondents to pay P1,075,592.95, the amount representing
the due and demandable obligation under the Promissory
Note dated June 5, 1992, including the stipulated interest
therein and the 25 percent of the total amount due as
attorney's fees.
During pre-trial, the parties stipulated on the following
issues: First, whether the respondents are liable to the
petitioner to pay the hospital bills arising from the
hospitalization of respondent Chua and Judith Chua; and
second, whether the parties are entitled to their respective
3
claims for damages. Furthermore, the parties stipulated on
the following facts: a) Judith Chua was confined from June
14, 1991 to May 2, 1992; b) respondents failed to pay the
balance despite repeated reminders; c) the said reminders
referred to the hospital bills of respondent Chua and Judith
Chua; d) one of the attending physicians of respondent Chua
was Dr. Rody Sy; and e) the petitioner ordered the removal
of the facilities in question from the room of its patient,
respondent Chua, with the qualification that they were
constrained to discontinue the same after the representative
of respondent Chua refused to update the hospital bills or
refused to transfer her to semi-deluxe room or ward to
4
lessen costs.
On September 30, 1997, the RTC rendered its Decision in
favor of the respondents, the dispositive portion of which
states:
WHEREFORE, premises considered, judgment on
the complaint is hereby rendered in favor of the
[respondents] as against the [petitioner] as follows:
[O]rdering the [petitioner] to pay the [respondents]
the following, to wit:
 a) P200,000.00 as moral damages;
b) P100,000.00 as exemplary damages;
and
c) P50,000.00 as attorney's fees and the
amount of P50,000.00 as litigation
costs.
5
SO ORDERED.
In brief, the RTC held that the removal of the facilities of the
room triggered the hypertension of respondent Chua; that
the petitioner acted in bad faith in removing the facilities
without prior notice; that her condition was aggravated by the
pressure employed by the administration upon her to pay the
hospital bills; that the food always came late as compared to
the other patients; that the beddings and clothes of
respondent Chua were no longer changed and, as a result,
bed sores emerged on her body; that there was an utter lack
of medical attendance; that, because of these, respondent
Chua suffered from self-pity and depression; that petitioner
clearly discriminated against the respondents; that
respondent Ty had no choice but to sign the promissory
notes in order to secure the release of her mother,
respondent Chua; that the foregoing actuations constitute an
abuse of rights; that petitioner failed to establish the
pecuniary loss it suffered and, hence, it is not entitled to
compensatory damages; and that, since the promissory note
is a contract of adhesion, the petitioner is not entitled to the
award of attorney's fees as stipulated thereon.
On appeal to the CA, the petitioner assigned the following
errors:
A.
THE HONORABLE TRIAL COURT COMMITTED
REVERSIBLE ERROR BY FINDING THE
ACTUATIONS OF THE ADMINISTRATION OF
DEFENDANT-APPELLANT TO BE IN BAD
FAITH, OPPRESSIVE AND UNNECESSARY AS
TO MAKE IT LIABLE TO PLAINTIFFS-
APPELLEES FOR DAMAGES AND ATTORNEY'S
FEES.
B.
THE HONORABLE TRIAL COURT COMMITTED
REVERSIBLE ERROR BY NOT RULING UPON
THE PERMISSIVE COUNTERCLAIM OF
DEFENDANT-APPELLANT WITH RESPECT TO
THE P1,075,592.95 REPRESENTING THE
HOSPITAL BILL OF PLAINTIFFS-APPELLEES,
WHICH OBLIGATION IS NOT DISPUTED AND
WHICH AMOUNT WAS NEVER
CONTROVERTED BY PLAINTIFFS-
6 social, done in bad faith without proper notice, with no
APPELLEES.
On October 2, 2001, the CA promulgated its Decision the
dispositive portion of which reads:
IN VIEW OF ALL THE FOREGOING, the
appealed Decision is hereby AFFIRMED with the
modification that the award of moral damages,
exemplary damages as well as attorney's fees is
reduced to Seventy Five Thousand Pesos
(P75,000.00), Thirty Thousand Pesos
(P30,000.00) and Twenty Thousand Pesos
(P20,000.00), respectively. Litigation costs are
hereby deleted. Costs against appellant.
7
SO ORDERED.
Apart from the reduction in the award of damages, the CA
affirmed all salient portions of the RTC Decision and
declined to disturb the findings of fact.
Petitioner is now before this Court raising essentially the
same grounds heard by the CA.
Incidentally, with respect to the related criminal case against
respondent Ty, this Court, on September 27, 2004,
promulgated its Decision entitled Ty v. People of the
8
Philippines, which affirmed the decisions of the lower courts
finding respondent Ty guilty of violating B.P. Blg. 22 and
ordering her to pay the private complainant, herein
petitioner, the total amount of the dishonored checks.
The petition is impressed with merit.
While, as a rule, only questions of law may be raised in a
petition for review on certiorari under Rule 45, under certain
exceptions, the Court may re-examine the evidence
presented by the parties during the trial. At least four
exceptions exist in this case, namely: (a) when the
conclusion is a finding grounded entirely on speculation,
surmises, or conjectures; (b) when the judgment is based on
a misapprehension of facts; (c) when the findings of fact are
premised on the supposed absence of evidence and
contradicted by the evidence on record; and (d) when the
courts a quo manifestly overlooked certain relevant facts not
disputed by the parties and which, if properly considered,
9
would justify a different conclusion.
The principal questions are, first, whether the actuations of
the petitioner amount to actionable wrongs, and second,
whether the counterclaims of the petitioner can be backed
up by the measure of preponderant evidence.
In brief, the courts a quo concurred in the holding that the
petitioner and its staff failed to take into consideration the
physical condition of its patient, respondent Chua, when it
10
removed the facilities provided in her room; that the
removal of these facilities, namely, the air-conditioner,
telephone lines, television, and refrigerator, aggravated the
condition of the patient, triggered her hypertension, and
11
caused her blood pressure to fluctuate, considering that
12
there was no proper ventilation in the room. In view of the
foregoing, the courts a quo concluded that the actuations of
13
the petitioner were oppressive, unnecessary, and anti-
14 15
16
intention other than to harass or irritate the respondents, all
17
of which constitute an abuse of rights.
We do not agree. The conclusions of the courts a quo are
either haphazard conjectures, or founded on a
misapprehension of facts. The record is replete with
evidence that justifies a different conclusion.

Indeed the operation of private pay hospitals and medical
clinics is impressed with public interest and imbued with a
heavy social responsibility. But the hospital is also a
business, and, as a business, it has a right to institute all
measures of efficiency commensurate to the ends for which
it is designed, especially to ensure its economic viability and
survival. And in the legitimate pursuit of economic
considerations, the extent to which the public may be served
and cured is expanded, the pulse and life of the medical
sector quickens, and the regeneration of the people as a
whole becomes more visibly attainable. In the institution of
cost-cutting measures, the hospital has a right to reduce the
facilities and services that are deemed to be non-essential,
such that their reduction or removal would not be detrimental
18
to the medical condition of the patient. For the moment, the
question to be considered is whether the subject facilities are
indeed non-essential – the air-conditioner, telephone,
television, and refrigerator – the removal of which would
cause the adverse health effects and emotional trauma the
respondents so claimed. Corollary to this question is whether
the petitioner observed the diligence of a good father of the
19
family in the course of ascertaining the possible
repercussions of the removal of the facilities prior to the
removal itself and for a reasonable time thereafter, with a
20
view to prevent damage.
After an extensive analysis of the record, it becomes rather
worrisome to this Court that the courts a quounreservedly
drew their conclusions from the self-serving and
uncorroborated testimonies of the respondents the probative
21
value of which is highly questionable. We hold that the
respondents failed to prove the damages so claimed.
The evidence in the record firmly establishes that the staff of
the petitioner took proactive steps to inform the relatives of
respondent Chua of the removal of facilities prior thereto,
and to carry out the necessary precautionary measures to
ensure that her health and well-being would not be adversely
affected: as early as around two weeks after her admission
on October 30, 1990, to the time when the facilities had been
22
removed sometime in the middle of May 1992, and even up
to the point when she actually left the premises of the
hospital three weeks later, or during the first week of June
23
1992, the medical condition of respondent Chua, as
consistently and indisputably confirmed by her attending
physician, Dr. Rody Sy, a cardiologist, who was called as
24
witness for both parties, whom even respondent Chua
repeatedly praised to be "my doctor" and "a very good
25
doctor" at that, and whose statements at times had been
corroborated as well by Sister Mary Philip Galeno, SPC, the
Administrator of the hospital and who also happens to be a
registered nurse, had been "relatively
26 27 28
well," "ambulatory," "walking around in the room," and
that she was "able to leave the hospital on her own without
29
any assistance;" that although she complained of
30
symptoms such as dizziness, weakness, and abdominal
31
discomfort, Dr. Sy requested several medical
examinations, such as the laboratory tests, renal tests, MRI,
32
ultrasound, and CT scan, all of which were administered
33
after procuring the consent of respondent Chua's family as
34
admitted by respondent Ty herself, and even called on
other specialists, such as a neurologist, endocrinologist, and
35
gastroenterologist, to look into her condition and conduct
36
other tests as well according to their fields of specialty, all
37
of which yielded no serious finding; that her illnesses were
38
"lifelong illnesses" at a stage where they cannot be totally
39
removed or abolished, making it clear to her family that
"one hundred percent recovery is not possible" despite being
40
given daily medication in the hospital; but that her
41
condition, nonetheless, is not serious, as the blood
pressure is more or less controlled and within acceptable
42 43
limits, "not that critical to precipitate any acute attack," nor
44
likely to fall into any emergency, nor yet does she require
45
continuous or prolonged hospitalization since she was
stable enough to be treated at home and on an "out-patient"
basis, so much so that Dr. Sy encouraged her to exercise
and avoid resting all the
46
time, and recommended that "anytime she may be
47
discharged"
48
even in just "two weeks after confinement," the propriety of
his order of discharge concurred upon by the other
49
specialists as well, had it not been for respondents'
insistence to stay in the hospital in view of their hope for
50
absolute recovery despite the admission of respondent
51
Chua herself that she cannot anymore be totally cured.
It is also undisputed that the hospital administrator, Sister
Galeno, prior to the removal of the facilities, consulted the
52
attending physician, Dr. Sy. To Sister Galeno, also a
registered nurse, the matter of removal and its possible
repercussions on the health of the patient, as a matter of
hospital policy, is a critical and sensitive maneuver, and,
hence, it is carried out only after discussing with the doctors
53
to evaluate all important factors. The fact of prior
54
consultation as well as the medical determination to the
effect that it was safe to remove the facilities and would
55
cause no harmful effect had been amply corroborated by
56
respondent Chua's own doctor himself. When Dr. Sy
testified as rebuttal witness for the respondents themselves
and whose credibility respondents failed to impeach, he
categorically stated that he consented to the removal since
the removal of the said facilities would not by itself be
detrimental to the health of his patient, respondent
57
Chua. And in this respect, he had been advising
respondent Ty, the daughter of the patient, that the facilities,
such as the air-conditioner, television, refrigerator, and
telephone, are not absolutely necessary, and, that although
they may add to the comfort of the patient, if absent, they will
not cause any significant deterioration of her
58
condition, given that, in his experience as a cardiologist,
and after personally attending respondent Chua on a daily
basis before, during, and after the removal and even up to
59
the time of her actual discharge, he concluded that many
hypertensive and diabetic patients, as in her case, do not at
all need in particular an air-conditioning unit, among the
60
other facilities aforementioned. And, contrary to the
findings of the courts a quo and the self-serving testimonies
of respondents that the lack of ventilation, after the removal
of the air-conditioner, triggered her hypertension, Dr. Sy
categorically stated that during his daily rounds with the
patient he was certain that, although admittedly the blood
pressure in general would fluctuate daily, there had been no
adverse effect on her, and that her blood pressure were
61
within acceptable limits, especially considering that he
treated the patient on a daily basis up to the point of actual
62
discharge, and accordingly, as confirmed by the medical
records, he made no change in the medications
63
thereafter. In support of Dr. Sy's findings, Sister Galeno,
testified that she knew the condition of the ventilation of the
patient's deluxe room, located at the fifth floor, even without
the air-conditioning, notably in times of brownout, and that
there had been enough ventilation since the grilled window
of that room was large enough which, if opened, would
64
permit sufficient ventilation. The Court finds that the
premise of the RTC judgment refers merely to hypothetical

statements which fail to establish any clear and direct link to
the injury allegedly suffered by the patient:
Q — You found it safe to remove these facilities
from the room of the patient suffering from
diabetes and hypertension?
A — Yes, Sir. Many hypertensive, diabetic patients
do not need air-conditioning, or T.V. or
refrigerator.
Q — Do you agree with me that hypertension is
triggered sometimes by excitement, anger or (sic)
a person suffering from such illness?
A — Hypertension can be triggered by anything.
Court:
Q — And even in other words the discomfort can
also trigger?
A — Sometimes mental stress can trigger.
xxxx
Court:
Q — You mentioned earlier that this hypertension
may be triggered mentally?
A — Yes, Your Honor.
Court:
Q — Will the removal of these facilities not affect
the patient including the relatives?
A — It may to a certain extent. And well, maybe
the days after the removal would prove that
fluctuation in blood pressure are within acceptable
limits.
65
With respect to the findings of the courts a quo that bed
sores appeared on the body of respondent Chua, that she
suffered from depression after the disconnection of the said
facilities, that her private midwives were barred, and that the
delivery of food was delayed, this Court holds, as above, that
these conclusions are bereft of sound evidentiary basis, self-
serving and uncorroborated as they are. Again, Dr. Sy
affirmed that during the daily rounds he would make on the
patient, he did not detect any skin lesion or any other
abnormality up to the time she was actually
66
discharged. Nor did he find any sign of depression,
although, admittedly, he observed that she had been "very
67
angry" because of the removal of the facilities. All the while
he did not receive any complaint from respondent Chua
indicating that she suffered from the foregoing
68
infirmities, considering that it is the responsibility of the
family of the patient to specifically inform the attending
physician or the nurses during their rounds whatever they
feel is important, or if there were any new developments
69
since the last visit. As corroborated by Sister Galeno,
throughout respondent Chua's confinement, she never
received any complaint from the latter or her relatives that
70
she had not been attended to by the nursing staff. Worth
noting again is the fact that the nursing staff and the
attending physicians, which included Dr. Sy, in accordance
with hospital policy, would routinely make their rounds on a
daily basis, or would visit the patient whenever they are
71
called for any problem, and, in the case of the specialists
other than the attending physician, they would visit the
72
patient about once a week. The nurses, on the other hand,
would make their rounds more frequently, that is, at least
73
once per shift, or every eight hours. Apart from the self-
serving statements of respondents, which by now have
become rather indicative of being mere afterthoughts, there
is no clear showing from the record that the petitioner and its
medical staff deviated from the foregoing policy and practice,
nor had they been called upon to look into the alleged
physical reactions or emotional trauma respondent Chua
claims to have suffered during and after the removal of the
facilities. It must be emphasized that, as stated above,
respondent Chua herself explicitly found Dr. Sy to be a "very
good doctor" because he personally attended to her "almost
74
every hour." And throughout her confinement, Dr. Sy
positively stated that her family employed a private midwife
75
who attended to her all the time.
The evidence in the record overwhelmingly demonstrates
that respondent Chua had been adequately attended to, and
this Court cannot understand why the courts a quo had
declared that there was an "utter lack of medical
attendance," or that her health suffered during the period
after the removal of the facilities. The Court finds that the
facilities in question are non-essential for the care of
respondent Chua and, hence, they may be lessened or
removed by the petitioner for the sake of economic necessity
and survival.
Though human experience would show that the deactivation
of the air-conditioner may cause a temperature differential
that may trigger some physical discomfort, or that the
removal of entertainment facilities such as the television set,
or the disconnection of communication devices such as the
telephone, may cause some exasperation on the part of the
one who benefits from these, nevertheless, all things
considered, and given the degree of diligence the petitioner
duly exerted, not every suppression of the things that one
has grown accustomed to enjoy amounts to an actionable
wrong, nor does every physical or emotional discomfort
amount to the kind of anguish that warrants the award of
moral damages under the general principles of tort. The
underlying basis for the award of tort damages is the
premise that an individual was injured in contemplation of
law. Thus, there must first be the breach of some duty and
the imposition of liability for that breach before damages may
be awarded; it is not sufficient to state that there should be
tort liability merely because the plaintiff suffered some pain
and suffering.
76
Moreover, this Court must reiterate the standard of tort to
arrive at a proper award for damages premised on matters
that suggest the application of medical knowledge,
especially in the description of the causal link between
external or environmental factors, on one hand, and their
effect unto the physical or emotional health of the patient, on
the other, expert opinion, as discussed in Cruz v. Court of
77
Appeals, is generally required:

All three courts below bewail the inadequacy of
the facilities of the clinic and its untidiness; the
lack of provisions such as blood, oxygen, and
certain medicines; the failure to subject the patient
to a cardio-pulmonary test prior to the operation;
the omission of any form of blood typing before
transfusion; and even the subsequent transfer of
Lydia to the San Pablo Hospital and the
reoperation performed on her by the petitioner. But
while it may be true that the circumstances pointed
out by the courts below seemed beyond cavil to
constitute reckless imprudence on the part of the
surgeon, this conclusion is still best arrived at not
through the educated surmises nor conjectures of
laymen, including judges, but by the
unquestionable knowledge of expert witnesses.
For whether a physician or surgeon has exercised
the requisite degree of skill and care in the
treatment of his patient is, in the generality of
cases, a matter of expert opinion. The deference
of courts to the expert opinions of qualified
physicians stems from its realization that the latter
possess unusual technical skills which laymen in
most instances are incapable of intelligently
evaluating. Expert testimony should have been
offered to prove that the circumstances cited by
the courts below are constitutive of conduct falling
below the standard of care employed by other
physicians in good standing when performing the
same operation. It must be remembered that when
the qualifications of a physician are admitted, as in
the instant case, there is an inevitable
presumption that in proper cases he takes the
necessary precaution and employs the best of his
knowledge and skill in attending to his clients,
unless the contrary is sufficiently established. This
presumption is rebuttable by expert opinion which
is so sadly lacking in the case at bench.
78
With respect to the propriety of the notice of removal of
facilities, the evidence shows that the hospital staff,
accompanied by Sister Gladys Lim, SPC, Finance
79
Administrative Assistant of the hospital, through written and
verbal notices as per hospital policy, forewarned the
respondents, through respondent Ty and her sister, Judith
Chua, of the impending removal of the facilities over a week
80
beforehand in view of their obstinate refusal to vacate and
81
transfer to a lower rate room or to update the mounting
82
hospital bills which, by then, had swollen to approximately
83
one million pesos. Respondent Ty refused to read many of
the written notices sent by the Credit
84
Department. After repeated attempts to contact respondent
85
Ty and before the actual removal of the facilities, the staff
of the petitioner tried to personally serve the final notice
86
dated April 23, 1992, signed by Sister Gladys Lim,
addressed to respondent Ty, which adopted the tenor of the
prior verbal warnings, and which expressly and sternly
warned the respondents that the hospital shall be
constrained to take legal action and that they shall be
compelled to transfer the patient, respondent Chua, to a
lower rate room unless the balance could be
87
satisfied. Respondent Ty, for no justifiable reason, and
sticking to her inclination to avoid the staff, refused to
88
receive or acknowledge this letter as well. Worth noting is
that Sister Galeno, testified that, as a matter of hospital
policy the tenor of which respondents, by virtue of the
Contract for Admission dated October 30, 1990, agreed to
89
comply with, the hospital can only cut off the non-essential
90
facilities – and only in extreme cases – if the patient
occupies a private room all to herself; had the room been
semi-private shared by other patients, or had it been the
ward, the hospital cannot disconnect the facilities since this
would unduly prejudice the other patients. But respondent
Chua herself insisted on staying in a private room despite
91
her being fully aware of the ballooning charges, and even if
she could have freely gone home anytime to her
condominium unit which, as admitted, was equipped with an
92
air-conditioner. With respect to the "pressure" and
"harassment" respondents allegedly suffered daily whenever
the hospital staff would follow up the billing during odd hours,
93
or at 10pm, 11pm, 12 midnight, 1am, or 2am, this averment
had been convincingly refuted by the witnesses for the
petitioner, namely, Editha L. Vecino, the Head of Credit and
Collection, and Sister Galeno, in that the Credit and
Collection Department would only hold office hours from
8am to 5pm and, hence, it is impossible to "harass" the
94
respondents during the times they so claimed.
The courts a quo found that respondent Ty had "no choice
but to sign the promissory note in order for her mother to be
95
released from the hospital," thus suggesting that the
hospital refused to actually discharge or bodily release its
patient, respondent Chua, until arrangements had been
made to settle the charges.
While there are portions of the testimonies of the witnesses
for the petitioner which state that although, as per standard
96
procedure, the patient "cannot leave" the hospital without
97
the "discharge," "clearance" or "gate pass" issued only
after
arrangements on the settlement of bills had been
98
made, still, it must be understood that these are only
demonstrative of the precondition that a patient cannot step
out of the premises "without the consent" of the hospital, or,
in other words, that the "clearance" merely indicates that the
hospital expressly consented to the actual release of the
99
patient, but, even without its consent, the patient is still free
to leave "anytime" as a matter of policy, in spite of the
100
refusal to issue a "clearance" or "gate pass," or even in
cases where the accounts have not yet been liquidated or
101
settled, or yet even if no promissory note or post-dated
check were executed in favor of the petitioner, as testified by
102
no less than Sister Galeno, and corroborated by Editha
103
Vecino; and that, petitioner, a private hospital established
104
for profit, being also a business, by warning respondents
that it shall withhold clearance, is simply exercising its right
to protest against an absconding patient as a precursor to
avail of other appropriate legal remedies; that, on the
contrary, the respondents opted not to leave because of their
own promise not to leave unless the hospital bills were fully
105
settled; that the accusations found in the Demand Letter
dated May 19, 1992, and signed by the counsel for the
106
respondents, particularly, that the petitioner "refused to
discharge the patient, [respondent Chua,] despite orders
from the attending physician, Dr. Rody Sy," had all been
refuted by Sister Galeno when she read its contents in front
of the counsel for respondents, emphatically telling him that
"we are not detaining his clients;" that "[respondent Ty] was
the one who told us that they are not going to leave the
107
hospital unless they have fully paid the hospital;" and that,
most importantly, no physical restraint upon the person of
respondent Chua or upon the person of her relatives had
been imposed by the staff.

Authorities, including those of common law origin, explicitly
declare that a patient cannot be detained in a hospital for
non-payment of the hospital bill. If the patient cannot pay the
hospital or physician's bill, the law provides a remedy for
them to pursue, that is, by filing the necessary suit in court
108
for the recovery of such fee or bill. If the patient is
prevented from leaving the hospital for his inability to pay the
bill, any person who can act on his behalf can apply in court
109
for the issuance of the writ of habeas corpus.
The form of restraint must be total; movement must be
restrained in all directions. If restraint is partial, e.g., in a
particular direction with freedom to proceed in another, the
110
restraint on the person's liberty is not total. However, the
hospital may legally detain a patient against his will when he
is a detained or convicted prisoner, or when the patient is
suffering from a very contagious disease where his release
will be prejudicial to public health, or when the patient is
mentally ill such that his release will endanger public
111
safety, or in other exigent cases as may be provided by
law. Moreover, under the common law doctrines on tort, it
does not constitute a trespass to the person to momentarily
prevent him from leaving the premises or any part thereof
because he refuses to comply with some reasonable
condition subject to which he entered them. In all cases, the
condition of this kind of restraint must be reasonable in the
112
light of the circumstances. At any rate, as stated above,
the patient is free to leave the premises, even in the
ostensible violation of these conditions, after being
momentarily interrupted by the hospital staff for purposes of
informing him of those reasonable conditions, such as the
assessment of whether the patient is fit to leave, insane, or
suffering from a contagious disease, etc., or simply for
purposes of making a demand to settle the bill. If the patient
chooses to abscond or leave without the consent of the
hospital in violation of any of the conditions deemed to be
reasonable under the circumstances, the hospital may
nonetheless register its protest and may choose to pursue
the legal remedies available under law, provided that the
hospital may not physically detain the patient, unless the
case falls under the exceptions abovestated.
Authorities are of the view that, ordinarily, a hospital,
113
especially if it is a private pay hospital, is entitled to be
compensated for its services, by either an express or an
implied contract, and if no express contract exists, there is
generally an implied agreement that the patient will pay the
114
reasonable value of the services rendered; when a
hospital treats a patient's injuries, it has an enforceable claim
for full payment for its services, regardless of the patient's
115
financial status. At this juncture, it must be noted that
there is testimony, though to a degree disputable, to the
effect that the execution of the promissory note and the
issuance of postdated checks were conditions imposed not
by the petitioner but voluntarily offered by the counsel for
116
respondents. At any rate, however, this Court holds, in
view of the foregoing authorities, that the requirement to
have the relative of respondent Chua to execute a
promissory note as part of the arrangement to settle the
unpaid obligations is a formality that converts any implied
contract into written form and, moreover, amounts to a
reasonable condition, the non-fulfillment of which, in itself,
however, as discussed, cannot allow the hospital to detain
the patient. It must also be stressed, contrary to the findings
of the courts a quo, that such an agreement embodied in a
promissory note, as well as the Contract for Admission and
Acknowledgment of Responsibility for Payment dated
October 30, 1990, do not become contracts of adhesion
simply because the person signing it was under stress that
117
was not the result of the actions of the hospital, especially
taking into account that there is testimony to the effect that
respondent Ty signed the Promissory Note dated June 5,
1992 in the presence of counsel and acting under his
118
advise.
But as to the propriety of the circumstances surrounding the
issuance of the postdated checks to cover the amount stated
in the Promissory Note dated June 5, 1992, this Court must
refer to the discussion of the recent case of Ty v. People of
119
the Philippines where this Court affirmed the conviction of
respondent Ty for the issuance of bouncing checks
addressed to the petitioner herein. While the instant case is
to be distinguished from the Ty case in nature, applicable
law, the standards of evidence, and in the defenses
available to the parties, hence, the judgment of conviction in
that case should not at all prejudice the disposition of this
case, even if the facts coincide, nonetheless, for purposes of
convenience and instructive utility, the Court quotes the
relevant portions:
In this case, far from it, the fear, if any, harbored
by Ty was not real and imminent. Ty claims that
she was compelled to issue the checks a condition
the hospital allegedly demanded of her before her
mother could be discharged for fear that her
mother's health might deteriorate further due to the
inhumane treatment of the hospital or worse, her
mother might commit suicide. This is speculative
fear; it is not the uncontrollable fear contemplated
by law.
To begin with, there was no showing that the
mother's illness was so life-threatening such that
her continued stay in the hospital suffering all its
alleged unethical treatment would induce a well-
grounded apprehension of her death. Secondly, it
is not the law's intent to say that any fear exempts
one from criminal liability much less petitioner's
flimsy fear that her mother might commit suicide.
In other words, the fear she invokes was not
impending or insuperable as to deprive her of all
volition and to make her a mere instrument without
will, moved exclusively by the hospital's threats or
demands.
Ty has also failed to convince the Court that she
was left with no choice but to commit a crime. She
did not take advantage of the many opportunities
available to her to avoid committing one. By her
very own words, she admitted that the collateral or
security the hospital required prior to the discharge
of her mother may be in the form of postdated
checks or jewelry. And if indeed she was coerced
to open an account with the bank and issue the
checks, she had all the opportunity to leave the
scene to avoid involvement.
Moreover, petitioner had sufficient knowledge that
the issuance of checks without funds may result in
a violation of B.P. 22. She even testified that her
counsel advised her not to open a current account
nor issue postdated checks "because the moment
I will not have funds it will be a big problem."
Besides, apart from petitioner's bare assertion, the
record is bereft of any evidence to corroborate and
bolster her claim that she was compelled or
 coerced to cooperate with and give in to the
hospital's demands.
Ty likewise suggests . . . that the justifying
circumstance of state of necessity under par. 4,
Art. 11 of the Revised Penal Code may find
application in this case.
We do not agree. The law prescribes the presence
of three requisites to exempt the actor from liability
under this paragraph: (1) that the evil sought to be
avoided actually exists; (2) that the injury feared
be greater than the one done to avoid it; (3) that
there be no other practical and less harmful
means of preventing it.
In the instant case, the evil sought to be avoided is
merely expected or anticipated. If the evil sought
to be avoided is merely expected or anticipated or
may happen in the future, this defense is not
applicable. Ty could have taken advantage of an
available option to avoid committing a crime. By
her own admission, she had the choice to give
jewelry or other forms of security instead of
postdated checks to secure her obligation.
Moreover, for the defense of state of necessity to
be availing, the greater injury feared should not
have been brought about by the negligence or
imprudence, more so, the willful inaction of the
actor. In this case, the issuance of the bounced
checks was brought about by Ty's own failure to
pay her mother's hospital bills.
The Court also thinks it rather odd that Ty has
chosen the exempting circumstance of
uncontrollable fear and the justifying circumstance
of state of necessity to absolve her of liability. It
would not have been half as bizarre had Ty been
able to prove that the issuance of the bounced
checks was done without her full volition. Under
the circumstances, however, it is quite clear that
neither uncontrollable fear nor avoidance of a
greater evil or injury prompted the issuance of the
bounced checks.
Parenthetically, the findings of fact in the Decision
of the trial court in the Civil Case for damages filed
by Ty's mother against the hospital is wholly
irrelevant for purposes of disposing the case at
bench. While the findings therein may establish a
claim for damages which, we may add, need only
be supported by a preponderance of evidence, it
does not necessarily engender reasonable doubt
120
as to free Ty from liability.
In view of the foregoing, the Court therefore holds that the
courts a quo committed serious errors in finding that the
121
petitioner was "biased," "discriminated" against the
122 123
respondents, and "purposely intended to irritate" or
124
"harass" them; that it "acted in bad faith in removing the
125
facilities without prior notice;" and that its acts were "anti-
126
social." The aforequoted declarations of the witnesses,
significant portions of which this Court considers as expert
testimony, are reliable and remain considerably trustworthy
to controvert respondents' assertions as well as to reverse
the conclusions of fact and law of the CA and the RTC that
respondent Chua suffered the physical and emotional
anguish so claimed, and so, for these reasons, the Court
holds that the petitioner inflicted no actionable wrong.
This Court observes that the courts a quo awarded both
respondents moral damages. But it is well-settled that in
127
case of physical injuries, with some exceptions, moral
damages are recoverable only by the party injured and not
by her spouse, next of kin, or relative who happened to
128
sympathize with the injured party. Hence, even if the
courts a quo were correct in their basis for damages, they
should have declined to award damages to respondent Ty.
The last issue to be resolved is the question whether the
counterclaims of the petitioner are supported by a
preponderance of evidence.
We agree with the petitioner that the courts a quo seriously
erred in mistaking the case of its compulsory counterclaim
for its permissive counterclaim and for failing to consider the
evidence which impressively supports the latter. First, for
failure without justifiable cause of respondents' counsel to
comment on the Partial Formal Offer of Evidence dated
129
February 14, 1996 filed by the petitioner, the RTC issued
an order during the course of the trial, which counsel for
respondents neither contested nor raised on appeal,
admitting Exhibits "1" to "16", together with their
submarkings and the purposes for which the same were
130
offered, all of which had also been previously
authenticated and their contents verified by the witnesses for
131
the petitioner. These documents include the Contract for
Admission of respondent Chua dated October 30, 1990, duly
executed by respondent Ty, incorporating therein the rules
and regulations of the hospital, including the duty to
132
understand the same as well as the undertaking of
respondent Ty to be jointly and severally liable for the
133
payment of the hospital bills of respondent Chua; the
Promissory Note dated June 5, 1992 in the amount of
P1,075,592.95 duly executed by respondent Ty in favor of
the petitioner agreeing to be jointly and severally liable to
pay the unpaid obligations of respondent Chua and Judith
Chua, including interest and attorney's fees in case of
134
default; the Undertakings signed by respondent Ty dated
March 3, 1992 and April 7, 1992 to maintain regular
135
deposits; and the credit memos and statements of account
that support the amount referring to the unpaid
136
obligation. Second, the parties stipulated during pre-trial
that respondents failed to pay the balance despite repeated
137
reminders. And third, respondent Ty in open court
identified and admitted that she signed the Contract of
Admission dated October 30, 1990 as well as the
Undertakings dated March 3, 1992 and April 7, 1992 but
which, for no justifiable reason, she "did not bother to
138
read," and, what is more, she repeatedly admitted during
the course of the trial that she failed to fully settle the
139
foregoing hospital bills. In fact, while the Ty case cannot
control the incidents of the instant case as heretofore stated,
it is still worth mentioning, at least for informative purposes,
the findings of this Court in Ty with respect to respondents'
obligations to the petitioner:
Ty's mother and sister availed of the services and
the facilities of the hospital. For the care given to
her kin, Ty had a legitimate obligation to pay the
hospital by virtue of her relationship with them and
by force of her signature on her mother's Contract
of Admission acknowledging responsibility for
 payment, and on the promissory note she G.R. No. 176484 November 25, 2008
140
executed in favor of the hospital.
CALAMBA MEDICAL CENTER, INC. vs.
In view of all these findings, the Court earnestly disagrees NATIONAL LABOR RELATIONS COMMISSION
with the sweeping conclusion of the CA that "[Petitioner]
141
failed to present any iota of evidence to prove his claim," a
The Calamba Medical Center (petitioner), a privately-owned
statement apparently referring to the permissive
hospital, engaged the services of medical doctors-spouses
counterclaim of P1,075,592.95. However, with respect to the
Ronaldo Lanzanas (Dr. Lanzanas) and Merceditha
compulsory counterclaim predicated on the filing of a
Lanzanas (Dr. Merceditha) in March 1992 and August 1995,
baseless suit and injury to its reputation, petitioner did not
respectively, as part of its team of resident physicians.
raise this matter on appeal and, hence, is deemed to have
Reporting at the hospital twice-a-week on twenty-four-hour
waived the same.
shifts, respondents were paid a monthly "retainer"
1
of P4,800.00 each. It appears that resident physicians were
But the Court in Ty made a partial finding on the civil liability also given a percentage share out of fees charged for out-
of respondent Ty with respect to the amount covered by patient treatments, operating room assistance and discharge
2
seven of the several dishonored checks she issued billings, in addition to their fixed monthly retainer.
equivalent to
The work schedules of the members of the team of resident
142
P210,000.00. Since this amount forms a fraction of her physicians were fixed by petitioner's medical director Dr.
total civil liability, then this amount, in deference to Ty, Raul Desipeda (Dr. Desipeda). And they were issued
3
should be deducted therefrom. identification cards by petitioner and were enrolled in the
4
Social Security System (SSS). Income taxes were withheld
5
from them.
The claim for attorney's fees, as stipulated under the
Promissory Note dated June 5, 1992, should be reduced for
being unreasonable under the circumstances, from 25 On March 7, 1998, Dr. Meluz Trinidad (Dr. Trinidad), also a
143
percent to 12 percent of the total amount due. resident physician at the hospital, inadvertently overheard a
telephone conversation of respondent Dr. Lanzanas with a
fellow employee, Diosdado Miscala, through an extension
As a final word, the Court takes judicial notice of the pending
telephone line. Apparently, Dr. Lanzanas and Miscala were
Senate Bill No. 337, entitled "An Act Prohibiting the
discussing the low "census" or admission of patients to the
Detention of Patients in Hospitals and Medical Clinics on 6
hospital.
Grounds of Non-Payment of Hospital Bills or Medical
Expenses," which declares, among others, that it shall be
unlawful for any hospital or medical clinic to cause directly or Dr. Desipeda whose attention was called to the above-said
indirectly the detention of patients for non-payment, in part or telephone conversation issued to Dr. Lanzanas a
144
in full, of their hospital bills, and, furthermore, requires Memorandum of March 7, 1998 reading:
patients who have fully recovered and are financially
incapable to settle the hospitalization expenses to execute a
As a Licensed Resident Physician employed in
promissory note, co-signed by another individual, to the
Calamba Medical Center since several years
extent of the unpaid obligation before leaving the
145 ago, the hospital management has committed
hospital. While this Court may have touched upon these
upon you utmost confidence in the performance of
matters in the adjudication of the instant case, it must be
duties pursuant thereto. This is the reason why
stated that this decision should in no way preempt any
you were awarded the privilege to practice in the
constitutional challenge to the provisions of Senate Bill No.
hospital and were entrusted hospital functions to
337 if passed into law, bearing in mind the standards for the
146 serve the interest of both the hospital and our
exercise of the power of judicial review as well as the
patients using your capability for independent
recognition that the tenor of the bill may adjust with the
judgment.
times, or that the bill itself may fail to pass, according to the
dynamism of the legislative process, especially in light of the
147
objections interposed by interest groups to date. Very recently though and unfortunately, you have
committed acts inimical to the interest of the
hospital, the details of which are contained in the
WHEREFORE, the petition is GRANTED. The Decision of
hereto attached affidavit of witness.
the Court of Appeals dated October 2, 2001, together with
the Decision dated September 30, 1997 of the Regional Trial
Court in Civil Case No. 63958, is REVERSED and SET You are therefore given 24 hours to explain
ASIDE. Another judgment is entered dismissing the why no disciplinary action should be taken
Complaint and ordering respondents, jointly and severally, to against you.
pay the petitioner the amount of P865,592.95, with stipulated
interest of 12 percent reckoned from the date of extrajudicial
demand until full payment, and 12 percent of the total Pending investigation of your case, you are
amount due as attorney's fees. hereby placed under 30-days [sic] preventive
suspension effective upon receipt
7
hereof. (Emphasis, italics and underscoring
No pronouncement as to costs. supplied)

SO ORDERED. Inexplicably, petitioner did not give respondent Dr.

Merceditha, who was not involved in the said incident, any
work schedule after sending her husband Dr. Lanzanas the
 8
memorandum, nor inform her the reason therefor, albeit she For these reasons as grounds for termination,
was later informed by the Human Resource Department you are hereby terminated for cause from
(HRD) officer that that was part of petitioner's cost-cutting employment effective today, April 25,
9
measures. 1998, without prejudice to further action for
revocation of your license before the Philippine
17
[sic] Regulations [sic] Commission. (Emphasis
Responding to the memorandum, Dr. Lanzanas, by letter of
10 and underscoring supplied)
March 9, 1998, admitted that he spoke with Miscala over
the phone but that their conversation was taken out of
context by Dr. Trinidad. Dr. Lanzanas thus amended his original complaint to include
18
illegal dismissal. His and Dr. Merceditha's complaints were
11 consolidated and docketed as NLRC CASE NO. RAB-IV-3-
On March 14, 1998, the rank-and-file employees union of
9879-98-L.
petitioner went on strike due to unresolved grievances over
12
terms and conditions of employment.
19
By Decision of March 23, 1999, Labor Arbiter Antonio R.
Macam dismissed the spouses' complaints for want of
On March 20, 1998, Dr. Lanzanas filed a complaint for illegal
13 jurisdiction upon a finding that there was no employer-
suspension before the National Labor Relations
employee relationship between the parties, the fourth
Commission (NLRC)-Regional Arbitration Board (RAB) IV.
requisite or the "control test" in the determination of an
Dr. Merceditha subsequently filed a complaint for illegal
14 employment bond being absent.
dismissal.
20
On appeal, the NLRC, by Decision of May 3,
In the meantime, then Sec. Cresenciano Trajano of the
2002, reversed the Labor Arbiter's findings, disposing as
Department of Labor and Employment (DOLE) certified the
follows:
labor dispute to the NLRC for compulsory arbitration
and issued on April 21, 1998 return-to-work Order to the
striking union officers and employees of petitioner pending WHEREFORE, the assailed decision is set aside.
15
resolution of the labor dispute. The respondents are ordered to pay the
complainants their full backwages; separation pay
16 of one month salary for every year of service in
In a memorandum of April 22, 1998, Dr. Desipeda echoed
lieu of reinstatement; moral damages
the April 22, 1998 order of the Secretary of Labor directing
of P500,000.00 each; exemplary damages
all union officers and members to return-to-work "on or April
of P250,000.00 each plus ten percent (10%) of the
23, 1998, except those employees that were already
total award as attorney's fees.
terminated or are serving disciplinary actions." Dr. Desipeda
thus ordered the officers and members of the union to
21
"report for work as soon as possible" to the hospital's SO ORDERED.
personnel officer and administrator for "work scheduling,
assignments and/or re-assignments."
Petitioner's motion for reconsideration having been denied, it
brought the case to the Court of Appeals on certiorari.
Petitioner later sent Dr. Lanzanas a notice of termination
which he received on April 25, 1998, indicating as grounds 22
The appellate court, by June 30, 2004 Decision, initially
therefor his failure to report back to work despite the DOLE
granted petitioner's petition and set aside the NLRC ruling.
order and his supposed role in the striking union, thus:
However, upon a subsequent motion for reconsideration filed
by respondents, it reinstated the NLRC decision in an
23
On April 23, 1998, you still did not report for work Amended Decision dated September 26, 2006 but
despite memorandum issued by the CMC Medical tempered the award to each of the spouses of moral and
Director implementing the Labor Secretary's exemplary damages to P100,000.00 and P50,000.00,
ORDER. The same is true on April 24, 1998 and respectively and omitted the award of attorney's fees.
April 25, 1998,--you still did not report for work
[sic].
In finding the existence of an employer-employee
relationship between the parties, the appellate court held:
You are likewise aware that you
were observed (re: signatories [sic] to the Saligang
x x x. While it may be true that the respondents
Batas of BMCMC-UWP) to be unlawfully
are given the discretion to decide on how to treat
participating as member in the rank-and-file
the petitioner's patients, the petitioner has not
union's concerted activities despite knowledge that
denied nor explained why its Medical Director still
your position in the hospital is managerial in
has the direct supervision and control over the
nature (Nurses, Orderlies, and staff of the
respondents. The fact is the petitioner's Medical
Emergency Room carry out your orders using your
Director still has to approve the schedule of
independent judgment) which participation is
duties of the respondents. The respondents
expressly prohibited by the New Labor Code and
stressed that the petitioner's Medical Director also
which prohibition was sustained by the Med-
issues instructions or orders to the
Arbiter's ORDER dated February 24, 1998.
respondents relating to the means and
(Emphasis and italics in the original; underscoring
methods of performing their duties, i.e.
partly in the original and partly supplied)
admission of patients, manner of characterizing
cases, treatment of cases, etc., and may even
overrule, review or revise the decisions of the
 resident physicians. This was not controverted
by the petitioner. The foregoing factors taken
together are sufficient to constitute the fourth
element, i.e. control test, hence, the existence of
the employer-employee relationship. In denying
that it had control over the respondents, the
petitioner alleged that the respondents were free
to put up their own clinics or to accept other
retainership agreement with the other hospitals.
But, the petitioner failed to substantiate the
allegation with substantial evidence. (Emphasis
24
and underscoring supplied)
The appellate court thus declared that respondents were
illegally dismissed.
x x x. The petitioner's ground for dismissing
respondent Ronaldo Lanzanas was based on his
alleged participation in union activities, specifically
in joining the strike and failing to observe the
return-to-work order issued by the Secretary of
Labor. Yet, the petitioner did not adduce any piece
of evidence to show that respondent Ronaldo
indeed participated in the strike. x x x.
In the case of respondent Merceditha Lanzanas,
the petitioner's explanation that "her marriage to
complainant Ronaldo has given rise to the
presumption that her sympat[hies] are likewise
with her husband" as a ground for her dismissal is
unacceptable. Such is not one of the grounds to
justify the termination of her
25
employment. (Underscoring supplied)
The fallo of the appellate court's decision reads:
WHEREFORE, the instant Motion for
Reconsideration is GRANTED, and the Court's
decision dated June 30, 2004, is SET ASIDE. In
lieu thereof, a new judgment is entered, as follows:
WHEREFORE, the petition is
DISMISSED. The assailed decision
dated May 3, 2002 and order dated
September 24, 2002 of the NLRC in
NLRC NCR CA No. 019823-99 are
AFFIRMED with the MODIFICATION
that the moral and exemplary damages
are reduced to P100,000.00 each
and P50,000.00 each, respectively.
26
SO ORDERED. (Emphasis and italics in the
original; underscoring supplied)
Preliminarily, the present petition calls for a determination of
whether there exists an employer-employee
27
relationship between petitioner and the spouses-
respondents.
Denying the existence of such relationship, petitioner argues
that the appellate court, as well as the NLRC, overlooked its
twice-a-week reporting arrangement with respondents who
are free to practice their profession elsewhere the rest of the
week. And it invites attention to the uncontroverted allegation
that respondents, aside from their monthly retainers, were
entitled to one-half of all suturing, admitting, consultation,
28
medico-legal and operating room assistance fees. These
circumstances, it stresses, are clear badges of the absence
of any employment relationship between them.
This Court is unimpressed.
Under the "control test," an employment relationship exists
between a physician and a hospital if the hospital controls
both the means and the details of the process by which the
29
physician is to accomplish his task.
Where a person who works for another does so more or less
at his own pleasure and is not subject to definite hours or
conditions of work, and is compensated according to the
result of his efforts and not the amount thereof, the element
30
of control is absent.
As priorly stated, private respondents maintained specific
work-schedules, as determined by petitioner through its
medical director, which consisted of 24-hour shifts totaling
forty-eight hours each week and which were strictly to be
observed under pain of administrative sanctions.
That petitioner exercised control over respondents gains
light from the undisputed fact that in the emergency room,
the operating room, or any department or ward for that
matter, respondents' work is monitored through its nursing
supervisors, charge nurses and orderlies. Without the
approval or consent of petitioner or its medical director, no
operations can be undertaken in those areas. For control
test to apply, it is not essential for the employer to actually
supervise the performance of duties of the employee, it
31
being enough that it has the right to wield the power.
With respect to respondents' sharing in some hospital fees,
this scheme does not sever the employment tie between
them and petitioner as this merely mirrors additional form or
another form of compensation or incentive similar to what
commission-based employees receive as contemplated in
Article 97 (f) of the Labor Code, thus:
"Wage" paid to any employee shall mean the
remuneration or earning, however designated,
capable of being expressed in terms of
money, whether fixed or ascertained on a time,
task, piece, or commission basis, or other
method of calculating the same, which is
payable by an employer to an employee under a
written or unwritten contract of employment for
work done or to be done, or for services rendered
or to be rendered and includes the fair and
reasonable value, as determined by the Secretary
of Labor, of board, lodging, or other facilities
customarily furnished by the employer to the
employee. x x x (Emphasis and underscoring
supplied),
Respondents were in fact made subject to petitioner-
32
hospital's Code of Ethics, the provisions of which cover
administrative and disciplinary measures on negligence of
duties, personnel conduct and behavior, and offenses
against persons, property and the hospital's interest.
More importantly, petitioner itself provided incontrovertible
proof of the employment status of respondents, namely, the
33
identification cards it issued them, the payslips and BIR W-
2 (now 2316) Forms which reflect their status as employees,
and the classification as "salary" of their remuneration.
Moreover, it enrolled respondents in the SSS and Medicare
(Philhealth) program. It bears noting at this juncture that
34
mandatory coverage under the SSS Law is premised on
the existence of an employer-employee
35
relationship, except in cases of compulsory coverage of the
self-employed. It would be preposterous for an employer to
report certain persons as employees and pay their SSS
premiums as well as their wages if they are not its
employees.
36
And if respondents were not petitioner's employees, how
does it account for its issuance of the earlier-quoted March
7, 1998 memorandum explicitly stating that respondent is
"employed" in it and of the subsequent termination letter
indicating respondent Lanzanas' employment status.
Finally, under Section 15, Rule X of Book III of
the Implementing Rules of the Labor Code, an employer-
employee relationship exists between the resident
physicians and the training hospitals, unless there is a
training agreement between them, and the training program
is duly accredited or approved by the appropriate
government agency. In respondents' case, they were not
undergoing any specialization training. They were
37
considered non-training general practitioners, assigned at
the emergency rooms and ward sections.
Turning now to the issue of dismissal, the Court upholds the
appellate court's conclusion that private respondents were
illegally dismissed.
Dr. Lanzanas was neither a managerial nor supervisory
employee but part of the rank-and-file. This is the import of
the Secretary of Labor's Resolution of May 22, 1998 in OS
A-05-15-98 which reads:
xxxx
In the motion to dismiss it filed before the Med-
Arbiter, the employer (CMC) alleged that 24
members of petitioner are supervisors, namely x x
x Rolando Lanzonas [sic] x x x.
A close scrutiny of the job descriptions of the
alleged supervisors narrated by the employer only
proves that except for the contention that these
employees allegedly supervise, they do not
however recommend any managerial action. At
most, their job is merely routinary in nature and
consequently, they cannot be considered
supervisory employees.
They are not therefore barred from
membership in the union of rank[-]and[-]file,
which the petitioner [the union] is seeking to
38
represent in the instant case. (Emphasis and
underscoring supplied)
xxxx
Admittedly, Dr. Lanzanas was a union member in the
hospital, which is considered indispensable to the national
interest. In labor disputes adversely affecting the continued
operation of a hospital, Article 263(g) of the Labor Code
provides:
ART. 263. STRIKES, PICKETING, AND
LOCKOUTS.–
xxxx
(g) x x x x
x x x x. In labor disputes adversely affecting
the continued operation of such hospitals,
clinics or medical institutions, it shall be the
duty of the striking union or locking-out employer
to provide and maintain an effective skeletal
workforce of medical and other health personnel,
whose movement and services shall be
unhampered and unrestricted, as are necessary to
insure the proper and adequate protection of the
life and health of its patients, most especially
emergency cases, for the duration of the strike or
lockout. In such cases, the Secretary of Labor and
Employment is mandated to immediately assume,
within twenty-four hours from knowledge of the
occurrence of such strike or lockout, jurisdiction
over the same or certify to the Commission for
compulsory arbitration. For this purpose, the
contending parties are strictly enjoined to
comply with such orders, prohibitions and/or
injunctions as are issued by the Secretary of
Labor and Employment or the Commission,
under pain of immediate disciplinary action,
including dismissal or loss of employment
status or payment by the locking-out employer
of backwages, damages and other affirmative
relief, even criminal prosecution against either
or both of them.
x x x x (Emphasis and underscoring supplied)
An assumption or certification order of the DOLE Secretary
automatically results in a return-to-work of
all striking workers, whether a corresponding return-to-work
39
order had been issued. The DOLE Secretary in fact issued
a return-to-work Order, failing to comply with which is
40
punishable by dismissal or loss of employment status.
Participation in a strike and intransigence to a return-to-work
order must, however, be duly proved in order to justify
immediate dismissal in a "national interest" case. As the
appellate court as well as the NLRC observed, however,
there is nothing in the records that would bear out Dr.
Lanzanas' actual participation in the strike. And the medical
41
director's Memorandum of April 22, 1998 contains nothing
more than a general directive to all union officers and
members to return-to-work. Mere membership in a labor
union does not ipso facto mean participation in a strike.
Dr. Lanzanas' claim that, after his 30-day preventive
suspension ended on or before April 9, 1998, he was never
42
given any work schedule was not refuted by petitioner.
Petitioner in fact never released any findings of its supposed
investigation into Dr. Lanzanas' alleged "inimical acts."
Petitioner thus failed to observe the two requirements,before
dismissal can be effected ─ notice and hearing ─ which
constitute essential elements of the statutory process; the
first to apprise the employee of the particular acts or
omissions for which his dismissal is sought, and the second
to inform the employee of the employer's decision to dismiss
43
him. Non-observance of these requirements runs afoul of
44
the procedural mandate.
The termination notice sent to and received by Dr. Lanzanas
on April 25, 1998 was the first and only time that he was
apprised of the reason for his dismissal. He was not
afforded, however, even the slightest opportunity to explain
his side. His was a "termination upon receipt" situation.
While he was priorly made to explain on his telephone
45
conversation with Miscala, he was not with respect to his
supposed participation in the strike and failure to heed the
return-to-work order.
As for the case of Dr. Merceditha, her dismissal was worse,
it having been effected without any just or authorized cause
and without observance of due process. In fact, petitioner
never proferred any valid cause for her dismissal except its
view that "her marriage to [Dr. Lanzanas] has given rise to
the presumption that her sympath[y] [is] with her husband;
[and that when [Dr. Lanzanas] declared that he was going to
boycott the scheduling of their workload by the medical
doctor, he was presumed to be speaking for himself [and] for
46
his wife Merceditha."
Petitioner's contention that Dr. Merceditha was a member of
the union or was a participant in the strike remained just that.
Its termination of her employment on the basis of her
conjugal relationship is not analogous to
47
any of the causes enumerated in Article 282 of the Labor
Code. Mere suspicion or belief, no matter how strong,
cannot substitute for factual findings carefully established
48
through orderly procedure.
The Court even notes that after the proceedings at the
NLRC, petitioner never even mentioned Dr. Merceditha's
case. There is thus no gainsaying that her dismissal was
both substantively and procedurally infirm.
Adding insult to injury was the circulation by petitioner of a
49
"watchlist" or "watch out list" including therein the names of
respondents. Consider the following portions of Dr.
Merceditha's Memorandum of Appeal:
3. Moreover, to top it all, respondents have
circulated a so called "Watch List" to other
hospitals, one of which [was] procured from
Foothills Hospital in Sto. Tomas, Batangas [that]
contains her name. The object of the said list is
precisely to harass Complainant and malign her
good name and reputation. This is not only
unprofessional, but runs smack of oppression as
CMC is trying permanently deprived [sic]
Complainant of her livelihood by ensuring that she
is barred from practicing in other hospitals.
4. Other co-professionals and brothers in the
profession are fully aware of these "watch out" lists
and as such, her reputation was not only
besmirched, but was damaged, and she suffered
social humiliation as it is of public knowledge that
she was dismissed from work. Complainant came
from a reputable and respected family, her father
being a retired full Colonel in the Army, Col.
Romeo A. Vente, and her brothers and sisters are
all professionals, her brothers, Arnold and Romeo
Jr., being engineers. The Complainant has a
family protection [sic] to protect. She likewise has
a professional reputation to protect, being a
licensed physician. Both her personal and
professional reputation were damaged as a result
50
of the unlawful acts of the respondents.
While petitioner does not deny the existence of such list, it
pointed to the lack of any board action on its part to initiate
such listing and to circulate the same, viz:
20. x x x. The alleged watchlist or "watch out list,"
as termed by complainants, were merely lists
obtained by one Dr. Ernesto Naval of PAMANA
Hospital. Said list was given by a stockholder
of respondent who was at the same time a
stockholder of PAMAN[A] Hospital. The giving
51
of the list was not a Board action. (Emphasis and
underscoring supplied)
The circulation of such list containing names of alleged union
members intended to prevent employment of workers for
union activities similarly constitutes unfair labor practice,
thereby giving a right of action for damages by the
52
employees prejudiced.
A word on the appellate court's deletion of the award of
attorney's fees. There being no basis advanced in deleting it,
53
as exemplary damages were correctly awarded, the award
of attorney's fees should be reinstated.
WHEREFORE, the Decision of the Court of Appeals in CA-
G.R. SP No. 75871 is AFFIRMED with MODIFICATION in
that the award by the National Labor Relations Commission
of 10% of the total judgment award as attorney's fees is
reinstated. In all other aspects, the decision of the appellate
court is affirmed.
SO ORDERED.
G.R. No. 167366 September 26, 2012
DR. PEDRO DENNIS CERENO, and DR. SANTOS ZAFE
vs.COURT OF APPEALS, SPOUSES DIOGENES S.
OLAVERE and FE R. SERRANO
1
Before the Court is a Petition for Review on Certiorari under
Rule 45 of the Rules of Court seeking the annulment and
2
setting aside of the 21 February 2005 decision of the Court
of Appeals (CA) in CA-G.R. CV No. 65800. In the assailed
decision, the CA affirmed in toto the decision of the Regional
Trial Court (R TC), Branch 22, Nag a City finding herein
petitioners Dr. Pedro Dennis Cereno (Dr. Cereno) and Dr.
Santos Zafe (Dr. Zafe) liable for damages.
Culled from the records are the following antecedent facts:
At about 9:15 in the evening of 16 September 1995,
Raymond S. Olavere (Raymond), a victim of a stabbing
incident, was rushed to the emergency room of the Bicol
Regional Medical Center (BRMC). There, Raymond was
attended to by Nurse Arlene Balares (Nurse Balares) and Dr.
Ruel Levy Realuyo (Dr. Realuyo) — the emergency room
resident physician.
Subsequently, the parents of Raymond—the spouses
Deogenes Olavere (Deogenes) and Fe R. Serrano—arrived
at the BRMC. They were accompanied by one Andrew
Olavere, the uncle of Raymond.
After extending initial medical treatment to Raymond, Dr.
Realuyo recommended that the patient undergo "emergency
exploratory laparotomy." Dr. Realuyo then requested the
parents of Raymond to procure 500 cc of type "O" blood
needed for the operation. Complying with the request,
Deogenes and Andrew Olavere went to the Philippine
National Red Cross to secure the required blood.
At 10:30 P.M., Raymond was wheeled inside the operating
room. During that time, the hospital surgeons, Drs. Zafe and
Cereno, were busy operating on gunshot victim Charles
Maluluy-on. Assisting them in the said operation was Dr.
Rosalina Tatad (Dr. Tatad), who was the only senior
anesthesiologist on duty at BRMC that night. Dr. Tatad also
happened to be the head of Anesthesiology Department of
the BRMC.
Just before the operation on Maluluy-on was finished,
another emergency case involving Lilia Aguila, a woman
who was giving birth to triplets, was brought to the operating
room.
At 10:59 P.M., the operation on Charles Maluluy-on was
finished. By that time, however, Dr. Tatad was already
working with the obstetricians who will perform surgery on
Lilia Aguila. There being no other available anesthesiologist
to assist them, Drs. Zafe and Cereno decided to defer the
operation on Raymond.
Drs. Zafe and Cereno, in the meantime, proceeded to
examine Raymond and they found that the latter’s blood
pressure was normal and "nothing in him was
3
significant." Dr. Cereno reported that based on the xray
result he interpreted, the fluid inside the thoracic cavity of
Raymond was minimal at around 200-300 cc.
At 11:15 P.M., Deogenes and Andrew Olavere returned to
the BRMC with a bag containing the requested 500 cc type
"O" blood. They handed over the bag of blood to Dr.
Realuyo.
After Dr. Tatad finished her work with the Lilia Aguila
operation, petitioners immediately started their operation on
Raymond at around 12:15 A.M. of 17 September 1995.
Upon opening of Raymond’s thoracic cavity, they found that
3,200 cc of blood was stocked therein. The blood was
evacuated and petitioners found a puncture at the inferior
pole of the left lung.
In his testimony, Dr. Cereno stated that considering the loss
of blood suffered by Raymond, he did not immediately
4
transfuse blood because he had to control the bleeders first.
Blood was finally transfused on Raymond at 1:40 A.M. At
1:45 A.M., while the operation was on-going, Raymond
suffered a cardiac arrest. The operation ended at 1:50 A.M.
and Raymond was pronounced dead at 2:30 A.M.
5
Raymond’s death certificate indicated that the immediate
cause of death was "hypovolemic shock" or the cessation of
6
the functions of the organs of the body due to loss of blood.
Claiming that there was negligence on the part of those who
attended to their son, the parents of Raymond, on 25
October 1995, filed before the RTC, Branch 22, Naga City a
7
complaint for damages against Nurse Balares, Dr. Realuyo
and attending surgeons Dr. Cereno and Dr. Zafe.
During trial, the parents of Raymond testified on their own
behalf. They also presented the testimonies of Andrew
Olavere and one Loira Oira, the aunt of Raymond. On the
other hand, Dr. Cereno, Dr. Realuyo, Nurse Balares and
Security Guard Diego Reposo testified for the defense. On
rebuttal, the parents of Raymond presented Dr. Tatad,
among others.
8
On 15 October 1999, the trial court rendered a decision the
dispositive portion of which reads:
WHEREFORE, premises considered, this Court hereby
renders judgment:
1. Dismissing the case against Dr. Ruel Levy
Realuyo and Arlene Balares for lack of merit;
2. Ordering defendants Dr. Santos Zafe and Dr.
Dennis Cereno to pay the heirs of Raymond
Olavere, jointly and severally the following
amounts:
1. ₱ 50,000.00 for the death of the
victim;
2. ₱ 150,000.00 as moral damages;
3. ₱ 100,000.00 as exemplary damages;
4. ₱ 30,000.00 for attorney’s fees; and
9
5. Cost of suit.
x x x x.
The trial court found petitioners negligent in not immediately
conducting surgery on Raymond. It noted that petitioners
have already finished operating on Charles Maluluy-on as
early as 10:30 in the evening, and yet they only started the
operation on Raymond at around 12:15 early morning of the
following day. The trial court held that had the surgery been
performed promptly, Raymond would not have lost so much
10
blood and, therefore, could have been saved.
The trial court also held that the non-availability of Dr. Tatad
after the operation on Maluluy-on was not a sufficient excuse
for the petitioners to not immediately operate on Raymond. It
called attention to the testimony of Dr. Tatad herself, which
disclosed the possibility of calling a standby anesthesiologist
in that situation. The trial court opined that the petitioners
could have just requested for the standby anesthesiologist
from Dr. Tatad, but they did not.
Lastly, the trial court faulted petitioners for the delay in the
transfusion of blood on Raymond.
care provider, in most cases a physician, either failed to
do something which a reasonably prudent health care
provider would have done, or that he or she did
something that a reasonably prudent provider would not
have done; and that the failure or action caused injury to
13
the patient. Stated otherwise, the complainant must prove:
(1) that the health care provider, either by his act or
omission, had been negligent, and (2) that such act or
omission proximately caused the injury complained of.

On appeal, the CA in a decision dated 21 February 2005

affirmed in toto the judgment rendered by the RTC finding
herein petitioners guilty of gross negligence in the
performance of their duties and awarding damages to private
respondents.
Hence, this petition for review on certiorari under Rule 45 of
the Rules of Court assailing the CA decision on the following
grounds:
1. THAT THE CA ERRED IN RULING THAT
PETITIONERS WERE GROSSLY NEGLIGENT IN
THE PERFORMANCE OF THEIR DUTIES;
The best way to prove these is through the opinions of
expert witnesses belonging in the same neighborhood and in
the same general line of practice as defendant physician or
surgeon. The deference of courts to the expert opinion of
qualified physicians stems from the former’s realization that
the latter possess unusual technical skills which laymen in
most instances are incapable of intelligently evaluating,
14
hence, the indispensability of expert testimonies.
Guided by the foregoing standards, We dissect the issues at
hand.
Petitioners Not Negligent

2. THAT THE CA ERRED IN NOT CONSIDERING

The trial court first imputed negligence on the part of the
THE BICOL REGIONAL MEDICAL CENTER AS
petitioners by their failure to perform the operation on
AN INDISPENSABLE PARTY AND
Raymond immediately after finishing the Maluluy-on
SUBSIDIARILY LIABLE SHOULD PETITIONERS
operation. It rejected as an excuse the nonavailability of Dr.
BE FOUND LIABLE FOR DAMAGES; and
Tatad. The trial court relied on the testimony of Dr. Tatad
about a "BRMC protocol" that introduces the possibility that
3. THAT THE CA ERRED IN NOT FINDING THE a standby anesthesiologist could have been called upon.
AWARD OF MORAL AND EXEMPLARY The pertinent portions of the testimony of Dr. Tatad provides:
DAMAGES AS WELL AS ATTORNEY’S FEES
EXORBITANT OR EXCESSIVE.
Q: Aside from you and Dr. Rebancos, who was the standby
anesthesiologist?
We grant the petition
A: We have a protocol at the Bicol Medical Center to have a
It is well-settled that under Rule 45 of the Rules of Court, consultant who is on call.
only questions of law may be raised. The reason behind this
is that this Court is not a trier of facts and will not re-examine
11 Q: How many of them?
and re-evaluate the evidence on record. Factual findings of
the CA, affirming that of the trial court, are therefore
generally final and conclusive on this Court. This rule is A: One.
subject to the following exceptions: (1) the conclusion is
grounded on speculations, surmises or conjectures; (2) the
Q: Who is she?
inference is manifestly mistaken, absurd or impossible; (3)
there is grave abuse of discretion; (4) the judgment is based
on a misapprehension of facts; (5) the findings of fact are A: Dra. Flores.
conflicting; (6) there is no citation of specific evidence on
which the factual findings are based; (7) the findings of
absence of fact are contradicted by the presence of Q: What is the first name?
evidence on record; (8) the findings of the CA are contrary to
those of the trial court; (9) the CA manifestly overlooked A: Rosalina Flores.
certain relevant and undisputed facts that, if properly
considered, would justify a different conclusion; (10) the
findings of the CA are beyond the issues of the case; and Q: Is she residing in Naga City?
(11) such findings are contrary to the admissions of both
12
parties. In this case, We find exceptions (1) and (4) to be A: In Camaligan.
applicable.
Q: She is on call anytime when there is an emergency case
The type of lawsuit which has been called medical to be attended to in the Bicol Medical Center?
malpractice or, more appropriately, medical negligence, is
that type of claim which a victim has available to him or her 15
to redress a wrong committed by a medical professional A: Yes sir.
which has caused bodily harm. In order to successfully
pursue such a claim, a patient must prove that a health Dr. Tatad further testified:
Q: Alright (sic), considering that you said you could not
attend to Raymond Olavere because another patient was
coming in the person of Lilia Aguila, did you not suggest to
Dr. Cereno to call the standby anesthesiologist?
A: They are not ones to do that. They have no right to call for
the standby anesthesiologist.
Q: Then, who should call for the standby anesthesiologist?
A: It is me if the surgeon requested.
Q: But in this case, the surgeon did not request you?
A: No. It is their prerogative.
Q: I just want to know that in this case the surgeon did not
request you to call for the standby anesthesiologist?
16
A: No sir.
From there, the trial court concluded that it was the duty of
the petitioners to request Dr. Tatad to call on Dr. Rosalina
Flores, the standby anesthesiologist. Since petitioners failed
to do so, their inability to promptly perform the operation on
Raymond becomes negligence on their part.
This Court does not agree with the aforesaid conclusion.
First. There is nothing in the testimony of Dr. Tatad, or in any
evidence on the record for that matter, which shows that the
petitioners were aware of the "BRMC protocol" that the
hospital keeps a standby anesthesiologist available on call.
Indeed, other than the testimony of Dr. Tatad, there is no
evidence that proves that any such "BRMC protocol" is being
practiced by the hospital’s surgeons at all.
Evidence to the effect that petitioners knew of the "BRMC
protocol" is essential, especially in view of the contrary
assertion of the petitioners that the matter of assigning
anesthesiologists rests within the full discretion of the BRMC
Anesthesiology Department. Without any prior knowledge of
the "BRMC protocol," We find that it is quite reasonable for
the petitioners to assume that matters regarding the
administration of anesthesia and the assignment of
anesthesiologists are concerns of the Anesthesiology
Department, while matters pertaining to the surgery itself fall
under the concern of the surgeons. Certainly, We cannot
hold petitioners accountable for not complying with
something that they, in the first place, do not know.
Second. Even assuming ex gratia argumenti that there is
such "BRMC protocol" and that petitioners knew about it, We
find that their failure to request for the assistance of the
standby anesthesiologist to be reasonable when taken in the
proper context. There is simply no competent evidence to
the contrary.
From the testimony of Dr. Tatad herself, it is clear that the
matter of requesting for a standby anaesthesiologist is not
within the full discretion of petitioners. The "BRMC protocol"
described in the testimony requires the petitioners to course
such request to Dr. Tatad who, as head of the Department of
Anesthesiology, has the final say of calling the standby
anesthesiologist.
As revealed by the facts, however, after the Maluluy-on
operation, Dr. Tatad was already assisting in the Lilia Aguila
operation. Drs. Zafe and Cereno then proceeded to examine
Raymond and they found that the latter’s blood pressure was
17
normal and "nothing in him was significant." Dr. Cereno
even concluded that based on the x-ray result he interpreted,
the fluid inside the thoracic cavity of Raymond was minimal
at around 200-300 cc. Such findings of Drs. Cereno and
Zafe were never challenged and were unrebutted.
Given that Dr. Tatad was already engaged in another urgent
operation and that Raymond was not showing any symptom
of suffering from major blood loss requiring an immediate
operation, We find it reasonable that petitioners decided to
wait for Dr. Tatad to finish her surgery and not to call the
standby anesthesiologist anymore. There is, after all, no
evidence that shows that a prudent surgeon faced with
similar circumstances would decide otherwise.
Here, there were no expert witnesses presented to testify
that the course of action taken by petitioners were not in
accord with those adopted by other reasonable surgeons in
similar situations. Neither was there any testimony given,
except that of Dr. Tatad’s, on which it may be inferred that
petitioners failed to exercise the standard of care, diligence,
learning and skill expected from practitioners of their
profession. Dr. Tatad, however, is an expert neither in the
field of surgery nor of surgical practices and diagnoses. Her
expertise is in the administration of anesthesia and not in the
determination of whether surgery ought or not ought to be
performed.
Another ground relied upon by the trial court in holding
petitioners negligent was their failure to immediately
transfuse blood on Raymond. Such failure allegedly led to
the eventual death of Raymond through "hypovolemic
shock." The trial court relied on the following testimony of Dr.
Tatad:
Q: In this case of Raymond Olavere was blood transfused to
him while he was inside the operating room?
A: The blood arrived at 1:40 a.m. and that was the time
when this blood was hooked to the patient.
xxxx
Q: Prior to the arrival of the blood, you did not request for
blood?
A: I requested for blood.
Q: From whom?
A: From the attending physician, Dr. Realuyo.
Q: What time was that?
xxxx
A: 9:30.
xxxx
Q: Had this blood been given to you before the operation
you could have transfused the blood to the patient?
A: Of course, yes.
Q: And the blood was transfused only after the operation?
A: Because that was the time when the blood was given to
us.
xxxx
Q: Have you monitored the condition of Raymond Olavere?
A: I monitored the condition during the time when I would
administer anesthesia.
Q: What time was that?
A: 11:45 already.
Q: What was the condition of the blood pressure at that
time?
A: 60/40 initial.
Q: With that kind of blood pressure the patient must have
been in critical condition?
A: At the time when the blood pressure was 60/40 I again
told Dr. Cereno that blood was already needed.
Q: With that condition, Doctor, that the patient had 60/40
blood pressure you did not decide on transfusing blood to
him?
A: I was asking for blood but there was no blood available.
Q: From whom did you ask?
A: From the surgeon. According to Dr. Zafe there was only
18
500 cc but still for cross-matching.
From the aforesaid testimony, the trial court ruled that there
was negligence on the part of petitioners for their failure to
have the blood ready for transfusion. It was alleged that at
11:15 P.M., the 500 cc of blood was given to Dr. Realuyo by
Raymond’s parents. At 11:45 P.M., when Dr. Tatad was
asking for the blood, 30 minutes had passed. Yet, the blood
was not ready for transfusion as it was still being cross-
19
matched. It took another two hours before blood was finally
transfused to Raymond at 1:40 A.M. of 17 September 1995.
Again, such is a mistaken conclusion.
First, the alleged delay in the cross-matching of the blood, if
there was any, cannot be attributed as the fault of the
petitioners. The petitioners were never shown to be
responsible for such delay. It is highly unreasonable and the
height of injustice if petitioners were to be sanctioned for
lapses in procedure that does not fall within their duties and
beyond their control.
Second, Dr. Cereno, in his unchallenged testimony, aptly
explained the apparent delay in the transfusion of blood on
Raymond before and during the operation.
Before the operation, Dr. Cereno explained that the reason
why no blood transfusion was made on Raymond was
because they did not then see the need to administer such
transfusion, viz:
Q: Now, you stated in your affidavit that prior to the operation
you were informed that there was 500 cc of blood available
and was still to be cross-matched. What time was that when
you were informed that 500 cc of blood was due for
crossmatching?
A: I am not sure of the time.
Q: But certainly, you learned of that fact that there was 500
cc of blood, which was due for crossmatching immediately
prior to the operation?
A: Yes, sir.
Q: And the operation was done at 12:15 of September 17?
A: Yes, sir.
Q: And that was the reason why you could not use the blood
because it was being crossmatched?
A: No, sir. That was done only for a few minutes. We did not
transfuse at that time because there was no need. There is
a necessity to transfuse blood when we saw there is
20
gross bleeding inside the body. (Emphasis supplied)
During the operation, on the other hand, Dr. Cereno was
already able to discover that 3,200 cc of blood was stocked
in the thoracic cavity of Raymond due to the puncture in the
latter’s left lung. Even then, however, immediate blood
transfusion was not feasible because:
Q: Now considering the loss of blood suffered by Raymund
Olavere, why did you not immediately transfuse blood to the
patient and you waited for 45 minutes to elapse before
transfusing the blood?
A: I did not transfuse blood because I had to control the
bleeders. If you will transfuse blood just the same the
blood that you transfuse will be lost. After evacuation of
blood and there is no more bleeding…
Q: It took you 45 minutes to evacuate the blood?
A: The evacuation did not take 45 minutes.
Q: So what was the cause of the delay why you only
transfuse blood after 45 minutes?
A: We have to look for some other lesions. It does not
mean that when you slice the chest you will see the
21
lesions already.
(Emphasis supplied)
Again, the foregoing testimonies of Dr. Cereno went
unchallenged or unrebutted. The parents of Raymond were
not able to present any expert witness to dispute the course
of action taken by the petitioners.
Causation Not Proven
In medical negligence cases, it is settled that the
complainant has the burden of establishing breach of duty
on the part of the doctors or surgeons. It must be proven that
such breach of duty has a causal connection to the resulting
22
death of the patient. A verdict in malpractice action cannot
be based on speculation or conjecture. Causation must be
proven within a reasonable medical probability based upon
competent expert testimony.
The parents of Raymond failed in this respect. Aside from
their failure to prove negligence on the part of the petitioners,
they also failed to prove that it was petitioners’ fault that
caused the injury. Their cause stands on the mere
assumption that Raymond’s life would have been saved had
petitioner surgeons immediately operated on him; had the
blood been cross-matched immediately and had the blood
been transfused immediately. There was, however, no proof
presented that Raymond’s life would have been saved had
those things been done. Those are mere assumptions and
cannot guarantee their desired result. Such cannot be made
basis of a decision in this case, especially considering that
the name, reputation and career of petitioners are at stake.
The Court understands the parents’ grief over their son’s
death.1âwphi1 That notwithstanding, it cannot hold
petitioners liable. It was noted that Raymond, who was a
victim of a stabbing incident, had multiple wounds when
brought to the hospital. Upon opening of his thoracic cavity,
it was discovered that there was gross bleeding inside the
body. Thus, the need for petitioners to control first what was
causing the bleeding. Despite the situation that evening i.e.
numerous patients being brought to the hospital for
emergency treatment considering that it was the height of
the Peñafrancia Fiesta, it was evident that petitioners
exerted earnest efforts to save the life of Raymond. It was
just unfortunate that the loss of his life was not prevented.
In the case of Dr. Cruz v. CA, it was held that "[d]octors are
protected by a special law. They are not guarantors of care.
They do not even warrant a good result. They are not
insurers against mishaps or unusual consequences.
Furthermore, they are not liable for honest mistake of
judgment…"
23
This Court affirms the ruling of the CA that the BRMC is not
an indispensible party. The core issue as agreed upon by
the parties and stated in the pre-trial order is whether
petitioners were negligent in the performance of their duties.
It pertains to acts/omissions of petitioners for which they
could be held liable. The cause of action against petitioners
may be prosecuted fully and the determination of their
liability may be arrived at without impleading the hospital
where they are employed. As such, the BRMC cannot be
considered an indispensible party without whom no final
24
determination can be had of an action.
IN THE LIGHT OF THE FOREGOING, the instant Petition
for Review on Certiorari is hereby GRANTED. The Court of
Appeals decision dated 21 February 2005 in CA-G.R. CV
No. 65800 is hereby REVERSED and SET ASIDE. No costs.
SO ORDERED.
G.R. No. 212054
ST. LUKE'S MEDICAL CENTER, INC. vs.
MARIA THERESA V. SANCHEZ
1
Assailed in this petition for review on certiorari are the
2
Decision dated November 21, 2013 and the
3
Resolution dated April 4, 2014 of the Court of Appeals (CA)
in CA-G.R. SP No. 129108 which affirmed the
4
Decision dated November 19, 2012 and the
5
Resolution dated January 14, 2013 of the National Labor
Relations Commission (NLRC) in NLRC LAC No. 06-
001858-12, declaring the dismissal of respondent Maria
Theresa V. Sanchez (Sanchez) illegal.
The Facts
On June 29, 2009, Sanchez was hired by petitioner St.
Luke's Medical Center, Inc. (SLMC) as a Staff Nurse, and
was eventually assigned at SLMC, Quezon City's Pediatric
Unit until her termination on July 6, 2011 for her purported
violation of SLMC's Code of Discipline, particularly Section 1,
Rule 1 on Acts of Dishonesty, i.e., Robbery, Theft, Pilferage,
6
and Misappropriation of Funds.
Records reveal that at the end of her shift on May 29, 2011,
Sanchez passed through the SLMC Centralization
Entrance/Exit where she was subjected to the standard
inspection procedure by the security personnel. In the
course thereof, the Security Guard on-duty, Jaime
Manzanade (SG Manzanade), noticed a pouch in her bag
7
and asked her to open the same. When opened, said pouch
contained the following assortment of medical stocks which
were subsequently confiscated: (a) Syringe 10cl [4 pieces];
(b) Syringe 5cl [3 pieces]; (c) Syringe 3cl [3 pieces]; (d)
Micropore [1 piece]; (e) Cotton Balls [1 pack]; (f) Neoflon g26
[1 piece]; (g) Venofix 25 [2 pieces]; and (h) Gloves [4 pieces]
8
(questioned items). Sanchez asked SG Manzanade if she
could just return the pouch inside the treatment room;
9
however, she was not allowed to do so. Instead, she was
brought to the SLMC In-House Security Department (IHSD)
where she was directed to write an Incident Report
explaining why she had the questioned items in her
10 11
possession. She complied with the directive and also
submitted an undated handwritten letter of
12
apology (handwritten letter) which reads as follows:
To In-House Security,

I am very sorry for bringing things from [SLMC] inside my
bag.
Pasensya na po. Taos-puso po akong humihingi ng tawad
sa aking pagkakasala, Alam ko po na ako ay nagkamali.
Hindi ko po dapat dinala yung mga gamit sa hospital. Hindi
ko po alam kung [paano] ako magsisimulang humingi ng
patawad. Kahit alam kong bawal ay nagawa kong makapag
uwi ng gamit. Marami pang gamit dahil sa naipon po. Paisa-
isa nagagawa kong makakuha pag nakakalimutan kong isoli.
Hindi ko na po naiwan sa nurse station dahil naisip kong
magagamit ko rin po pag minsang nagkakaubusan ng stocks
at talagang may kailangan.
Humihingi po ako ng tawad sa aking ginawa. Isinakripisyo ko
ang hindi pagiging "toxic" sa pagkuha ng gamit para sa
bagay na alam kong mali. Inaamin ko na ako'y naging
madamot, pasuway at makasalanan. Inuna ko ang comfort
ko keysa gumawa ng tama. Manikluhod po akong humihingi
ng tawad.
13
Sorry po. Sorry po. Sorry po talaga.
14
In a memorandum of even date, the IHSD, Customer
Affairs Division, through Duty Officer Hernani R. Janayon,
apprised SLMC of the incident, highlighting that Sanchez
expressly admitted that she intentionally brought out the
questioned items.1awp++i1
An initial investigation was also conducted by the SLMC
15
Division of Nursing which thereafter served Sanchez a
16
notice to explain.
On May 31, 2011, Sanchez submitted an Incident Report
17
Addendum (May 31, 2011 letter), explaining that the
questioned items came from the medication drawers of
patients who had already been discharged, and, as similarly
practiced by the other staff members, she started saving
these items as excess stocks in her pouch, along with other
18
basic items that she uses during her shift. She then put the
pouch inside the lowest drawer of the bedside table in the
treatment room for use in immediate procedures in case
replenishment of stocks gets delayed. However, on the day
of the incident, she failed to return the pouch inside the
medication drawer upon getting her tri-colored pen and
calculator and, instead, placed it inside her bag. Eventually,
she forgot about the same as she got caught up in work,
until it was noticed by the guard on duty on her way out of
SMLC's premises.
Consequently, Sanchez was placed under preventive
suspension effective June 3, 2011 until the conclusion of the
investigation by SLMC's Employee and Labor Relations
19
Department (ELRD) which, thereafter, required her to
explain why she should not be terminated from service for
"acts of dishonesty" due to her possession of the questioned
items in violation of Section 1, Rule I of the SLMC Code of
20 21
Discipline. In response, she submitted a letter dated June
13, 2011, which merely reiterated her claims in her previous
May 31, 2011 letter. She likewise requested for a case
22 23
conference, which SLMC granted. After hearing her side,
SLMC, on July 4, 2011, informed Sanchez of its decision to
terminate her employment effective closing hours of July 6,
24
2011. This prompted her to file a complaint for illegal
dismissal before the NLRC, docketed as NLRC NCR Case
No. 07-11042-11.
25
In her position paper, Sanchez maintained her innocence,
claiming that she had no intention of bringing outside the
SLMC's premises the questioned items since she merely
inadvertently left the pouch containing them in her bag as
she got caught up in work that day. She further asserted that
she could not be found guilty of pilferage since the
questioned items found in her possession were neither
SLMC's nor its employees' property. She also stressed the
fact that SLMC did not file any criminal charges against her.
Anent her supposed admission in her handwritten letter, she
claimed that she was unassisted by counsel when she
executed the same and, thus, was inadmissible for being
26
unconstitutional.
27
For its part, SLMC contended that Sanchez was validly
dismissed for just cause as she had committed theft in
28
violation of Section 1, Rule I of the SLMC Code of
29
Discipline, which punishes acts of dishonesty, i.e., robbery,
theft, pilferage, and misappropriation of funds, with
termination from service.
The LA Ruling
30
In a Decision dated May 27, 2012, the Labor Arbiter (LA)
31
ruled that Sanchez was validly dismissed for intentionally
taking the property of SLMC's clients for her own personal
32
benefit, which constitutes an act of dishonesty as provided
under SLMC's Code of Discipline.
According to the LA, Sanchez's act of theft was evinced by
her attempt to bring the questioned items that did not belong
to her out of SLMC's premises; this was found to be
analogous to serious misconduct which is a just cause to
33
dismiss her. The fact that the items she took were neither
SLMC's nor her co-employees' property was not found by
the LA to be material since the SLMC Code of Discipline
clearly provides that acts of dishonesty committed to SLMC,
its doctors, its employees, as well as its customers, are
34
punishable by a penalty of termination from service. To
this, the LA opined that "[i]t is rather illogical to distinguish
the persons with whom the [said] acts may be committed as
SLMC is also answerable to the properties of its
35
patients." Moreover, the LA observed that Sanchez was
aware of SLMC's strict policy regarding the taking of
hospital/medical items as evidenced by her handwritten
36
letter, but nonetheless committed the said misconduct.
Finally, the LA pointed out that SLMC's non-filing of a
criminal case against Sanchez did not preclude a
determination of her serious misconduct, considering that
the filing of a criminal case is entirely separate and distinct
from the determination of just cause for termination of
37
employment.
38
Aggrieved, Sanchez appealed to the NLRC.
The NLRC Ruling
39
In a Decision dated November 19, 2012, the NLRC
reversed and set aside the LA ruling, and held that Sanchez
was illegally dismissed.
The NLRC declared that the alleged violation of Sanchez
was a unique case, considering that keeping excess hospital
stocks or "hoarding" was an admitted practice amongst
nurses in the Pediatric Unit which had been tolerated by
40
SLMC management for a long time. The NLRC held that
while Sanchez expressed remorse for her misconduct in her
handwritten letter, she manifested that she only "hoarded"
the questioned items for future use in case their medical
41
supplies are depleted, and not for her personal benefit. It
further held that SLMC failed to establish that Sanchez was
motivated by ill-will when she brought out the questioned
items, noting: (a) the testimony of SG Manzanade during the
conference before the ELRD of Sanchez's demeanor when
she was apprehended, i.e., "[d]i naman siya masyado
42
nataranta," and her consequent offer to return the
43
pouch; and (b) that the said pouch was not hidden
44
underneath the bag. Finally, the NLRC concluded that the
punishment of dismissal was too harsh and the one
(1) month preventive suspension already imposed
on and served by Sanchez was the appropriate
45
penalty. Accordingly, the NLRC ordered her
reinstatement, and the payment of backwages,
46
other benefits, and attorney's fees.
47
Unconvinced, SLMC moved for reconsideration which was,
48
however, denied in a Resolution dated January 14, 2013.
49
Thus, it filed a petition for certiorari before the CA.
The CA Ruling
50
In a Decision dated November 21, 2013, the CA upheld the
NLRC, ruling that the latter did not gravely abuse its
discretion in finding that Sanchez was illegally dismissed.
It ruled that Sanchez's offense did not qualify as serious
misconduct, given that: (a) the questioned items found in her
possession were not SLMC property since said items were
paid for by discharged patients, thus discounting any
material or economic damage on SLMC's part; (b) the
retention of excess medical supplies was an admitted
practice amongst nurses in the Pediatric Unit which was
tolerated by SLMC; (c) it was illogical for Sanchez to leave
the pouch in her bag since she would be subjected to a
routine inspection; (d) Sanchez's lack of intention to bring out
the pouch was manifested by her composed demeanor upon
apprehension and offer to return the pouch to the treatment
room; and (e) had SLMC honestly believed that Sanchez
committed theft or pilferage, it should have filed the
51
appropriate criminal case, but failed to do so. Moreover,
while the CA recognized that SLMC had the management
prerogative to discipline its erring employees, it, however,
declared that such right must be exercised humanely. As
such, SLMC should only impose penalties commensurate
with the degree of infraction. Considering that there was no
indication that Sanchez's actions were perpetrated for self-
interest or for an unlawful objective, the penalty of dismissal
imposed on her was grossly oppressive and disproportionate
52
to her offense.
53
Dissatisfied, SLMC sought for reconsideration, but was
denied in a Resolution54 dated April 4, 2014, hence, this
petition.
The Issue Before the Court
The core issue to be resolved is whether or not Sanchez
was illegally dismissed by SLMC.
The Court's Ruling
The petition is meritorious.
The right of an employer to regulate all aspects of
employment, aptly called "management prerogative," gives
employers the freedom to regulate, according to their
discretion and best judgment, all aspects of employment,
including work assignment, working methods, processes to
be followed, working regulations, transfer of employees,
work supervision, lay-off of workers and the discipline,
55
dismissal and recall of workers. In this light, courts often
decline to interfere in legitimate business decisions of
employers. In fact, labor laws discourage interference in
employers' judgment concerning the conduct of their
56
business.
Among the employer's management prerogatives is the right
to prescribe reasonable rules and regulations necessary or
proper for the conduct of its business or concern, to provide
certain disciplinary measures to implement said rules and to
assure that the same would be complied with. At the same
time, the employee has the corollary duty to obey all
reasonable rules, orders, and instructions of the employer;
and willful or intentional disobedience thereto, as a general
rule, justifies termination of the contract of service and the
57
dismissal of the employee. Article 296 (formerly Article
58
282) of the Labor Code provides:
Article 296. Termination by Employer. - An employer may
terminate an employment for any of the following causes:
(a) Serious misconduct or willful disobedience by the
employee of the lawful orders of his employer or his
representative in connection with his work;
xxxx
Note that for an employee to be validly dismissed on this
ground, the employer's orders, regulations, or instructions
must be: (1) reasonable and lawful, (2) sufficiently known to
the employee, and (3) in connection with the duties which
59
the employee has been engaged to discharge."
Tested against the foregoing, the Court finds that Sanchez
was validly dismissed by SLMC for her willful disregard and
disobedience of Section 1, Rule I of the SLMC Code of
Discipline, which reasonably punishes acts of dishonesty,
i.e., "theft, pilferage of hospital or co-employee property, x x
x or its attempt in any form or manner from the hospital, co-
employees, doctors, visitors, [and] customers (external and
60
internal)" with termination from employment. Such act is
obviously connected with Sanchez's work, who, as a staff
nurse, is tasked with the proper stewardship of medical
supplies. Significantly, records show that Sanchez made a
61 62
categorical admission in her handwritten letter - i.e.,
"[k]ahit alam kong bawal ay nagawa kong [makapag-uwi] ng
63
gamit" - that despite her knowledge of its express
prohibition under the SLMC Code of Discipline, she still
knowingly brought out the subject medical items with her. It
is apt to clarify that SLMC cannot be faulted in construing the
taking of the questioned items as an act of dishonesty
(particularly, as theft, pilferage, or its attempt in any form or
manner) considering that the intent to gain may be
reasonably presumed from the furtive taking of useful
64
property appertaining to another. Note that Section 1, Rule
1 of the SLMC Code of Discipline is further supplemented by
the company policy requiring the turn-over of excess medical
 65
supplies/items for proper handling and providing a G.R. No. 130547 October 3, 2000
restriction on taking and bringing such items out of the
SLMC premises without the proper authorization or "pass"
66 LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and
from the official concerned, which Sanchez was equally
67 minors LLOYD and KRISTINE, all surnamed REYES,
aware thereof. Nevertheless, Sanchez failed to turn-over
represented by their mother, LEAH ALESNA REYES
the questioned items and, instead, "hoarded" them, as
vs.
purportedly practiced by the other staff members in the
SISTERS OF MERCY HOSPITAL, SISTER ROSE
Pediatric Unit. As it is clear that the company policies subject
PALACIO, DR. MARVIE BLANES, and DR. MARLYN
of this case are reasonable and lawful, sufficiently known to
RICO.
the employee, and evidently connected with the latter's work,
the Court concludes that SLMC dismissed Sanchez for a just
1
cause. This is a petition for review of the decision of the Court of
Appeals in CA-G.R. CV No. 36551 affirming the decision of
the Regional Trial Court, Branch IX, Cebu City which
On a related point, the Court observes that there lies no
dismissed a complaint for damages filed by petitioners
competent basis to support the common observation of the
against respondents.
NLRC and the CA that the retention of excess medical
supplies was a tolerated practice among the nurses at the
Pediatric Unit. While there were previous incidents of The facts are as follows:
"hoarding," it appears that such acts were - in similar fashion
- furtively made and the items secretly kept, as any excess
Petitioner Leah Alesna Reyes is the wife of the late Jorge
items found in the concerned nurse's possession would have
68 Reyes. The other petitioners, namely, Rose Nahdja, Johnny,
to be confiscated. Hence, the fact that no one was caught
and/or sanctioned for transgressing the prohibition therefor Lloyd, and Kristine, all surnamed Reyes, were their children.
Five days before his death on January 8, 1987, Jorge had
does not mean that the so-called "hoarding" practice was
been suffering from a recurring fever with chills. After he
tolerated by SLMC. Besides, whatever maybe the
justification behind the violation of the company rules failed to get relief from some home medication he was
taking, which consisted of analgesic, antipyretic, and
regarding excess medical supplies is immaterial since it has
antibiotics, he decided to see the doctor.
been established that an infraction was deliberately
69
committed. Doubtless, the deliberate disregard or
disobedience of rules by the employee cannot be On January 8, 1987, he was taken to the Mercy Community
countenanced as it may encourage him or her to do even Clinic by his wife. He was attended to by respondent Dr.
worse and will render a mockery of the rules of discipline Marlyn Rico, resident physician and admitting physician on
70
that employees are required to observe. duty, who gave Jorge a physical examination and took his
medical history. She noted that at the time of his admission,
Finally, the Court finds it inconsequential that SLMC has not Jorge was conscious, ambulatory, oriented, coherent, and
2
with respiratory distress. Typhoid fever was then prevalent
suffered any actual damage. While damage aggravates the
in the locality, as the clinic had been getting from 15 to 20
charge, its absence does not mitigate nor negate the 3
71
employee's liability. Neither is SLMC's non- filing of the cases of typhoid per month. Suspecting that Jorge could be
suffering from this disease, Dr. Rico ordered a Widal Test, a
appropriate criminal charges relevant to this analysis. An
standard test for typhoid fever, to be performed on Jorge.
employee's guilt or innocence in a criminal case is not
determinative of the existence of a just or authorized cause Blood count, routine urinalysis, stool examination, and
4
72 malarial smear were also made. After about an hour, the
for his or her dismissal. It is well- settled that conviction in a
medical technician submitted the results of the test from
criminal case is not necessary to find just cause for
73
termination of employment, as in this case. Criminal and which Dr. Rico concluded that Jorge was positive for typhoid
fever. As her shift was only up to 5:00 p.m., Dr. Rico
labor cases involving an employee arising from the same
indorsed Jorge to respondent Dr. Marvie Blanes.
infraction are separate and distinct proceedings which
should not arrest any judgment from one to the other.
Dr. Marvie Blanes attended to Jorge at around six in the
evening. She also took Jorge’s history and gave him a
As it stands, the Court thus holds that the dismissal of
Sanchez was for a just cause, supported by substantial physical examination. Like Dr. Rico, her impression was that
Jorge had typhoid fever. Antibiotics being the accepted
evidence, and is therefore in order. By declaring otherwise,
treatment for typhoid fever, she ordered that a compatibility
bereft of any substantial bases, the NLRC issued a patently
and grossly erroneous ruling tantamount to grave abuse of test with the antibiotic chloromycetin be done on Jorge. Said
test was administered by nurse Josephine Pagente who also
discretion, which, in turn, means that the CA erred when it
gave the patient a dose of triglobe. As she did not observe
affirmed the same. In consequence, the grant of the present
petition is warranted. any adverse reaction by the patient to chloromycetin, Dr.
Blanes ordered the first five hundred milligrams of said
antibiotic to be administered on Jorge at around 9:00 p.m. A
WHEREFORE, the petition is GRANTED. The Decision second dose was administered on Jorge about three hours
dated November 21, 2013 and the Resolution dated April 4, later just before midnight.
2014 of the Court of Appeals in CA-G.R. SP No. 129108 are
REVERSED and SET ASIDE. The Labor Arbiter's Decision
At around 1:00 a.m. of January 9, 1987, Dr. Blanes was
dated May 27, 2012 in NLRC Case No. NCR 07-11042-11
finding respondent Maria Theresa V. Sanchez to have been called as Jorge’s temperature rose to 41°C. The patient also
experienced chills and exhibited respiratory distress,
validly dismissed by petitioner St. Luke's Medical Center,
nausea, vomiting, and convulsions. Dr. Blanes put him under
Inc. is hereby REINSTATED.
oxygen, used a suction machine, and administered
hydrocortisone, temporarily easing the patient’s convulsions.
SO ORDERED. When he regained consciousness, the patient was asked by
Dr. Blanes whether he had a previous heart ailment or had
suffered from chest pains in the past. Jorge replied he did
5
not. After about 15 minutes, however, Jorge again started to
vomit, showed restlessness, and his convulsions returned.
Dr. Blanes re-applied the emergency measures taken before
and, in addition, valium was administered. Jorge, however,
did not respond to the treatment and slipped into cyanosis, a
bluish or purplish discoloration of the skin or mucous
membrane due to deficient oxygenation of the blood. At
around 2:00 a.m., Jorge died. He was forty years old. The
cause of his death was "Ventricular Arrythemia Secondary to
Hyperpyrexia and typhoid fever."
On June 3, 1987, petitioners filed before the Regional Trial
6
Court of Cebu City a complaint for damages against
respondents Sisters of Mercy, Sister Rose Palacio, Dr.
Marvie Blanes, Dr. Marlyn Rico, and nurse Josephine
Pagente. On September 24, 1987, petitioners amended their
complaint to implead respondent Mercy Community Clinic as
additional defendant and to drop the name of Josephine
Pagente as defendant since she was no longer connected
with respondent hospital. Their principal contention was that
7
Jorge did not die of typhoid fever. Instead, his death was
due to the wrongful administration of chloromycetin. They
contended that had respondent doctors exercised due care
and diligence, they would not have recommended and
rushed the performance of the Widal Test, hastily concluded
that Jorge was suffering from typhoid fever, and
administered chloromycetin without first conducting sufficient
tests on the patient’s compatibility with said drug. They
charged respondent clinic and its directress, Sister Rose
Palacio, with negligence in failing to provide adequate
8
facilities and in hiring negligent doctors and nurses.
Respondents denied the charges. During the pre-trial
conference, the parties agreed to limit the issues on the
following: (1) whether the death of Jorge Reyes was due to
or caused by the negligence, carelessness, imprudence, and
lack of skill or foresight on the part of defendants; (2)
whether respondent Mercy Community Clinic was negligent
in the hiring of its employees; and (3) whether either party
was entitled to damages. The case was then heard by the
trial court during which, in addition to the testimonies of the
parties, the testimonies of doctors as expert witnesses were
presented.
Petitioners offered the testimony of Dr. Apolinar Vacalares,
Chief Pathologist at the Northern Mindanao Training
Hospital, Cagayan de Oro City. On January 9, 1987, Dr.
Vacalares performed an autopsy on Jorge Reyes to
determine the cause of his death. However, he did not open
9
the skull to examine the brain. His findings showed that the
gastro-intestinal tract was normal and without any ulceration
or enlargement of the nodules. Dr. Vacalares testified that
Jorge did not die of typhoid fever. He also stated that he had
not seen a patient die of typhoid fever within five days from
the onset of the disease.
For their part, respondents offered the testimonies of Dr.
Peter Gotiong and Dr. Ibarra Panopio. Dr. Gotiong is a
diplomate in internal medicine whose expertise is
microbiology and infectious diseases. He is also a consultant
at the Cebu City Medical Center and an associate professor
of medicine at the South Western University College of
Medicine in Cebu City. He had treated over a thousand
cases of typhoid patients. According to Dr. Gotiong, the
patient’s history and positive Widal Test results ratio of 1:320
would make him suspect that the patient had typhoid fever.
As to Dr. Vacalares’ observation regarding the absence of
ulceration in Jorge’s gastro-intestinal tract, Dr. Gotiong said
that such hyperplasia in the intestines of a typhoid victim
may be microscopic. He noted that since the toxic effect of
typhoid fever may lead to meningitis, Dr. Vacalares’ autopsy
10
should have included an examination of the brain.
The other doctor presented was Dr. Ibarra Panopio, a
member of the American Board of Pathology, examiner of
the Philippine Board of Pathology from 1978 to 1991, fellow
of the Philippine Society of Pathologist, associate professor
of the Cebu Institute of Medicine, and chief pathologist of the
Andres Soriano Jr. Memorial Hospital in Toledo City. Dr.
Panopio stated that although he was partial to the use of the
culture test for its greater reliability in the diagnosis of
typhoid fever, the Widal Test may also be used. Like Dr.
Gotiong, he agreed that the 1:320 ratio in Jorge’s case was
already the maximum by which a conclusion of typhoid fever
may be made. No additional information may be deduced
11
from a higher dilution. He said that Dr. Vacalares’ autopsy
on Jorge was incomplete and thus inconclusive.
On September 12, 1991, the trial court rendered its decision
absolving respondents from the charges of negligence and
dismissing petitioners’ action for damages. The trial court
likewise dismissed respondents’ counterclaim, holding that,
in seeking damages from respondents, petitioners were
impelled by the honest belief that Jorge’s death was due to
the latter’s negligence.
Petitioners brought the matter to the Court of Appeals. On
July 31, 1997, the Court of Appeals affirmed the decision of
the trial court.
Hence this petition.
Petitioners raise the following assignment of errors:
I. THE HONORABLE COURT OF APPEALS
COMMITTED A REVERSIBLE ERROR WHEN IT
RULED THAT THE DOCTRINE OF RES IPSA
LOQUITUR IS NOT APPLICABLE IN THE
INSTANT CASE.
II. THE HONORABLE COURT OF APPEALS
COMMITTED REVERSIBLE ERROR WHEN IT
MADE AN UNFOUNDED ASSUMPTION THAT
THE LEVEL OF MEDICAL PRACTICE IS LOWER
IN ILIGAN CITY.
III. THE HONORABLE COURT OF APPEALS
GRAVELY ERRED WHEN IT RULED FOR A
LESSER STANDARD OF CARE AND DEGREE
OF DILIGENCE FOR MEDICAL PRACTICE IN
ILIGAN CITY WHEN IT APPRECIATE[D] NO
DOCTOR’S NEGLIGENCE IN THE TREATMENT
OF JORGE REYES.
Petitioner’s action is for medical malpractice. This is a
particular form of negligence which consists in the failure of
a physician or surgeon to apply to his practice of medicine
that degree of care and skill which is ordinarily employed by
the profession generally, under similar conditions, and in like
12
surrounding circumstances. In order to successfully pursue
such a claim, a patient must prove that the physician or
surgeon either failed to do something which a reasonably
prudent physician or surgeon would have done, or that he or
she did something that a reasonably prudent physician or
surgeon would not have done, and that the failure or action
13
caused injury to the patient. There are thus four elements
involved in medical negligence cases, namely: duty, breach,
injury, and proximate causation.
In the present case, there is no doubt that a physician-
patient relationship existed between respondent doctors and
Jorge Reyes. Respondents were thus duty-bound to use at
least the same level of care that any reasonably competent
doctor would use to treat a condition under the same
circumstances. It is breach of this duty which constitutes
14
actionable malpractice. As to this aspect of medical
malpractice, the determination of the reasonable level of
care and the breach thereof, expert testimony is essential.
Inasmuch as the causes of the injuries involved in
malpractice actions are determinable only in the light of
scientific knowledge, it has been recognized that expert
testimony is usually necessary to support the conclusion as
15
to causation.
Res Ipsa Loquitur
There is a case when expert testimony may be dispensed
with, and that is under the doctrine of res ipsa loquitur. As
16
held in Ramos v. Court of Appeals:
Although generally, expert medical testimony is relied upon
in malpractice suits to prove that a physician has done a
negligent act or that he has deviated from the standard
medical procedure, when the doctrine of res ipsa loquitor is
availed by the plaintiff, the need for expert medical testimony
is dispensed with because the injury itself provides the proof
of negligence. The reason is that the general rule on the
necessity of expert testimony applies only to such matters
clearly within the domain of medical science, and not to
matters that are within the common knowledge of mankind
which may be testified to by anyone familiar with the
facts. Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient
has been treated or operated upon with a reasonable degree
of skill and care. However, testimony as to the statements
and acts of physicians and surgeons, external appearances,
and manifest conditions which are observable by any one
may be given by non-expert witnesses. Hence, in cases
where the res ipsa loquitur is applicable, the court is
permitted to find a physician negligent upon proper proof of
injury to the patient, without the aid of expert testimony,
where the court from its fund of common knowledge can
determine the proper standard of care. Where common
knowledge and experience teach that a resulting injury
would not have occurred to the patient if due care had been
exercised, an inference of negligence may be drawn giving
rise to an application of the doctrine of res ipsa
loquitur without medical evidence, which is ordinarily
required to show not only what occurred but how and why it
occurred. When the doctrine is appropriate, all that the
patient must do is prove a nexus between the particular act
or omission complained of and the injury sustained while
under the custody and management of the defendant without
need to produce expert medical testimony to establish the
standard of care. Resort to res ipsa loquitor is allowed
because there is no other way, under usual and ordinary
conditions, by which the patient can obtain redress for injury
suffered by him.
Thus, courts of other jurisdictions have applied the doctrine
in the following situations: leaving of a foreign object in the
body of the patient after an operation, injuries sustained on a
healthy part of the body which was not under, or in the area,
of treatment, removal of the wrong part of the body when
another part was intended, knocking out a tooth while a
patient’s jaw was under anesthetic for the removal of his
tonsils, and loss of an eye while the patient was under the
influence of anesthetic, during or following an operation for
17
appendicitis, among others.
Petitioners asserted in the Court of Appeals that the doctrine
of res ipsa loquitur applies to the present case because
Jorge Reyes was merely experiencing fever and chills for
five days and was fully conscious, coherent, and ambulant
when he went to the hospital. Yet, he died after only ten
hours from the time of his admission.
This contention was rejected by the appellate court.
Petitioners now contend that all requisites for the application
of res ipsa loquitur were present, namely: (1) the accident
was of a kind which does not ordinarily occur unless
someone is negligent; (2) the instrumentality or agency
which caused the injury was under the exclusive control of
the person in charge; and (3) the injury suffered must not
have been due to any voluntary action or contribution of the
18
person injured.
The contention is without merit. We agree with the ruling of
the Court of Appeals. In the Ramos case, the question was
whether a surgeon, an anesthesiologist, and a hospital
should be made liable for the comatose condition of a patient
19
scheduled for cholecystectomy. In that case, the patient
was given anesthesia prior to her operation. Noting that the
patient was neurologically sound at the time of her operation,
the Court applied the doctrine of res ipsa loquitur as mental
brain damage does not normally occur in a gallblader
operation in the absence of negligence of the
anesthesiologist. Taking judicial notice that anesthesia
procedures had become so common that even an ordinary
person could tell if it was administered properly, we allowed
the testimony of a witness who was not an expert. In this
case, while it is true that the patient died just a few hours
after professional medical assistance was rendered, there is
really nothing unusual or extraordinary about his death. Prior
to his admission, the patient already had recurring fevers
and chills for five days unrelieved by the analgesic,
antipyretic, and antibiotics given him by his wife. This shows
that he had been suffering from a serious illness and
professional medical help came too late for him.
Respondents alleged failure to observe due care was not
immediately apparent to a layman so as to justify application
of res ipsa loquitur. The question required expert opinion on
the alleged breach by respondents of the standard of care
required by the circumstances. Furthermore, on the issue of
the correctness of her diagnosis, no presumption of
negligence can be applied to Dr. Marlyn Rico.As held
in Ramos:
. . . . Res ipsa loquitur is not a rigid or ordinary doctrine to be
perfunctorily used but a rule to be cautiously applied,
depending upon the circumstances of each case. It is
generally restricted to situations in malpractice cases where
a layman is able to say, as a matter of common knowledge
and observation, that the consequences of professional care
were not as such as would ordinarily have followed if due
care had been exercised. A distinction must be made
between the failure to secure results, and the occurrence of
something more unusual and not ordinarily found if the
service or treatment rendered followed the usual procedure
of those skilled in that particular practice. It must be
conceded that the doctrine of res ipsa loquitur can have no
application in a suit against a physician or a surgeon which
involves the merits of a diagnosis or of a scientific treatment.
The physician or surgeon is not required at his peril to
explain why any particular diagnosis was not correct, or why
any particular scientific treatment did not produce the
20
desired result.
Specific Acts of Negligence
We turn to the question whether petitioners have established
specific acts of negligence allegedly committed by
respondent doctors.
Petitioners contend that: (1) Dr. Marlyn Rico hastily and
erroneously relied upon the Widal test, diagnosed Jorge’s
illness as typhoid fever, and immediately prescribed the
21
administration of the antibiotic chloromycetin; and (2) Dr.
Marvie Blanes erred in ordering the administration of the
second dose of 500 milligrams of chloromycetin barely three
22
hours after the first was given. Petitioners presented the
testimony of Dr. Apolinar Vacalares, Chief Pathologist of the
Northern Mindanao Training Hospital, Cagayan de Oro City,
who performed an autopsy on the body of Jorge Reyes. Dr.
Vacalares testified that, based on his findings during the
autopsy, Jorge Reyes did not die of typhoid fever but of
shock undetermined, which could be due to allergic reaction
or chloromycetin overdose. We are not persuaded.
First. While petitioners presented Dr. Apolinar Vacalares as
an expert witness, we do not find him to be so as he is not a
specialist on infectious diseases like typhoid fever.
Furthermore, although he may have had extensive
experience in performing autopsies, he admitted that he had
yet to do one on the body of a typhoid victim at the time he
conducted the postmortem on Jorge Reyes. It is also plain
from his testimony that he has treated only about three
23
cases of typhoid fever. Thus, he testified that:
ATTY. PASCUAL:
Q Why? Have you not testified earlier that you have never
seen a patient who died of typhoid fever?
A In autopsy. But, that was when I was a resident physician
yet.
Q But you have not performed an autopsy of a patient who
died of typhoid fever?
A I have not seen one.
Q And you testified that you have never seen a patient who
died of typhoid fever within five days?
A I have not seen one.
Q How many typhoid fever cases had you seen while you
were in the general practice of medicine?
A In our case we had no widal test that time so we cannot
consider that the typhoid fever is like this and like that. And
the widal test does not specify the time of the typhoid fever.
Q The question is: how many typhoid fever cases had you
seen in your general practice regardless of the cases now
you practice?
A I had only seen three cases.
Q And that was way back in 1964?
A Way back after my training in UP.
Q Clinically?
A Way back before my training.
He is thus not qualified to prove that Dr. Marlyn Rico erred in
her diagnosis. Both lower courts were therefore correct in
discarding his testimony, which is really inadmissible.
In Ramos, the defendants presented the testimony of a
pulmonologist to prove that brain injury was due to oxygen
24
deprivation after the patient had bronchospasms triggered
25
by her allergic response to a drug, and not due to faulty
intubation by the anesthesiologist. As the issue was whether
the intubation was properly performed by an
anesthesiologist, we rejected the opinion of the
pulmonologist on the ground that he was not: (1) an
anesthesiologist who could enlighten the court about
anesthesia practice, procedure, and their complications; nor
(2) an allergologist who could properly advance expert
opinion on allergic mediated processes; nor (3) a
pharmacologist who could explain the pharmacologic and
toxic effects of the drug allegedly responsible for the
bronchospasms.
Second. On the other hand, the two doctors presented by
respondents clearly were experts on the subject. They
vouched for the correctness of Dr. Marlyn Rico’s diagnosis.
Dr. Peter Gotiong, a diplomate whose specialization is
infectious diseases and microbiology and an associate
professor at the Southwestern University College of
Medicine and the Gullas College of Medicine, testified that
he has already treated over a thousand cases of typhoid
26
fever. According to him, when a case of typhoid fever is
27
suspected, the Widal test is normally used, and if the 1:320
results of the Widal test on Jorge Reyes had been presented
to him along with the patient’s history, his impression would
28
also be that the patient was suffering from typhoid fever. As
to the treatment of the disease, he stated that chloromycetin
29
was the drug of choice. He also explained that despite the
measures taken by respondent doctors and the intravenous
administration of two doses of chloromycetin, complications
of the disease could not be discounted. His testimony is as
30
follows:
ATTY. PASCUAL:

Q If with that count with the test of positive for 1 is to 320,
what treatment if any would be given?
A If those are the findings that would be presented to me,
the first thing I would consider would be typhoid fever.
Q And presently what are the treatments commonly used?
A Drug of choice of chloramphenical.
Q Doctor, if given the same patient and after you have
administered chloramphenical about 3 1/2 hours later, the
o
patient associated with chills, temperature - 41 C, what could
possibly come to your mind?
A Well, when it is change in the clinical finding, you have to
think of complication.
Q And what will you consider on the complication of typhoid?
A One must first understand that typhoid fever is toximia.
The problem is complications are caused by toxins produced
by the bacteria . . . whether you have suffered complications
to think of -- heart toxic myocardities; then you can consider
a toxic meningitis and other complications and perforations
and bleeding in the ilium.
Q Even that 40-year old married patient who received
medication of chloromycetin of 500 milligrams intravenous,
after the skin test, and received a second dose of
chloromycetin of 500 miligrams, 3 hours later, the patient
o
developed chills . . . rise in temperature to 41 C, and then
o
about 40 minutes later the temperature rose to 100 F,
cardiac rate of 150 per minute who appeared to be coherent,
restless, nauseating, with seizures: what significance could
you attach to these clinical changes?
A I would then think of toxemia, which was toxic meningitis
and probably a toxic meningitis because of the high cardiac
rate.
Q Even if the same patient who, after having given
intramuscular valium, became conscious and coherent about
20 minutes later, have seizure and cyanosis and rolling of
eyeballs and vomitting . . . and death: what significance
would you attach to this development?
A We are probably dealing with typhoid to meningitis.
Q In such case, Doctor, what finding if any could you expect
on the post-mortem examination?
A No, the finding would be more on the meninges or
covering of the brain.
Q And in order to see those changes would it require
opening the skull?
A Yes.
As regards Dr. Vacalares’ finding during the autopsy that the
deceased’s gastro-intestinal tract was normal, Dr. Rico
31
explained that, while hyperplasia in the payer’s patches or
layers of the small intestines is present in typhoid fever, the
same may not always be grossly visible and a microscope
32
was needed to see the texture of the cells.
Respondents also presented the testimony of Dr. Ibarra T.
Panopio who is a member of the Philippine and American
Board of Pathology, an examiner of the Philippine Board of
Pathology, and chief pathologist at the MetroCebu
Community Hospital, Perpetual Succor Hospital, and the
Andres Soriano Jr. Memorial Medical Center. He stated that,
as a clinical pathologist, he recognized that the Widal test is
used for typhoid patients, although he did not encourage its
use because a single test would only give a presumption
necessitating that the test be repeated, becoming more
conclusive at the second and third weeks of the
33
disease. He corroborated Dr. Gotiong’s testimony that the
danger with typhoid fever is really the possible complications
which could develop like perforation, hemorrhage, as well as
34
liver and cerebral complications. As regards the 1:320
results of the Widal test on Jorge Reyes, Dr. Panopio stated
that no additional information could be obtained from a
35
higher ratio. He also agreed with Dr. Gotiong that
36
hyperplasia in the payer’s patches may be microscopic.
Indeed, the standard contemplated is not what is actually the
average merit among all known practitioners from the best to
the worst and from the most to the least experienced, but the
reasonable average merit among the ordinarily good
37
physicians. Here, Dr. Marlyn Rico did not depart from the
reasonable standard recommended by the experts as she in
fact observed the due care required under the
circumstances. Though the Widal test is not conclusive, it
remains a standard diagnostic test for typhoid fever and, in
the present case, greater accuracy through repeated testing
was rendered unobtainable by the early death of the patient.
The results of the Widal test and the patient’s history of fever
with chills for five days, taken with the fact that typhoid fever
was then prevalent as indicated by the fact that the clinic had
been getting about 15 to 20 typhoid cases a month, were
sufficient to give upon any doctor of reasonable skill the
impression that Jorge Reyes had typhoid fever.
Dr. Rico was also justified in recommending the
administration of the drug chloromycetin, the drug of choice
for typhoid fever. The burden of proving that Jorge Reyes
was suffering from any other illness rested with the
petitioners. As they failed to present expert opinion on this,
preponderant evidence to support their contention is clearly
absent.
Third. Petitioners contend that respondent Dr. Marvie
Blanes, who took over from Dr. Rico, was negligent in
ordering the intravenous administration of two doses of 500
milligrams of chloromycetin at an interval of less than three
hours. Petitioners claim that Jorge Reyes died of
38
anaphylactic shock or possibly from overdose as the
second dose should have been administered five to six
hours after the first, per instruction of Dr. Marlyn Rico. As
held by the Court of Appeals, however:
That chloromycetin was likewise a proper prescription is best
established by medical authority. Wilson, et. al., in Harrison’s
Principle of Internal Medicine, 12th ed. write that
chlorampenicol (which is the generic of chloromycetin) is the
drug of choice for typhoid fever and that no drug has yet
proven better in promoting a favorable clinical response.
"Chlorampenicol (Chloromycetin) is specifically indicated for
bacterial meningitis, typhoid fever, rickettsial infections,
bacteriodes infections, etc." (PIMS Annual, 1994, p.
211) The dosage likewise including the first administration of
five hundred milligrams (500 mg.) at around nine o’clock in
the evening and the second dose at around 11:30 the same
night was still within medically acceptable limits, since the
recommended dose of chloromycetin is one (1) gram every
six (6) hours. (cf. Pediatric Drug Handbook, 1st Ed.,
Philippine Pediatric Society, Committee on Therapeutics and
Toxicology, 1996). The intravenous route is likewise correct.
(Mansser, O’Nick, Pharmacology and Therapeutics) Even if
the test was not administered by the physician-on-duty, the
evidence introduced that it was Dra. Blanes who interpreted
the results remain uncontroverted. (Decision, pp. 16-17)
Once more, this Court rejects any claim of professional
negligence in this regard.
....
As regards anaphylactic shock, the usual way of guarding
against it prior to the administration of a drug, is the skin test
of which, however, it has been observed: "Skin testing with
haptenic drugs is generally not reliable. Certain drugs cause
nonspecific histamine release, producing a weal-and-flare
reaction in normal individuals. Immunologic activation of
mast cells requires a polyvalent allergen, so a negative skin
test to a univalent haptenic drug does not rule out
anaphylactic sensitivity to that drug." (Terr, "Anaphylaxis and
Urticaria" in Basic and Clinical Immunology, p. 349) What all
this means legally is that even if the deceased suffered from
an anaphylactic shock, this, of itself, would not yet establish
the negligence of the appellee-physicians for all that the law
requires of them is that they perform the standard tests and
perform standard procedures. The law cannot require them
to predict every possible reaction to all drugs administered.
The onus probandi was on the appellants to establish,
before the trial court, that the appellee-physicians ignored
standard medical procedure, prescribed and administered
medication with recklessness and exhibited an absence of
the competence and skills expected of general practitioners
similarly situated.
39
Fourth. Petitioners correctly observe that the medical
profession is one which, like the business of a common
carrier, is affected with public interest. Moreover, they assert
that since the law imposes upon common carriers the duty of
observing extraordinary diligence in the vigilance over the
40
goods and for the safety of the passengers, physicians and
surgeons should have the same duty toward their
41
patients. They also contend that the Court of Appeals erred
when it allegedly assumed that the level of medical practice
is lower in Iligan City, thereby reducing the standard of care
and degree of diligence required from physicians and
surgeons in Iligan City.
The standard of extraordinary diligence is peculiar to
common carriers. The Civil Code provides:
Art. 1733. Common carriers, from the nature of their
business and for reasons of public policy, are bound to
observe extraordinary diligence in the vigilance over the
goods and for the safety of the passengers transported by
them, according to the circumstances of each case. . . .
The practice of medicine is a profession engaged in only by
qualified individuals.1âwphi1 It is a right earned through
years of education, training, and by first obtaining a license
from the state through professional board examinations.
Such license may, at any time and for cause, be revoked by
the government. In addition to state regulation, the conduct
of doctors is also strictly governed by the Hippocratic Oath,
an ancient code of discipline and ethical rules which doctors
have imposed upon themselves in recognition and
acceptance of their great responsibility to society. Given
these safeguards, there is no need to expressly require of
doctors the observance of "extraordinary" diligence. As it is
now, the practice of medicine is already conditioned upon
the highest degree of diligence. And, as we have already
noted, the standard contemplated for doctors is simply the
reasonable average merit among ordinarily good physicians.
That is reasonable diligence for doctors or, as the Court of
Appeals called it, the reasonable "skill and competence . . .
that a physician in the same or similar locality . . . should
apply."
WHEREFORE, the instant petition is DENIED and the
decision of the Court of Appeals is AFFIRMED.
SO ORDERED
G.R. No. 185664 April 8, 2015
ANGELES P. BALINGHASAY, RENATO M. BERNABE,
ALODIA L. DEL ROSARIO, CATALINA T. FUNTILA,
TERESITA L. GAYANILO, RUSTICO A. JIMENEZ, ARCELI
P. JO, ESMERALDA D. MEDINA, CECILIA S.
MONTALBAN, VIRGILIO R. OBLEPIAS, CARMENCITA R.
PARRENO, EMMA L. REYES, REYNALDO L. SAVET,
SERAPIO P. TACCAD, VICENTE I. VALDEZ, SALVACION
F. VILLAMORA, and DIONISIA M.
VILLAREAL,Petitioners,
vs.
CECILIA CASTILLO, OSCAR DEL ROSARIO, ARTURO S.
FLORES, XERXES NAVARRO, MARIAANTONIAA.
TEMPLO and MEDICAL CENTER PARAÑAQUE,
INC., Respondents.
1
The instant Petition for Review on Certiorari assails the
2 3
Decision dated May 23, 2008 and Resolution dated
December 12, 2008 of the Court of Appeals (CA) in CA-G.R.
SP No. 89279. The CA reversed and set aside the Decision
dated March 22, 2005 of the Regional Trial Court (RTC) of
Parañaque City, Branch 258, in Civil Case No. 01-0140,
which dismissed the amended complaint for injunction,
accounting and damages filed by Cecilia Castillo (Castillo),
Oscar del Rosario (Oscar), Arturo Flores (Flores), Xerxes
Navarro (Navarro), Maria Antonia Templo (Templo) and
Medical Center Parañaque, Inc. (MCPI) (respondents)
against Angeles Balinghasay (Balinghasay), Renato
Bernabe (Bernabe), Alodia Del Rosario (Alodia), Catalina
Funtila, Teresita Gayanilo, Rustico Jimenez (Jimenez),
Arceli Jo, Esmeralda Medina, Cecilia Montalban, Virgilio
Oblepias (Oblepias), Carmencita Parreño, Emma Reyes,
Reynaldo Savet (Savet), Commodore Serapio Taccad,
Vicente Valdez (Valdez), Salvacion Villamora (Villamora)
4
and Dionisia Villareal (Villareal) (petitioners).
Antecedents
The MCPI, a domestic corporation organized in 1977,
operates the Medical Center Parañaque (MCP) locatedin Dr.
A. Santos Avenue, Sucat, Parañaque City. Castillo, Oscar,
Flores, Navarro, and Templo are minority stockholders of
MCPI. Each of them holds 25 Class B shares. On the other
hand, nine of the herein petitioners, namely, Balinghasay,
Bernabe, Alodia, Jimenez, Oblepias, Savet,
Villamora,Valdez and Villareal, are holders of Class A shares
and were Board Directors of MCPI. The other eight
petitioners are holders of Class B shares. The petitioners are
part of a group who invested in the purchase of ultrasound
equipment, the operation of and earnings from which gave
rise to the instant controversy.
Before 1997, the laboratory, physical therapy, pulmonary
and ultrasound services in MCP were provided to patients by
way of concessions granted to independent entities. When
the concessions expired in 1997, MCPI decided that it would
5
provide on its own the said services, except ultrasound.
In 1997, the MCPI’s Board of Directors awarded the
operation of the ultrasound unit to a group of investors
(ultrasound investors) composed mostly of Obstetrics-
Gynecology (Ob-gyne) doctors. The ultrasound investors
held either Class A or Class B shares of MCPI. Among them
were nine of the herein petitioners, who were then, likewise,
MCPI Board Directors. The group purchased a Hitachi model
EUB-200 C ultrasound equipment costing ₱850,000.00 and
operated the same. Albeit awarded by the Board of
Directors, the operation was not yet covered by a written
6 years 1997 to 1999, MCPI received a net share of
contract.
In the meeting of the MCPI’s Board of Directors held on
August 14, 1998, seven (7) of the twelve (12) Directors
present were part of the ultrasound investors. The Board
Directors made a counter offer anent the operation of the
ultrasound unit. Hence, essentially then, the award of the
7 The petitioners challenged the RTC’s judgment before the
ultrasound operation still bore no formal stamp of approval.
On February 5, 1999, twelve (12) Board Directors attended
the Board meeting and eight (8) of them were among the
ultrasound investors. A Memorandum of Agreement (MOA)
was entered into by and between MCPI, represented by its
President then, Bernabe, and the ultrasound investors,
represented by Oblepias. Per MOA, the gross income to be
derived from the operation of the ultrasound unit, minus the
sonologists’ professional fees, shall be divided between the
ultrasound investors and MCPI, in the proportion of 60% and
40%, respectively. Come April 1, 1999, MCPI’s share would
be 45%, while the ultrasound investors would receive 55%.
Further, the ownership of the ultrasound machine would
8
eventually be transferred to MCPI.
On October 6, 1999, Flores wrote MCPI’s counsel a letter
challenging the Board of Directors’ approval of the MOA for
being prejudicial to MCPI’s interest. Thereafter, on February
7, 2000, Flores manifested to MCPI’s Board of Directors and
President his view regarding the illegality of the MOA, which,
9 17
therefore, cannot be validly ratified.
On March 22, 2001, the herein respondents filed with the
10
RTC a derivative suit against the petitioners for violation of
11
Section 31 of the Corporation Code. Among the prayers in
the Complaint were: (a) the annulment of the MOA and the
accounting of and refund by the petitioners of all profits,
income and benefits derived from the said agreement; and
12
(b) payment of damages and attorney’s fees.
In their Answer with Counterclaim, the petitioners argued
that the derivative suit must be dismissed for non-joinder of
MCPI, an indispensable party. The petitioners likewise
13
claimed that under Section 32 of the Corporation Code, the
MOA was merely voidable. Since there was no proof that the
subsequent Board of Directors of MCPI moved to annul the
MOA, the same should be considered as having been
ratified. Further, in the Annual Stockholders Meeting held on
February 11, 2000, the MOA had already been discussed
14
and passed upon.
To implead MCPI as a party-plaintiff, the individual
respondents filed an Amended Complaint dated September
15
11, 2001. The RTC admitted the said amended complaint
on October 12, 2001.
Rulings of the RTC and the CA
On March 22, 2005, the RTC rendered a Decision
dismissing the respondents’ amended complaint. The RTC
found that MCPI had, in effect, impliedly ratified the MOA by
accepting or retaining benefits flowing therefrom. Moreover,
the elected MCPI’s Board Directors for the years 1998 to
2000 did not institute legal actions against the petitioners.
MCPI slept on its rights for almost four years, and estoppel
had already set in before the derivative suit was filed in
2001. The RTC likewise stressed that the sharing
agreement, per MOA provisions, was fair, just and
reasonable. From the ultrasound unit’s operations for the
₱1,567,699.78, while the ultrasound investors only got
₱803,723.00. Further, under the "business judgment rule,"
the trial court cannot undertake to control the discretion of
the corporation’s board as long as good faith attends its
16
exercise.
CA.
On May 23, 2008, the CA rendered the herein assailed
decision, the dispositive portion of which reads:
WHEREFORE, premises considered, the Petition for Review
is GRANTED. The Decision dated 22 March 2005 of the
[RTC] of Parañaque City, Branch 258 in Civil Case No. 01-
0140is REVERSED and SET ASIDEand a new one entered
declaring the [MOA] (ultrasound contract) as invalid. Further,
[petitioners] Angeles Balinghasay, Dr. Renato Bernabe, Dr.
Alodia del Rosario, Dr. Rustico Jimenez, Dr. Virgilio
Oblepias, Dr. Reynaldo Savet, Dr. Salvacion Villamoraand
Dr. Humberto Villarealare hereby ordered to fully account to
[respondent MCPI] all the profits from said ultrasound
contract which otherwise would have accrued to [MCPI]and
to jointly and severally pay the amount of ₱200,000.00 as
attorney’s fees in favor of the [respondents]. Costs against
said named [petitioners].
SO ORDERED.
The CA, however, denied the respondents’ claims for moral
and exemplary damages. The appellate court explained that
moral damages cannot be awarded in favor of a corporation,
which in this case is MCPI, the real party-in-interest. Further,
there is no ample evidence to prove that the petitioners
18
acted wantonly, recklessly and oppressively.
In declaring the invalidity of the MOA, the CA explained that:
"Quorum" is defined as that number of members of a body
which, when legally assembled in their proper places, will
enable the body to transact its proper business. "Majority,"
when required to constitute a quorum, means the greater
number than half or more than half of any total.
In the case at bar, the majority of the number of directors, if it
is indeed thirteen (13), is seven (7), while if it is eleven (11),
the majority is six (6). During the meetings held by the MCPI
Board of Directors i.e.1) 14 August 1998 meeting x x x,
twelve (12)directors were present, and of said number,
seven (7) of them belong to the ultrasound investors x x x,
and at which meeting, the Board decided to make a counter-
offer x x x to the ultrasound group and; 2) 05 February 1999
meeting x x x, twelve (12) directors were present, and of said
number, eight (8) of them belong to the ultrasound investors
x x x, and at which meeting, the Board decided to proceed
with the signing of the [MOA] x x x. As can be gleaned from
the Minutes of said Board meetings, without the presence of
the [petitioners] directors/ultrasound investors, there can be
no quorum. At any rate, during the Board meeting on 14
August 1998, the [MOA] was not approved as only a
counter-offer was agreed upon. As to the 05 February 1999
Board meeting, without considering the votes of the
[petitioners] directors/ultrasound investors, in connection
with the signing of the [MOA], no valid decision can be
made. It further appears that x x x [Oblepias], who signed
the [MOA] on behalf of the ultrasound/Ob-Gyne group as
OWNER of the ultrasound equipment, and x x x President
Dr. Bernabe, who signed the same on behalf of MCPI x x x,
are both ultrasound investors. Thus, We find that the [MOA]
was not validly approved by the MCPI Board. Plainly, [the
petitioners/directors] x x x, in acquiring an interest adverse to
the corporation, are liable as trustees for the corporation and
must account for the profits under the [MOA] which
otherwise would have accrued to MCPI.
xxxx
x x x [T]he presence of the [petitioners] directors/ultrasound
investors who approved the signing of the [MOA] was
necessary to constitute a quorum for such meeting on 05
February 1999 and the votes of [the petitioners]
directors/ultrasound investors were necessary in connection
with the decision to proceed with the signing of the [MOA].
Further, there is no clear and convincing evidence that the
[MOA] was ratified by the vote of 2/3 of the outstanding
capital stock of MCPI in a meeting called for the purpose and
that a full disclosure of the interest of the [petitioners]
directors/ultrasound investors, was made at such meeting.
At any rate, if the ultrasound contract has indeed been
impliedly ratified[,] there would have been no need to submit
the matter repeatedly to the stockholders of MCPI in a vain
attempt to have the same ratified.
The [RTC’s] observation that [the respondents’] silence and
acquiescence to the [MOA] impliedly ratified the same is also
belied by the fact that [the respondents] did not stop
questioning the validity of the [MOA]. x x x.
Further, under the Corporation Code, where a corporation is
an injured party, its power to sue is lodged with its board of
directors or trustees. But an individual stockholder may be
permitted to institute a derivative suit in behalf of the
corporation in order to protect or vindicate corporate rights
whenever the officials of the corporation refuse to sue, or
when a demand upon them to file the necessary action
would be futile because they are the ones to be sued, or
because they hold control of the corporation. In such actions,
the corporation is the real party-in-interest while the suing
stockholder, in behalf of the corporation, is only a nominal
party.
xxxx
In the instant case, [the respondents] filed an Amended
Complaint dated 11 September 2001. Paragraphs 1a, 3 and
17-24 thereof sufficiently allege their derivative action. There
was compliance with Section 1, Rule 8 of the Interim Rules
of Procedure for Intra-Corporate Controversies. x x x It is
undisputed that [the respondents] are stockholders of MCPI
x x x; [the respondents] exerted all reasonable efforts to
exhaust all remedies available to them x x x; there are no
appraisal rights available to [the respondents] for the act
complained of; and the case is clearly not a nuisance or
harassment suit. x x x
xxxx
It is clear that under the "business judgment rule", the courts
are barred from intruding into the business judgments of the
corporation, when the same are made in good faith.
xxxx
[The petitioners] MCPI directors, who are ultrasound
investors, in violation of their duty as such directors,
acquired an interest adverse to the corporation when they
entered into the ultrasound contract. By doing so, they have
unjustly profited from the transaction which otherwise would
have accrued to MCPI. In fact, as reflected in the ultrasound
income x x x for the year 1997 to 2001, the ultrasound
investors earned a net share of ₱4,417,573.81. [The
petitioners] directors/ultrasound investors failed to inhibit
themselves from participating in the meeting and from voting
with respect to the decision to proceed with the signing of
the [MOA]. Certainly, said [petitioners] directors/ultrasound
investors have dealt in their behalf and took an interest
adverse to MCPI.
Moreover, based on the audited financial statements of
MCPI x x x for the year 1996-2000, it appears that the
corporation has available cash to purchase its own
ultrasound unit. It was testified to by Dr. Villamora that the
cost of the ultrasound unit is ₱850,000.00, while the cash
and cash equivalents of MCPI for the year 1996 is
₱5,479,242.00; for the year 1997, ₱5,509,058.51; and for
19
the year 1998, ₱8,662,909.00. (Citations omitted)
20
In the now assailed Resolution issued on December 12,
2008, the CA denied the Motion for Reconsideration filed by
the herein petitioners.
Issues
Undaunted, the petitioners are before this Court raising the
issues of whether or not the CA: (1) committed an error of
law in ignoring the circumstances under which the MOA was
conceived and implemented; (2) failed to consider that the
MOA was a very informal agreement meant to address an
urgent hospital necessity; (3) committed an error of law in
not applying the "business judgment rule"; and (4) committed
an error of law in assessing attorney’s fees of
21
₱200,000.00against the directors-contributors.
The petitioners allege that the ultrasound equipment was
purchased for its transvaginal probe capacity. Prior to its
purchase, the Philippine Board of Obstetrics and
Gynecology of the Philippine Obstetrical and Gynecology
Society adopted a policy enjoining the Ob-gyne departments
of hospitals to have their own ultrasound equipment for the
purpose of being able to pinpoint responsibility for their
22
use.
Further, the MCP’s Ob-gyne doctors observed that the
absence of ultrasound equipment within MCP may compel
the patients to go instead to other hospitals, thus, resulting to
both loss of income and an unpleasant reputation of being ill-
equipped. The MCP’s Ob-gyne doctors were, hence, moved
to pass around the hat to raise the amount of ₱850,000.00
for the equipment’s purchase. However, not all of the Board
Directors and holders of Class A shares contributed as there
was no guaranteed return of investments to speak of.
Several holders of Class B shares participated though. As
for MCPI, it was then interested to acquire a lot adjacent to
the hospital and was, therefore, not in the financial position
23
to buy the ultrasound equipment.
Admittedly, little formality was observed by the MCP’s Ob-
gyne doctors in raising the funds for and purchasing the
ultrasound equipment, but the endeavor was motivated by
24
good faith. At the outset, the antecedents leading to the
purchase and operation of the ultrasound equipment were
not introduced into the records, but the respondents
themselves acknowledged these circumstances in the
25
petition they filed before the CA.
The petitioners likewise reiterate the RTC’s declaration that
"[q]uestions of policy or of management are left solely to the
honest decision of the board as the business manager of the
corporation, and the court is without authority to substitute its
judgment for that of the board, and as long as its acts in
good faith and in the exercise of honest judgment in the
interest of the corporation, its orders are not reviewable by
26
the courts."
As regards the award of attorney’s fees, the petitioners claim
the same to be erroneous as their acts were all performed in
27
good faith and profit was not their consideration.
28
In their Motion to Dismiss filed on January 19, 2009 and
29
Comment filed on April 30, 2009, the respondents argue
that the instant petition should be outrightly dismissed as the
material portions of the records, to wit, copies of the MOA,
30
complaint, answer and RTC decision, are not attached.
Moreover, the issues raised herein are essentially all factual
in nature, requiring a recalibration of the evidence offered by
the parties. Specifically, the instant petition prays for the
Court to determine the existence of: (a) circumstances
surrounding the purchase and operation of the ultrasound
equipment; (b) an urgent hospital necessity justifying the
MOA’s approval; (c) conditions precedent to the application
of the business judgment rule; and (d) or absence of
justifications for the award of attorney’s fees, which the CA
31
had supposedly all ignored.
In the case at bar, to the petitioners’ own detriment, they
admit that the antecedents and circumstances surrounding
the operation of the ultrasound unit, which they invoke to
prove good faith on their part, were not introduced into the
32
records during the trial.
The respondents once again stress that MCPI’s Balance
Sheets for the years 1996 up to 2000 unequivocally show
that the corporation had more than enough cash and cash
equivalents to purchase and operate the ultrasound
33
equipment. Hence, the petitioners were either impelled by
bad faith or were grossly negligent when they failed to
conduct a simple examination of MCPI’s financial
34
records. As regards MCPI’s intent to buy the lot adjacent to
the hospital, the respondents claim that the allegation is an
35
afterthought and no evidence supports it. The respondents
also contend that estoppel does not apply in the instant case
as they had repeatedly, but in vain, asked the MCPI’s Board
of Directors for a copy of the MOA, and letters were
36
thereafter sent to challenge its validity.
The respondents aver as well that the petitioners’ several
attempts for the MOA’s ratification by the stockholders
through the required two-third votes had failed in the years
2000 up to2003. Despite the foregoing, the ultrasound
investors continue to operate the unit and receive income
37
therefrom causing prejudice to MCPI. Pursuant to Section
31 of the Corporation Code, the petitioners should therefore
be liable not just for the profits or revenues they had
received from the ultrasound unit’s operation, but for all
38
profits which otherwise would have accrued to MCPI.
Ruling of the Court
The Court affirms but clarifies and modifies the CA’s
disquisition.
The instant petition raises mere
factual issues and no exceptional
grounds exist for the Court to
re-evaluate the evidence submitted
by the parties.
39
Century Iron Works, Inc. v. Banas explains what the proper
subjects of a petition filed under Rule 45 of the Rules of
Court are, viz:
A petition for review on certiorari under Rule 45 is an appeal
from a ruling of a lower tribunal on pure questions of law. It is
40
only in exceptional circumstances that we admit and review
questions of fact.
A question of law arises when there is doubt as to what the
law is on a certain state of facts, while there is a question of
fact when the doubt arises as to the truth or falsity of the
alleged facts. For a question to be one of law, the question
must not involve an examination of the probative value of the
evidence presented by the litigants or any of them. The
resolution of the issue must rest solely on what the law
provides on the given set of circumstances. Once it is clear
that the issue invites a review of the evidence presented, the
question posed is one of fact. Thus, the test of whether a
question is one of law or of fact is not the appellation given
to such question by the party raising the same; rather, it is
whether the appellate court can determine the issue raised
without reviewing or evaluating the evidence, in which case,
it is a question of law; otherwise it is a question of
41
fact. (Citations omitted)
In the instant petition, the Court agrees with the respondents
that the issues presented are not legal. The RTC and the CA
differed in their factual findings and their appreciation of the
same. However, no compelling grounds exist for this Court
to apply the exception in lieu of the general rule that
evidence shall not be re-evaluated.
As acknowledged by the petitioners and aptly pointed out by
the respondents, the existence of the circumstances and
urgent hospital necessity justifying the purchase and
operation of the ultrasound unit by the investors were not at
the outset offered as evidence. Having been belatedly
raised, the aforesaid defenses were not scrutinized during
the trial and their truth or falsity was not uncovered. This is
fatal to the petitioners’ cause. The CA thus cannot be faulted
for ruling against the petitioners in the face of evidence
showing that: (a) there was no quorum when the Board
meetings were held on August 14, 1998 and February 5,
1999; (b) the MOA was not ratified by a vote of two-thirds of
MCPI’s outstanding capital stock; and (c) the Balance
Sheets for the years 1996 to 2000 indicated that MCPI was
in a financial position to purchase the ultrasound equipment.
The petitioners harp on their lofty purpose, which had
supposedly moved them to purchase and operate the
ultrasound unit. Unfortunately, their claims are not evident in
the records.1âwphi1 Further, even if their claims were to be
assumed as true for argument’s sake, the fact remains that
the Board Directors, who approved the MOA, did not
outrightly inform the stockholders about it. The ultrasound
equipment was purchased and had been in operation since
1997, but the matter was only brought up for ratification by
the stockholders in the annual meetings held in the years
2000 to 2003. This circumstance lends no credence to the
petitioners’ cause.
The Court thus finds the CA’s ruling anent the invalidity of
the MOA as amply supported by both evidence and
jurisprudence.
The acts of petitioner MCPI Board
of Directors compelled the
respondents to litigate, hence, the
CA’s award of attorney’s fees is
proper.
Anent when attorney’s fees should be awarded, the Court, in
42
Benedicto v. Villaflores, declared that:
It is settled that the award of attorney’s fees is the exception
rather than the rule and counsel’s fees are not to be
awarded every time a party wins suit. The power of the court
to award attorney’s fees under Article 2208 of the Civil Code
demands factual, legal, and equitable justification; its basis
cannot be left to speculation or conjecture. Where granted,
the court must explicitly state in the body of the decision, and
not only in the dispositive portion thereof, the legal reason
43
for the award of attorney’s fees.
In the case before this Court, the CA awarded the amount of
₱200,000.00 as attorney’s fees in favor of the respondents,
predicating the same on the unjustified acts of the petitioners
and the interval of time it took for the controversy to be
resolved. The CA had laid down the basis for the award and
the Court now finds the same to be reasonable under the
circumstances.
However, the herein assailed decision and resolution still
need to be modified lest unjust enrichment flows therefrom.
To prevent unjust enrichment, the
ultrasound investors should retain
ownership of the equipment.
Article 22 of the New Civil Code provides that "every person
who through an act of performance by another, or any other
means, acquires or comes into possession of something at
the expense of the latter without just or legal ground, shall
return the same to him." The main objective of the principle
against unjust enrichment is to prevent one from enriching
himself at the expense of another without just cause or
44
consideration.
In the case at bar, the ultrasound investors pooled together
the amount of ₱850,000.00, which was used to purchase the
equipment.1âwphi1 Because of the MOA’s invalidity, the
ultrasound investors can no longer operate the ultrasound
unit within MCP. Nonetheless, it is only fair for the ultrasound
investors to retain ownership of the equipment, which they
may use or dispose of independently of MCPI.
IN VIEW OF THE FOREGOING, the instant petition is
DENIED. The Decision dated May 23, 2008 and Resolution
dated December 12, 2008 of the Court of Appeals in CA-
G.R. SP No. 89279 are AFFIRMED but with the following
CLARIFICATIONS/ MODIFICATIONS:
(a) The petitioners Angeles Balinghasay, Renato
Bernabe, Alodia del Rosario, Rustico Jimenez,
Virgilio Oblepias, Reynaldo Savet, Salvacion
Villamora and Dionisia Villareal are directed, within
SIXTY (60) DAYS from notice hereof, to FULLY
ACCOUNT FOR and RETURN TO Medical Center
Parañaque, Inc. ALL INCOME the corporation
should have earned from the operation of the
ultrasound unit from 1997 to present;
(b) The petitioners Angeles Balinghasay, Renato
Bernabe, Alodia del Rosario, Rustico Jimenez,
Virgilio Oblepias, Reynaldo Savet, Salvacion
Villamora and Dionisia Villareal are also directed
to JOINTLY AND SEVERALLY PAY the amount of
₱200,000.00 as ATTORNEY'S FEES to
respondents Cecilia Castillo, Oscar del Rosario,
Arturo Flores, Xerxes Navarro, Maria Antonia
Templo and Medical Center Parañaque, Inc.; and
(c) In accordance with Nacar v. Gallery
45
Frames, the NET INCOME to be RETURNED to
Medical Center Parafiaque, Inc., plus ₱200,000.00
awarded as ATTORNEY'S FEES, shall be subject
to INTEREST at the rate of six percent (6%) per
annum, to be reckoned sixty days from notice of
this Resolution until full satisfaction thereof.
The Court's directives are without prejudice to the right of
reimbursement, which the petitioners Angeles Balinghasay,
Renato Bernabe, Alodia del Rosario, Rustico Jimenez,
Virgilio Oblepias, Reynaldo Savet, Salvacion Villamora and
Dionisia Villareal may pursue against the rest of the
ultrasound investors.
SO ORDERED.
G.R. No. 171127 March 11, 2015
NOEL CASUMPANG, RUBY SANGA-MIRANDA and SAN
JUAN DEDIOS HOSPITAL, Petitioners,
vs.
NELSON CORTEJO, Respondent.
x-----------------------x
G.R. No. 171217
DRA. RUBY SANGA-MIRANDA, Petitioner,
vs.
NELSON CORTEJO, Respondent.
x-----------------------x
G.R. No. 171228
SAN JUAN DEDIOS HOSPITAL, Petitioner,
vs.
NELSON CORTEJO, Respondent.
We resolve the three (3) consolidated petitions for review on
1
Certiorari involving medical negligence, commonly assailing
2
the October 29, 2004 decision and the January 12, 2006
3
resolution of the Court of Appeals (CA) in CA-G.R. CV No.
56400. This CA decision affirmed en totothe ruling of the
Regional Trial Court (RTC), Branch 134, Makati City.
The RTC awarded Nelson Cortejo (respondent) damages in
the total amount of ₱595,000.00, for the wrongful death of
his son allegedly due to the medical negligence of the
petitioning doctors and the hospital.
Factual Antecedents
The common factual antecedents are briefly summarized
below.
On April 22, 1988, at about 11:30 in the morning, Mrs.
Jesusa Cortejo brought her 11-year old son, Edmer Cortejo
(Edmer), to the Emergency Room of the San Juan de Dios
Hospital (SJDH) because of difficulty in breathing, chest
4
pain, stomach pain, and fever.
Dr. Ramoncito Livelo (Dr. Livelo) initially attended to and
examined Edmer. In her testimony, Mrs. Cortejo narrated
that in the morning of April 20, 1988, Edmer had developed
a slight fever that lasted for one day; a few hours upon
discovery, she brought Edmer to their family doctor; and two
hours after administering medications, Edmer’s fever had
subsided.
5 Upon seeing Dr. Sanga, the respondent showed her
After taking Edmer’s medical history, Dr. Livelo took his vital
6
signs, body temperature, and blood pressure. Based on
these initial examinations and the chest x-ray test that
followed, Dr. Livelo diagnosed Edmer with
7
"bronchopneumonia. " Edmer’s blood was also taken for
testing, typing, and for purposes of administering antibiotics.
Afterwards, Dr. Livelo gave Edmer an antibiotic medication
to lessen his fever and to loosen his phlegm.
Mrs. Cortejo did not know any doctor at SJDH. She used her
Fortune Care card and was referred to an accredited
Fortune Care coordinator, who was then out of town. She
was thereafter assigned to Dr. Noel Casumpang (Dr.
Casumpang), a pediatrician also accredited with Fortune
Care.
8
At 5:30 in the afternoon of the same day, Dr. Casumpang for
the first time examined Edmer in his room. Using only a
stethoscope, he confirmed the initial diagnosis of
9
"Bronchopneumonia."
At that moment, Mrs. Cortejo recalled entertaining doubts on
the doctor’s diagnosis. She immediately advised Dr.
Casumpang that Edmer had a high fever, and had no colds
10
or cough but Dr. Casumpang merely told her that her son’s
11
"blood pressure is just being active," and remarked that
"that’s the usual bronchopneumonia, no colds, no
12
phlegm." Dr. Casumpang next visited and examined Edmer
13
at 9:00 in the morning the following day. Still suspicious
about his son’s illness, Mrs. Cortejo again called Dr.
Casumpang’s attention and stated that Edmer had a fever,
throat irritation, as well as chest and stomach pain. Mrs.
Cortejo also alerted Dr. Casumpang about the traces of
blood in Edmer’s sputum. Despite these pieces of
information, however, Dr. Casumpang simply nodded,
inquired if Edmer has an asthma, and reassured Mrs.
14
Cortejo that Edmer’s illness is bronchopneumonia.
At around 11:30 in the morning of April 23, 1988, Edmer
15
vomited "phlegm with blood streak" prompting the
respondent (Edmer’s father) to request for a doctor at the
16
nurses’ station. Forty-five minutes later, Dr. Ruby Miranda-
Sanga (Dr. Sanga), one of the resident physicians of SJDH,
arrived. She claimed that although aware that Edmer had
vomited "phlegm with blood streak," she failed to examine
the blood specimen because the respondent washed it
away. She then advised the respondent to preserve the
specimen for examination.
Thereafter, Dr. Sanga conducted a physical check-up
covering Edmer’s head, eyes, nose, throat, lungs, skin and
abdomen; and found that Edmer had a low-grade non-
continuing fever, and rashes that were not typical of dengue
17
fever. Her medical findings state:
the patient’s rapid breathing and then the lung showed
sibilant and the patient’s nose is flaring which is a sign that
the patient is in respiratory distress; the abdomen has
negative finding; the patient has low grade fever and not
continuing; and the rashes in the patient’s skin were not
"Herman’s Rash" and not typical of dengue fever.
18
At 3:00 in the afternoon, Edmer once again vomited blood.
Edmer’s blood specimen, and reported that Edmer had
complained of severe stomach pain and difficulty in moving
19
his right leg.
Dr. Sanga then examined Edmer’s "sputum with blood" and
noted that he was bleeding. Suspecting that he could be
afflicted with dengue, she inserted a plastic tube in his nose,
drained the liquid from his stomach with ice cold normal
saline solution, and gave an instruction not to pull out the
tube, or give the patient any oral medication.
Dr. Sanga thereafter conducted a tourniquet test, which
20
turned out to be negative. She likewise ordered the
monitoring of the patient’s blood pressure and some blood
tests. Edmer’s blood pressure was later found to be
21
normal.
At 4:40 in the afternoon, Dr. Sanga called up Dr.
Casumpang at his clinic and told him about Edmer’s
22
condition. Upon being informed, Dr. Casumpang ordered
several procedures done including: hematocrit, hemoglobin,
blood typing, blood transfusion and tourniquet tests.
The blood test results came at about 6:00 in the evening.
Dr. Sanga advised Edmer’s parents that the blood test
results showed that Edmer was suffering from "Dengue
Hemorrhagic Fever." One hour later, Dr. Casumpang arrived
at Edmer’s room and he recommended his transfer to the
Intensive Care Unit (ICU), to which the respondent
consented. Since the ICU was then full, Dr. Casumpang
suggested to the respondent that they hire a private nurse.
The respondent, however, insisted on transferring his son to
Makati Medical Center.
After the respondent had signed the waiver, Dr. Casumpang,
for the last time, checked Edmer’s condition, found that his
blood pressure was stable, and noted that he was
"comfortable." The respondent requested for an ambulance
but he was informed that the driver was nowhere to be
found. This prompted him to hire a private ambulance that
23
cost him ₱600.00.
At 12:00 midnight, Edmer, accompanied by his parents and
by Dr. Casumpang, was transferred to Makati Medical
Center.
Dr. Casumpang immediately gave the attending physician
the patient’s clinical history and laboratory exam results.
Upon examination, the attending physician diagnosed
"Dengue Fever Stage IV" that was already in its irreversible
stage.
24
Edmer died at 4:00 in the morning of April 24, 1988. His
Death Certificate indicated the cause of death as
"Hypovolemic Shock/hemorrhagic shock;" "Dengue
Hemorrhagic Fever Stage IV."
Believing that Edmer’s death was caused by the negligent
and erroneous diagnosis of his doctors, the respondent
instituted an action for damages against SJDH, and its
attending physicians: Dr. Casumpang and Dr. Sanga
(collectively referred to as the "petitioners") before the RTC
of Makati City.
The Ruling of the Regional Trial Court
25
In a decision dated May 30, 1997, the RTC ruled in favor of
the respondent, and awarded actual and moral damages,
plus attorney's fees and costs.
In ruling that the petitioning doctors were negligent, the RTC
found untenable the petitioning doctors’ contention that
Edmer’s initial symptoms did not indicate dengue fever. It
faulted them for heavily relying on the chest x-ray result and
for not considering the other manifestations that Edmer’s
parents had relayed. It held that in diagnosing and treating
an illness, the physician’s conduct should be judged not only
by what he/she saw and knew, but also by what he/she
could have reasonably seen and known. It also observed
that based on Edmer’s signs and symptoms, his medical
history and physical examination, and also the information
that the petitioning doctors gathered from his family
members, dengue fever was a reasonably foreseeable
illness; yet, the petitioning doctors failed to take a second
look, much less, consider these indicators of dengue.
The trial court also found that aside from their self-serving
testimonies, the petitioning doctors did not present other
evidence to prove that they exercised the proper medical
attention in diagnosing and treating the patient, leading it to
conclude that they were guilty of negligence. The RTC also
held SJDH solidarily liable with the petitioning doctors for
damages based on the following findings of facts: first, Dr.
Casumpang, as consultant, is an ostensible agent of SJDH
because before the hospital engaged his medical services, it
scrutinized and determined his fitness, qualifications, and
competence as a medical practitioner; and second, Dr.
Sanga, as resident physician, is an employee of SJDH
because like Dr. Casumpang, the hospital, through its
screening committee, scrutinized and determined her
qualifications, fitness,and competence before engaging her
services; the hospital also exercised control over her work.
The dispositive portion of the decision reads:
WHEREFORE, judgment is hereby rendered in favor of the
plaintiff and against the defendants, ordering the latter to pay
solidarily and severally plaintiff the following:
(1) Moral damages in the amount of ₱500,000.00;
(2) Costs of burial and funeral in the amount of
₱45,000.00;
(3) Attorney’s fees of ₱50,000.00; and
(4) Cost of this suit.
SO ORDERED.
The petitioners appealed the decision to the CA.
The Ruling of the Court of Appeals
In its decision dated October 29, 2004, the CA affirmed en
toto the RTC’s ruling, finding that SJDH and its attending
physicians failed to exercise the minimum medical care,
attention, and treatment expected of an ordinary doctor
under like circumstances.
The CA found the petitioning doctors’ failure to read even the
most basic signs of "dengue fever" expected of an ordinary
doctor as medical negligence. The CA also considered the
petitioning doctors’ testimonies as self-serving, noting that
they presented no other evidence to prove that they
exercised due diligence in diagnosing Edmer’s illness.
The CA likewise found Dr. Rodolfo Jaudian’s (Dr. Jaudian)
26
testimony admissible. It gave credence to his opinion that:
(1) given the exhibited symptoms of the patient, dengue
fever should definitely be considered, and
bronchopneumonia could be reasonably ruled out; and (2)
dengue fever could have been detected earlier than 7:30 in
the evening of April 23, 1988 because the symptoms were
already evident; and agreed with the RTC that the petitioning
doctors should not have solely relied on the chest-x-ray
result, as it was not conclusive.
On SJDH’s solidary liability, the CA ruled that the hospital’s
liability is based on Article 2180 of the Civil Code. The CA
opined that the control which the hospital exercises over its
consultants, the hospital’s power to hire and terminate their
services, all fulfill the employer-employee relationship
requirement under Article 2180.
Lastly, the CA held that SJDH failed to adduce evidence
showing that it exercised the diligence of a good father of a
family in the hiring and the supervision of its physicians.
The petitioners separately moved to reconsider the CA
decision, but the CA denied their motion in its resolution of
January 12, 2006; hence, the present consolidated petitions
pursuant to Rule 45 of the Rules of Court.
The Petitions
I. Dr. Casumpang’s Position (G.R. No. 171127)
Dr. Casumpang contends that he gave his patient medical
treatment and care to the best of his abilities, and within the
proper standard of care required from physicians under
similar circumstances. He claims that his initial diagnosis of
bronchopneumonia was supported by the chest x-ray result.
Dr. Casumpang also contends that dengue fever occurs only
after several days of confinement. He alleged that when he
had suspected that Edmer might be suffering from dengue
fever, he immediately attended and treated him.
Dr. Casumpang likewise raised serious doubts on Dr.
Jaudian’s credibility, arguing that the CA erred in
appreciating his testimony as an expert witness since he
lacked the necessary training, skills, and experience as a
specialist in dengue fever cases.
II. Dr. Sanga’s Position (G.R. No. 171217)
In her petition, Dr. Sanga faults the CA for holding her
responsible for Edmer’s wrong diagnosis, stressing that the
function of making the diagnosis and undertaking the
medical treatment devolved upon Dr. Casumpang, the
doctor assigned to Edmer, and who confirmed
"bronchopneumonia."
Dr. Sanga also alleged that she exercised prudence in
performing her duties as a physician, underscoring that it
was her professional intervention that led to the correct
diagnosis of "Dengue Hemorrhagic Fever." Furthermore,
Edmer’s Complete Blood Count (CBC) showed leukopenia
and an increase in balance as shown by the differential
count, demonstrating that Edmer’s infection, more or less, is
of bacterial and not viral in nature.
Dr. Sanga as well argued that there is no causal relation
between the alleged erroneous diagnosis and medication for
"Bronchopneumonia," and Edmer’s death due to "Dengue
Hemorrhagic Fever."
Lastly, she claimed that Dr. Jaudianis not a qualified expert
witness since he never presented any evidence of formal
residency training and fellowship status in Pediatrics.
III. SJDH’s Position (G.R. No. 171228)
SJDH, on the other hand, disclaims liability by asserting that
Dr. Casumpang and Dr. Sanga are mere independent
contractors and "consultants" (not employees) of the
hospital. SJDH alleges that since it did not exercise control
or supervision over the consultants’ exercise of medical
profession, there is no employer-employee relationship
between them, and consequently, Article 2180 of the Civil
Code does not apply.
SJDH likewise anchored the absence of employer-employee
relationship on the following circumstances: (1) SJDH does
not hire consultants; it only grants them privileges to admit
patients in the hospital through accreditation; (2) SJDH does
not pay the consultants wages similar to an ordinary
employee; (3) the consultants earn their own professional
fees directly from their patients; SJDH does not fire or
terminate their services; and (4) SJDH does not control or
interfere with the manner and the means the consultants use
in the treatment of their patients. It merely provides them
with adequate space in exchange for rental payment.
Furthermore, SJDH claims that the CA erroneously applied
the control test when it treated the hospital’s practice of
accrediting consultants as an exercise of control. It explained
that the control contemplated by law is that which the
employer exercises over the: (i) end result; and the (ii)
manner and means to be used to reach this end, and not
any kind of control, however significant, in accrediting the
consultants.
SJDH moreover contends that even if the petitioning doctors
are considered employees and not merely consultants of the
hospital, SJDH cannot still be held solidarily liable under
Article 2180 of the Civil Code because it observed the
diligence of a good father of a family in their selection and
supervision as shown by the following: (1) the adequate
measures that the hospital undertakes to ascertain the
petitioning doctors’ qualifications and medical competence;
and (2) the documentary evidence that the petitioning
doctors presented to prove their competence in the field of
27
pediatrics.
SJDH likewise faults the CA for ruling that the petitioning
doctors are its agents, claiming that this theory, aside from
being inconsistent with the CA’s finding of employment
relationship, is unfounded because: first, the petitioning
doctors are independent contractors, not agents of SJDH;
and second, as a medical institution, SJDH cannot practice
medicine, much more, extend its personality to physicians to
practice medicine on its behalf.
Lastly, SJDH maintains that the petitioning doctors arrived at
an intelligently deduced and correct diagnosis. It claimed
that based on Edmer's signs and symptoms at the time of
28 29
admission (i.e., one day fever, bacterial infection, and
30
lack of hemorrhagic manifestations ), there was no
reasonable indication yet that he was suffering from dengue
fever, and accordingly, their failure to diagnose dengue
fever, does not constitute negligence on their part.
The Case for the Respondent
In his comment, the respondent submits that the issues the
petitioners raised are mainly factual in nature, which a
petition for review on certiorari under Rule 45 of the Rules of
Courts does not allow.
In any case, he contends that the petitioning doctors were
negligent in conducting their medical examination and
diagnosis based on the following: (1) the petitioning doctors
failed to timely diagnose Edmer’s correct illness due to their
non-observance of the proper and acceptable standard of
medical examination; (2) the petitioning doctors’ medical
examination was not comprehensive, as they were always in
a rush; and (3) the petitioning doctors employed a guessing
game in diagnosing bronchopneumonia.
The respondent also alleges that there is a causal
connection between the petitioning doctors’ negligence and
Edmer’s untimely death, warranting the claim for damages.
The respondent, too, asserted that SJDH is also negligent
because it was not equipped with proper paging system, has
no bronchoscope, and its doctors are not proportionate to
the number of its patients. He also pointed out that out of the
seven resident physicians in the hospital, only two resident
physicians were doing rounds at the time of his son’s
confinement.
The Issues
The case presents to us the following issues:
1. Whether or not the petitioning doctors had
committed "inexcusable lack of precaution" in
diagnosing and in treating the patient;
2. Whether or not the petitioner hospital is
solidarily liable with the petitioning doctors;
3. Whether or not there is a causal connection
between the petitioners’ negligent act/omission
and the patient’s resulting death; and
4. Whether or not the lower courts erred in
considering Dr. Rodolfo Tabangcora Jaudian as
an expert witness.
Our Ruling
We find the petition partly meritorious.
A Petition for Review on Certiorari
under Rule 45 of the Rules of Court
is Limited to Questions of Law.
The settled rule is that the Court’s jurisdiction in a petition for
review on certiorari under Rule 45 of the Rules of Court is
limited only to the review of pure questions of law. It is not
the Court’s function to inquire on the veracity of the appellate
court’s factual findings and conclusions; this Court is not a
31
trier of facts.
A question of law arises when there is doubt as to what the
law is on a certain state of facts, while there is a question of
fact when the doubt arises as to the truth or falsity of the
32
alleged facts.
These consolidated petitions before us involve mixed
questions of fact and law. As a rule, we do not resolve
questions of fact. However, in determining the legal question
of whether the respondent is entitled to claim damages
under Article 2176 of the Civil Code for the petitioners’
alleged medical malpractice, the determination of the factual
issues – i.e., whether the petitioning doctors were grossly
negligent in diagnosing the patient’s illness, whether there is
causal relation between the petitioners’ act/omission and the
patient’s resulting death, and whether Dr. Jaudian is
qualified as an expert witness– must necessarily be
resolved. We resolve these factual questions solely for the
purpose of determining the legal issues raised.
Medical Malpractice Suit as a
Specialized Area of Tort Law
The claim for damages is based on the petitioning doctors’
negligence in diagnosing and treating the deceased Edmer,
the child of the respondent. It is a medical malpractice suit,
an action available to victims to redress a wrong committed
by medical professionals who caused bodily harm to, or the
33
death of, a patient. As the term is used, the suit is brought
whenever a medical practitioner or health care provider fails
to meet the standards demanded by his profession, or
deviates from this standard, and causes injury to the patient.
To successfully pursue a medical malpractice suit, the
plaintiff (in this case, the deceased patient’s heir) must prove
that the doctor either failed to do what a reasonably prudent
doctor would have done, or did what a reasonably prudent
doctor would not have done; and the act or omission had
34
caused injury to the patient. The patient’s heir/s bears the
burden of proving his/her cause of action.
The Elements of a Medical Malpractice Suit
The elements of medical negligence are: (1) duty; (2)
breach; (3) injury; and (4) proximate causation.
Duty refers to the standard of behavior that imposes health care plan, and by accepting the hospital’s assigned
35
restrictions on one's conduct. It requires proof of doctor without objections.
professional relationship between the physician and the
patient. Without the professional relationship, a physician
b. The Relationship Between Dr. Sanga and Edmer
owes no duty to the patient, and cannot therefore incur any
liability.
With respect to Dr. Sanga, her professional relationship with
Edmer arose when she assumed the obligation to provide
A physician-patient relationship is created when a patient
36 resident supervision over the latter. As second year resident
engages the services of a physician, and the latter accepts
37 doctor tasked to do rounds and assist other physicians, Dr.
or agrees to provide care to the patient. The establishment
38 Sanga is deemed to have agreed to the creation of
of this relationship is consensual, and the acceptance by
physician-patient relationship with the hospital’s patients
the physician essential. The mere fact that an individual
when she participated in the diagnosis and prescribed a
approaches a physician and seeks diagnosis, advice or
course of treatment for Edmer.
treatment does not create the duty of care unless the
39
physician agrees.
The undisputed evidence shows that Dr. Sanga examined
Edmer twice (at around 12:00 and 3:30 in the afternoon of
The consent needed to create the relationship does not
40 April 23, 1988),and in both instances, she prescribed
always need to be express. In the absence of an express
treatment and participated in the diagnosis of Edmer’s
agreement, a physician-patient relationship may be implied
medical condition. Her affirmative acts amounted to her
from the physician’s affirmative action to diagnose and/or
acceptance of the physician-patient relationship, and
treat a patient, or in his participation in such diagnosis and/or
41 incidentally, the legal duty of care that went with it.
treatment. The usual illustration would be the case of a
patient who goes to a hospital or a clinic, and is examined
46
and treated by the doctor. In this case, we can infer, based In Jarcia, Jr. v. People of the Philippines, the Court found
on the established and customary practice in the medical the doctors who merely passed by and were requested to
community that a patient-physician relationship exists. attend to the patient, liable for medical malpractice. It held
that a physician-patient relationship was established when
they examined the patient, and later assured the mother that
Once a physician-patient relationship is established, the
everything was fine.
legal duty of care follows. The doctor accordingly becomes
duty-bound to use at least the same standard of care that a
47
reasonably competent doctor would use to treat a medical In the US case of Mead v. Legacy Health System, the
condition under similar circumstances. Court also considered the rendering of an opinion in the
course of the patient’s care as the doctor’s assent to the
physician-patient relationship. It ruled that the relationship
Breach of duty occurs when the doctor fails to comply with,
was formed because of the doctor’s affirmative action.
or improperly performs his duties under professional 48
Likewise, in Wax v. Johnson, the court found that a
standards. This determination is both factual and legal, and
42 physician patient relationship was formed between a
is specific to each individual case.
physician who "contracts, agrees, undertakes, or otherwise
assumes" the obligation to provide resident supervision at a
If the patient, as a result of the breach of duty, is injured in teaching hospital, and the patient with whom the doctor had
body or in health, actionable malpractice is committed, no direct or indirect contract.
43
entitling the patient to damages.
Standard of Care and Breach of Duty
To successfully claim damages, the patient must lastly prove
the causal relation between the negligence and the injury.
A determination of whether or not the petitioning doctors met
This connection must be direct, natural, and should be
the required standard of care involves a question of mixed
unbroken by any intervening efficient causes. In other words,
fact and law; it is factual as medical negligence cases are
the negligence must be the proximate cause of the
44 highly technical in nature, requiring the presentation of
injury. The injury or damage is proximately caused by the
expert witnesses to provide guidance to the court on matters
physician’s negligence when it appears, based on the
clearly falling within the domain of medical science, and
evidence and the expert testimony, that the negligence
legal, insofar as the Court, after evaluating the expert
played an integral part in causing the injury or damage, and
testimonies, and guided by medical literature, learned
that the injury or damage was either a direct result, or a
treatises, and its fund of common knowledge, ultimately
reasonably probable consequence of the physician’s
45 determines whether breach of duty took place. Whether or
negligence.
not Dr. Casumpang and Dr. Sanga committed a breach of
duty is to be measured by the yardstick of professional
a. The Relationship Between Dr. Casumpang and Edmer standards observed by the other members of the medical
49
profession in good standing under similar circumstances. It
is in this aspect of medical malpractice that expert testimony
In the present case, the physician-patient relationship
is essential to establish not only the professional standards
between Dr. Casumpang and Edmer was created when the
observed in the medical community, but also that the
latter’s parents sought the medical services of Dr.
physician’s conduct in the treatment of care falls below such
Casumpang, and the latter knowingly accepted Edmer as a 50
standard.
patient. Dr. Casumpang’s acceptance is implied from his
affirmative examination, diagnosis and treatment of Edmer.
On the other hand, Edmer’s parents, on their son’s behalf, In the present case, expert testimony is crucial in
manifested their consent by availing of the benefits of their determining first, the standard medical examinations, tests,
and procedures that the attending physicians should have
undertaken in the diagnosis and treatment of dengue fever; and the presence of blood in his saliva. All these
and second, the dengue fever signs and symptoms that the manifestations were present and known to Dr. Casumpang
attending physicians should have noticed and considered. at the time of his first and second visits to Edmer. While he
noted some of these symptoms in confirming
bronchopneumonia, he did not seem to have considered the
Both the RTC and the CA relied largely on Dr. Jaudian’s
patient’s other manifestations in ruling out dengue fever or
expert testimony on dengue diagnosis and management to 58
dengue hemorrhagic fever. To our mind, Dr. Casumpang
support their finding that the petitioning doctors were guilty of
selectively appreciated some, and not all of the symptoms;
breach of duty of care.
worse, he casually ignored the pieces of information that
could have been material in detecting dengue fever. This is
Dr. Jaudian testified that Edmer’s rapid breathing, chest and evident from the testimony of Mrs. Cortejo:
stomach pain, fever, and the presence of blood in his saliva
are classic symptoms of dengue fever. According to him, if
TSN, Mrs. Cortejo, November 27, 1990
the patient was admitted for chest pain, abdominal pain, and
difficulty in breathing coupled with fever, dengue fever
51
should definitely be considered; if the patient spits coffee Q: Now, when Dr. Casumpang visited your son for the first
ground with the presence of blood, and the patient’s platelet time at 5:30 p.m., what did he do, if any?
count drops to 47,000, it becomes a clear case of dengue
52
fever, and bronchopneumonia can be reasonably ruled out.
A: He examined my son by using stethoscope and after that,
he confirmed to me that my son was suffering from broncho
Furthermore, the standard of care according to Dr. Jaudian pneumonia.
is to administer oxygen inhalation, analgesic, and fluid
53
infusion or dextrose. If the patient had twice vomited fresh
Q: After he confirmed that your son was suffering broncho
blood and thrombocytopenia has already occurred, the
pneumonia, what did you say if any?
doctor should order blood transfusion, monitoring of the
patient every 30 minutes, hemostatic to stop bleeding, and
54
oxygen if there is difficulty in breathing. A: Again, I told Dr. Casumpang, how come it was broncho
pneumonia when my son has no cough or colds.
We find that Dr. Casumpang, as Edmer’s attending
physician, did not act according to these standards and, Q: What was the answer of Dr. Casumpang to your
hence, was guilty of breach of duty. We do not find Dr. statement?
Sanga liable for the reasons discussed below.
xxxx
Dr. Casumpang’s Negligence
A: And then, Dr. Casumpang answered "THAT’S THE
a. Negligence in the Diagnosis USUAL BRONCHO PNEUMONIA, NO COLDS, NO
PHLEGM."
At the trial, Dr. Casumpang declared that a doctor’s
impression regarding a patient’s illness is 90% based on the Q: How long did Dr. Casumpang stay in your son’s room?
physical examination, the information given by the patient or
the latter’s parents, and the patient’s medical history.55 He
testified that he did not consider either dengue fever or A: He stayed for a minute or 2.
dengue hemorrhagic fever because the patient’s history
showed that Edmer had low breath and voluntary xxxx
submission, and that he was up and about playing
56
basketball. He based his diagnosis of bronchopneumonia
on the following observations: "difficulty in breathing, clearing Q: When Dr. Casumpang arrived at 9:00 o’clock a.m. on
run nostril, harsh breath sound, tight air, and sivilant April 23, what did you tell him, if any?
57
sound."
xxxx
It will be recalled that during Dr. Casumpang’s first and
second visits to Edmer, he already had knowledge of A: I told Dr. Casumpang… After examining my son using
Edmer’s laboratory test result (CBC), medical history, and stethoscope and nothing more, I told Dr. Casumpang about
symptoms (i.e., fever, rashes, rapid breathing, chest and the traces of blood in my son’s sputum and I told him what is
stomach pain, throat irritation, difficulty in breathing, and all about and he has throat irritation.
traces of blood in the sputum). However, these information
did not lead Dr. Casumpang to the possibility that Edmer
could be suffering from either dengue fever, or dengue Q: What did he tell you?
hemorrhagic fever, as he clung to his diagnosis of broncho
pneumonia. This means that given the symptoms exhibited, A: He just nodded his head but he did not take the initiative
Dr. Casumpang already ruled out the possibility of other of looking at the throat of my son.
diseases like dengue.
Q: So what happened after that?
In other words, it was lost on Dr. Casumpang that the
characteristic symptoms of dengue (as Dr. Jaudian testified)
are: patient’s rapid breathing; chest and stomach pain; fever; A: I also told Dr. Casumpang about his chest pain and also
stomach pain.
Q: So what did Dr. Casumpang do after you have narrated
all these complaints of your son?
A: Nothing. He also noticed the rapid breathing of my son
and my son was almost moving because of rapid breathing
and he is swaying in the bed.
Q: Do you know what action was taken by Dr. Casumpang
when you told him that your son is experiencing a rapid
breathing?
A: No action. He just asked me if my son has an asthma but
I said none.
Q: So how long did Dr. Casumpang stay and attended your
son on April 23?
A: More or less two (2) minutes then I followed him up to the
door and I repeated about the fever of my son.
Q: What did he tell you, if any, regarding that information you
gave him that your son had a fever?
A: He said, that is broncho pneumonia, It’s only being active
now. [Emphasis supplied]
We also find it strange why Dr. Casumpang did not even
bother to check Edmer’s throat despite knowing that as early
as 9:00 in the morning of April 23, 1988, Edmer had blood
streaks in his sputum. Neither did Dr. Casumpang order
confirmatory tests to confirm the source of bleeding. The
59
Physician’s Progress Notes stated: "Blood streaks on
phlegm can be due to bronchial irritation or congestion,"
which clearly showed that Dr. Casumpang merely assumed,
without confirmatory physical examination, that
bronchopneumonia caused the bleeding.
Dr. Jaudian likewise opined that Dr. Casumpang’s medical
examination was not comprehensive enough to reasonably
60
lead to a correct diagnosis. Dr. Casumpang only used a
stethoscope in coming up with the diagnosis that Edmer was
suffering from bronchopneumonia; he never confirmed this
finding with the use of a bronchoscope. Furthermore, Dr.
Casumpang based his diagnosis largely on the chest x-ray
61
result that is generally inconclusive.
Significantly, it was only at around 5:00 in the afternoon of
April 23, 1988 (after Edmer’s third episode of bleeding) that
Dr. Casumpang ordered the conduct of hematocrit,
hemoglobin, blood typing, blood transfusion and tourniquet
tests. These tests came too late, as proven by: (1) the blood
test results that came at about 6:00 in the evening,
confirming that Edmer’s illness had developed to "Dengue
Hemorrhagic Fever;" and (2) Dr. Jaudian’s testimony that
"dengue fever could have been detected earlier than 7:30 in
the evening of April 23, 1988 because the symptoms were
62
already evident."
63
In Spouses Flores v. Spouses Pineda, a case involving a
medical malpractice suit, the Court ruled that the petitioner
doctors were negligent because they failed to immediately
order tests to confirm the patient’s illness. Despite the
doctors’ suspicion that the patient could be suffering from
diabetes, the former still proceeded to the D&C operation. In
that case, expert testimony showed that tests should have
been ordered immediately on admission to the hospital in
view of the symptoms presented. The Court held:
When a patient exhibits symptoms typical of a particular
disease, these symptoms should, at the very least, alert the
physician of the possibility that the patient may be afflicted
with the suspected disease.
The Court also ruled that reasonable prudence would have
shown that diabetes and its complications were foreseeable
harm. However, the petitioner doctors failed to take this into
consideration and proceeded with the D&C operation. Thus,
the Court ruled that they failed to comply with their duty to
observe the standard of care to be given to
hyperglycemic/diabetic patients.
64
Similarly, in Jarcia, involving the negligence of the doctors
in failing to exercise reasonable prudence in ascertaining the
extent of the patient’s injuries, this Court declared that:
In failing to perform an extensive medical examination to
determine the extent of Roy Jr.’s injuries, Dr. Jarcia and Dr.
Bastan were remiss of their duties as members of the
medical profession. Assuming for the sake of argument that
they did not have the capacity to make such thorough
evaluation at that stage, they should have referred the
patient to another doctor with sufficient training and
experience instead of assuring him and his mother that
everything was all right. [Emphasis supplied]
Even assuming that Edmer’s symptoms completely
coincided with the diagnosis of bronchopneumonia (so that
this diagnosis could not be considered "wrong"), we still find
Dr. Casumpang guilty of negligence.
First, we emphasize that we do not decide the correctness of
a doctor’s diagnosis, or the accuracy of the medical findings
and treatment. Our duty in medical malpractice cases is to
decide – based on the evidence adduced and expert opinion
presented– whether a breach of duty took place.
Second, we clarify that a wrong diagnosis is not by itself
65
medical malpractice. Physicians are generally not liable for
damages resulting from a bona fide error of judgment.
Nonetheless, when the physician’s erroneous diagnosis was
the result of negligent conduct (e.g., neglect of medical
history, failure to order the appropriate tests, failure to
recognize symptoms), it becomes an evidence of medical
malpractice.
Third, we also note that medicine is not an exact
66
science; and doctors, or even specialists, are not expected
to give a 100% accurate diagnosis in treating patients who
come to their clinic for consultations. Error is possible as the
exercise of judgment is called for in considering and reading
the exhibited symptoms, the results of tests, and in arriving
at definitive conclusions. But in doing all these, the doctor
must have acted according to acceptable medical practice
standards.
In the present case, evidence on record established that in
confirming the diagnosis of bronchopneumonia, Dr.
Casumpang selectively appreciated some and not all of the
symptoms presented, and failed to promptly conduct the
appropriate tests to confirm his findings. In sum, Dr.
Casumpang failed to timely detect dengue fever, which
failure, especially when reasonable prudence would have
shown that indications of dengue were evident and/or
foreseeable, constitutes negligence.
a. Negligence in the Treatment and Management of Dengue
Apart from failing to promptly detect dengue fever, Dr.
Casumpang also failed to promptly undertake the proper
medical management needed for this disease.
As Dr. Jaudian opined, the standard medical procedure once
the patient had exhibited the classic symptoms of dengue
fever should have been: oxygen inhalation, use of analgesic,
67
and infusion of fluids or dextrose; and once the patient had
twice vomited fresh blood, the doctor should have ordered:
blood transfusion, monitoring of the patient every 30
minutes, hemostatic to stop bleeding, and oxygen if there is
68
difficulty in breathing.
Dr. Casumpang failed to measure up to these standards.
The evidence strongly suggests that he ordered a
transfusion of platelet concentrate instead of blood
transfusion. The tourniquet test was only conducted after
Edmer’s second episode of bleeding, and the medical
management (as reflected in the records) did not include
antibiotic therapy and complete physical examination. Dr.
Casumpang’s testimony states:
Q: Now, after entertaining – After considering that the patient
Edmer Cortero was already suffering from dengue
hemorrhagic fever, what did you do, if any?
A: We ordered close monitoring of the blood pressure, the
cardiac rate and respiratory rate of the patient.
Q: Now, was your instructions carried on?
A: Yes, sir.
Q: What was the blood pressure of the patient?
A: During those times, the blood pressure of the patient was
even normal during those times.
Q: How about the respiratory rate?
A: The respiratory rate was fast because the patient in the
beginning since admission had difficulty in breathing.
Q: Then, after that, what did you do with the patient?
Doctor?
A: We transfused platelet concentrate and at the same time,
we monitor [sic] the patient.
Q: Then, who monitor [sic] the patient?
A: The pediatric resident on duty at that time.
Q: Now, what happened after that?
Q: While monitoring the patient, all his vital signs were
_____; his blood pressure was normal so we continued with
the supportive management at that time.
Q: Now, after that?
A: In the evening of April 23, 1988, I stayed in the hospital
and I was informed by the pediatric resident on duty at
around 11:15 in the evening that the blood pressure of the
patient went down to .60 palpatory.
Q: What did you do upon receipt of that information?
A: I immediately went up to the room of the patient and we
changed the IV fluid from the present fluid which was D5 0.3
sodium chloride to lactated ringers solution.
Q: You mean to say you increased the dengue [sic] of the
intervenus [sic] fluid?
A: We changed the IV fluid because lactated ringers was
necessary to resume the volume and to bring back the blood
pressure, to increase the blood pressure. [Emphasis
supplied]
Although Dr. Casumpang presented the testimonies of Dr.
Rodolfo Jagonap and Dr. Ellewelyn Pasion (Dr. Pasion),
Personnel Officer and Medical Director of SJDH,
respectively as well as the testimonies of Dr. Livelo and Dr.
Reyes (the radiologist who read Edmer’s chest x-ray result),
these witnesses failed to dispute the standard of action that
Dr. Jaudian established in his expert opinion. We cannot
consider them expert witnesses either for the sole reason
that they did not testify on the standard of care in dengue
69
cases.
On the whole, after examining the totality of the adduced
evidence, we find that the lower courts correctly did not rely
on Dr. Casumpang’s claim that he exercised prudence and
due diligence in handling Edmer’s case. Aside from being
self-serving, his claim is not supported by competent
evidence. As the lower courts did, we rely on the
uncontroverted fact that he failed, as a medical professional,
to observe the most prudent medical procedure under the
circumstances in diagnosing and treating Edmer.
Dr. Sanga is Not Liable for Negligence
In considering the case of Dr. Sanga, the junior resident
physician who was on-duty at the time of Edmer’s
confinement, we see the need to draw distinctions between
the responsibilities and corresponding liability of Dr.
Casumpang, as the attending physician, and that of Dr.
Sanga.
In his testimony, Dr. Pasion declared that resident applicants
are generally doctors of medicine licensed to practice in the
Philippines and who would like to pursue a particular
70
specialty. They are usually the front line doctors
responsible for the first contact with the patient. During the
71
scope of the residency program, resident physicians (or
72
"residents") function under the supervision of attending
 73
physicians or of the hospital’s teaching staff. Under this
arrangement, residents operate merely as subordinates who
usually defer to the attending physician on the decision to be
made and on the action to be taken.
The attending physician, on the other hand, is primarily
responsible for managing the resident’s exercise of duties.
While attending and resident physicians share the collective
responsibility to deliver safe and appropriate care to the
74
patients, it is the attending physician who assumes the
75
principal responsibility of patient care. Because he/she
exercises a supervisory role over the resident, and is
ultimately responsible for the diagnosis and treatment of the
patient, the standards applicable to and the liability of the
resident for medical malpractice is theoretically less than that
of the attending physician. These relative burdens and
distinctions, however, do not translate to immunity from the
76
legal duty of care for residents, or from the responsibility
arising from their own negligent act.
77
In Jenkins v. Clark, the Ohio Court of Appeals held that the
applicable standard of care in medical malpractice cases
involving first-year residents was that of a reasonably
prudent physician and not that of interns. According to
Jenkins:
It is clear that the standard of care required of physicians is
not an individualized one but of physicians in general in the
community. In order to establish medical malpractice, it must
be shown by a preponderance of the evidence that a
physician did some particular thing or things that a physician
or surgeon of ordinary skill, care and diligence would not
have done under like or similar conditions or circumstances,
or that he failed or omitted to do some particular thing or
things that a physician or surgeon of ordinary skill, care and
diligence would have done under like or similar conditions or
circumstances, and that the inquiry complained of was the
direct result of such doing or failing to do such thing or
things.
We note that the standard of instruction given by the court
was indeed a proper one. It clearly informed the jury that the
medical care required is that of reasonably careful
physicians or hospital emergency room operators, not of
interns or residents. [Emphasis supplied]
78
A decade later, Centman v. Cobb, affirmed the Jenkins
ruling and held that interns and first-year residents are
"practitioners of medicine required to exercise the same
standard of care applicable to physicians with unlimited
licenses to practice." The Indiana Court held that although a
first-year resident practices under a temporary medical
permit, he/she impliedly contracts that he/she has the
reasonable and ordinary qualifications of her profession and
that he/she will exercise reasonable skill, diligence, and care
in treating the patient.
We find that Dr. Sanga was not independently negligent.
Although she had greater patient exposure, and was subject
to the same standard of care applicable to attending
physicians, we believe that a finding of negligence should
also depend on several competing factors, among them, her
authority to make her own diagnosis, the degree of
supervision of the attending physician over her, and the
shared responsibility between her and the attending
physicians.
In this case, before Dr. Sanga attended to Edmer, both Dr.
Livelo and Dr. Casumpang had diagnosed Edmer with
bronchopneumonia. In her testimony, Dr. Sanga admitted
that she had been briefed about Edmer’s condition, his
79
medical history, and initial diagnosis; and based on these
pieces of information, she confirmed the finding of
bronchopneumonia.
Dr. Sanga likewise duly reported to Dr. Casumpang, who
admitted receiving updates regarding Edmer’s
80
condition. There is also evidence supporting Dr. Sanga’s
claim that she extended diligent care to Edmer. In fact, when
she suspected – during Edmer’s second episode of
bleeding– that Edmer could be suffering from dengue fever,
she wasted no time in conducting the necessary tests, and
promptly notified Dr. Casumpang about the incident.
Indubitably, her medical assistance led to the finding of
dengue fever.
We note however, that during Edmer’s second episode of
81
bleeding, Dr. Sanga failed to immediately examine and
note the cause of the blood specimen. Like Dr. Casumpang,
she merely assumed that the blood in Edmer’s phlegm was
caused by bronchopneumonia. Her testimony states:
TSN, June 8, 1993:
Q: Let us get this clear, you said that the father told you the
patient cocked [sic] out phlegm.
A: With blood streak.
Q: Now, you stated specimen, were you not able to examine
the specimen?
A: No, sir, I did not because according to the father he wash
[sic] his hands.
xxxx
Q: Now, from you knowledge, what does that indicate if the
patient expels a phlegm and blood streak?
A: If a patient cocked [sic] out phlegm then the specimen
82
could have come from the lung alone. [Emphasis supplied]
xxxx
TSN, June 17, 1993:
Q: Now, in the first meeting you had, when that was relayed
to you by the father that Edmer Cortejo had coughed out
blood, what medical action did you take?
A: I examined the patient and I thought that, that coughed
out phlegm was a product of broncho pneumonia.
xxxx
Q: So what examination did you specifically conduct to see
that there was no internal bleeding? A: At that time I did not
do anything to determine the cause of coughing of the blood
because I presumed that it was a mucous (sic) produced by
broncho pneumonia, And besides the patient did not even
83
show any signs of any other illness at that time.
Based on her statements we find that Dr. Sanga was not
entirely faultless. Nevertheless, her failure to discern the
import of Edmer’s second bleeding does not necessarily
amount to negligence as the respondent himself admitted
that Dr. Sanga failed to examine the blood specimen
because he wash edit away. In addition, considering the
diagnosis previously made by two doctors, and the
uncontroverted fact that the burden of final diagnosis
pertains to the attending physician (in this case, Dr.
Casumpang), we believe that Dr. Sanga’s error was merely
an honest mistake of judgment influenced in no small
measure by her status in the hospital hierarchy; hence, she
should not be held liable for medical negligence.
Dr. Jaudian’s Professional Competence and Credibility
One of the critical issues the petitioners raised in the
proceedings before the lower court and before this Court
was Dr. Jaudian’s competence and credibility as an expert
witness. The petitioners tried to discredit his expert
testimony on the ground that he lacked the proper training
and fellowship status in pediatrics.
● Criteria in Qualifying as an Expert Witness
The competence of an expert witness is a matter for the trial
court to decide upon in the exercise of its discretion. The test
of qualification is necessarily a relative one, depending upon
the subject matter of the investigation, and the fitness of the
84
expert witness. In our jurisdiction, the criterion remains to
be the expert witness’ special knowledge experience and
practical training that qualify him/her to explain highly
technical medical matters to the Court.
85
In Ramos v. Court of Appeals, the Court found the expert
witness, who is a pulmonologist, not qualified to testify on
the field of anesthesiology. Similarly, in Cereno v. Court of
86
Appeals, a 2012 case involving medical negligence, the
Court excluded the testimony of an expert witness whose
specialty was anesthesiology, and concluded that an
anesthesiologist cannot be considered an expert in the field
of surgery or even in surgical practices and diagnosis.
Interestingly in this case, Dr. Jaudian, the expert witness
was admittedly not a pediatrician but a practicing physician
87
who specializes in pathology. He likewise does not
possess any formal residency training in pediatrics.
Nonetheless, both the lower courts found his knowledge
acquired through study and practical experience sufficient to
advance an expert opinion on dengue-related cases.
We agree with the lower courts.
A close scrutiny of Ramos and Cereno reveals that the Court
primarily based the witnesses’ disqualification to testify as an
expert on their incapacity to shed light on the standard of
care that must be observed by the defendant-physicians.
That the expert witnesses’ specialties do not match the
physicians’ practice area only constituted, at most, one of
the considerations that should not be taken out of context.
After all, the sole function of a medical expert witness,
regardless of his/her specialty, is to afford assistance to the
courts on medical matters, and to explain the medical facts
in issue.
Furthermore, there was no reasonable indication in Ramos
and Cereno that the expert witnesses possess a sufficient
familiarity with the standard of care applicable to the
physicians’ specialties. US jurisprudence on medical
malpractice demonstrated the trial courts’ wide latitude of
discretion in allowing a specialist from another field to testify
against a defendant specialist.
88
In Brown v. Sims, a neurosurgeon was found competent to
give expert testimony regarding a gynecologist's standard of
pre-surgical care. In that case, the court held that since
negligence was not predicated on the gynecologist’s
negligent performance of the operation, but primarily on the
claim that the pre-operative histories and physicals were
inadequate, the neurosurgeon was competent to testify as
an expert.
89
Frost v. Mayo Clinic also allowed an orthopedic surgeon to
testify against a neurologist in a medical malpractice action.
The court considered that the orthopedic surgeon’s opinion
on the "immediate need for decompression" need not come
from a specialist in neurosurgery. The court held that:
It is well established that "the testimony of a qualified
medical doctor cannot be excluded simply because he is not
a specialist x x x." The matter of "x x x training and
specialization of the witness goes to the weight rather than
admissibility x x x."
xxxx
It did not appear to the court that a medical doctor had to be
a specialist in neurosurgery to express the opinions
permitted to be expressed by plaintiffs’ doctors, e.g., the
immediate need for a decompression in the light of certain
neurological deficits in a post-laminectomy patient. As stated
above, there was no issue as to the proper execution of the
neurosurgery. The medical testimony supported plaintiffs’
theory of negligence and causation. (Citations omitted)
90
In another case, the court declared that it is the specialist’s
knowledge of the requisite subject matter, rather than his/her
specialty that determines his/her qualification to testify.
91
Also in Evans v. Ohanesian, the court set a guideline in
qualifying an expert witness:
To qualify a witness as a medical expert, it must be shown
that the witness (1) has the required professional knowledge,
learning and skill of the subject under inquiry sufficient to
qualify him to speak with authority on the subject; and (2) is
familiar with the standard required of a physician under
similar circumstances; where a witness has disclosed
sufficient knowledge of the subject to entitle his opinion to go
to the jury, the question of the degree of his knowledge goes
more to the weight of the evidence than to its admissibility.
xxxx
Nor is it critical whether a medical expert is a general
practitioner or a specialist so long as he exhibits knowledge
of the subject. Where a duly licensed and practicing
physician has gained knowledge of the standard of care
applicable to a specialty in which he is not directly engaged
but as to which he has an opinion based on education,
experience, observation, or association wit that specialty, his
opinion is competent.(Emphasis supplied)
92
Finally, Brown v. Mladineo adhered to the principle that the
witness’ familiarity, and not the classification by title or
specialty, which should control issues regarding the expert
witness’ qualifications:
The general rule as to expert testimony in medical
malpractice actions is that "a specialist in a particular branch
within a profession will not be required." Most courts allow a
doctor to testify if they are satisfied of his familiarity with the
standards of a specialty, though he may not practice the
specialty himself. One court explained that "it is the scope of
the witness’ knowledge and not the artificial classification by
title that should govern the threshold question of
admissibility. (Citations omitted)
● Application to the Present Case
In the case and the facts before us, we find that Dr. Jaudian
is competent to testify on the standard of care in dengue
fever cases.1avvphi1
to less than 2%. Hence, the survival of the patient is directly
95
related to early and proper management of the illness.
To reiterate, Dr. Casumpang failed to timely diagnose Edmer
with dengue fever despite the presence of its characteristic
symptoms; and as a consequence of the delayed diagnosis,
he also failed to promptly manage Edmer’s illness. Had he
immediately conducted confirmatory tests, (i.e., tourniquet
tests and series of blood tests)and promptly administered
the proper care and management needed for dengue fever,
the risk of complications or even death, could have been
substantially reduced.
Furthermore, medical literature on dengue shows that early
diagnosis and management of dengue is critical in reducing
the risk of complications and avoiding further spread of the
96
virus. That Edmer later died of "Hypovolemic
Shock/hemorrhagic shock," "Dengue Hemorrhagic Fever
Stage IV," a severe and fatal form of dengue fever,
established the causal link between Dr. Casumpang’s
negligence and the injury.
Based on these considerations, we rule that the respondent
successfully proved the element of causation.
Liability of SJDH
We now discuss the liability of the hospital.

The respondent submits that SJDH should not only be held

Although he specializes in pathology, it was established
vicariously liable for the petitioning doctors’ negligence but
during trial that he had attended not less than 30 seminars
also for its own negligence. He claims that SJDH fell short of
held by the Pediatric Society, had exposure in pediatrics,
its duty of providing its patients with the necessary facilities
had been practicing medicine for 16 years, and had handled
and equipment as shown by the following circumstances:
not less than 50 dengue related cases.

(a) SJDH was not equipped with proper paging

As a licensed medical practitioner specializing in pathology,
system;
who had practical and relevant exposure in pediatrics and
dengue related cases, we are convinced that Dr. Jaudian
demonstrated sufficient familiarity with the standard of care (b) the number of its doctors is not proportionate to
to be applied in dengue fever cases. Furthermore, we agree the number of patients;
that he possesses knowledge and experience sufficient to
qualify him to speak with authority on the subject.
(c) SJDH was not equipped with a bronchoscope;

The Causation Between Dr. Casumpang’s

(d) when Edmer’s oxygen was removed, the
Negligent Act/Omission, and the Patient’s
Resulting Death was Adequately Proven medical staff did not immediately provide him with
portable oxygen;

Dr. Jaudian’s testimony strongly suggests that due to Dr.

Casumpang’s failure to timely diagnose Edmer with dengue,
the latter was not immediately given the proper treatment. In
fact, even after Dr. Casumpang had discovered Edmer’s real
illness, he still failed to promptly perform the standard
medical procedure. We agree with these findings.
As the respondent had pointed out, dengue fever, if left
untreated, could be a life threatening disease. As in any fatal
93
diseases, it requires immediate medical attention. With the
correct and timely diagnosis, coupled with the proper
medical management, dengue fever is not a life threatening
94
disease and could easily be cured.
Furthermore, as Dr. Jaudian testified, with adequate
intensive care, the mortality rate of dengue fever should fall
(e) when Edmer was about to be transferred to
another hospital, SJDH’s was not ready and had
no driver; and
(f) despite Edmer’s critical condition, there was no
doctor attending to him from 5:30 p.m. of April 22,
to 9:00 a.m. of April 23, 1988.
SJDH on the other hand disclaims liability by claiming that
the petitioning doctors are not its employees but are mere
consultants and independent contractors.
We affirm the hospital’s liability not on the basis of Article
2180 of the Civil Code, but on the basis of the doctrine of
apparent authority or agency by estoppel.
There is No Employer-Employee Relationship The doctrine was applied in Nogales v. Capitol Medical
101
Center where this Court, through the ponencia of
Associate Justice Antonio T. Carpio, discussed the two
Between SJDH and the Petitioning Doctors
factors in determining hospital liability as follows:

In determining whether an employer-employee relationship

The first factor focuses on the hospital’s manifestations and
exists between the parties, the following elements must be
is sometimes described as an inquiry whether the hospital
present: (1) selection and engagement of services; (2)
acted in a manner which would lead a reasonable person to
payment of wages; (3) the power to hire and fire; and (4) the
conclude that the individual who was alleged to be negligent
power to control not only the end to be achieved, but the
97 was an employee or agent of the hospital. In this regard, the
means to be used in reaching such an end.
hospital need not make express representations to the
patient that the treating physician is an employee of the
Control, which is the most crucial among the elements, is not hospital; rather a representation may be general and implied.
present in this case.
xxxx
Based on the records, no evidence exists showing that
SJDH exercised any degree of control over the means,
The second factor focuses on the patient's reliance. It is
methods of procedure and manner by which the petitioning
sometimes characterized as an inquiry on whether the
doctors conducted and performed their medical profession.
plaintiff acted in reliance upon the conduct of the hospital or
SJDH did not control their diagnosis and treatment.
its agent, consistent with ordinary care and prudence.
Likewise, no evidence was presented to show that SJDH
(Citation omitted)
monitored, supervised, or directed the petitioning doctors in
the treatment and management of Edmer’s case. In these
lights, the petitioning doctors were not employees of SJDH, In sum, a hospital can be held vicariously liable for the
but were mere independent contractors. negligent acts of a physician (or an independent contractor)
providing care at the hospital if the plaintiff can prove these
two factors: first, the hospital’s manifestations; and second,
SJDH is Solidarily Liable Based
the patient’s reliance.
on The Principle of Agency or Doctrine
of Apparent Authority
a. Hospital’s manifestations
Despite the absence of employer-employee relationship
between SJDH and the petitioning doctors, SJDH is not free It involves an inquiry on whether the hospital acted in a
98
from liability. manner that would lead a reasonable person to conclude
that the individual alleged to be negligent was an employee
or agent of the hospital. As pointed out in Nogales, the
As a rule, hospitals are not liable for the negligence of its
hospital need not make express representations to the
independent contractors. However, it may be found liable if
patient that the physician or independent contractor is an
the physician or independent contractor acts as an
employee of the hospital; representation may be general and
ostensible agent of the hospital. This exception is also 102
99 implied.
known as the "doctrine of apparent authority."
103
In Pamperin v. Trinity Memorial Hospital, questions were
The US case of Gilbert v. Sycamore Municipal
100 raised on "what acts by the hospital or its agent are sufficient
Hospital abrogated the hospitals’ immunity to vicarious
to lead a reasonable person to conclude that the individual
liability of independent contractor physicians. In that case,
was an agent of the hospital." In ruling that the hospital’s
the Illinois Supreme Court held that under the doctrine of
manifestations can be proven without the express
apparent authority, hospitals could be found vicariously liable
representation by the hospital, the court relied on several
for the negligence of an independent contractor:
cases from other jurisdictions, and held that:

Therefore, we hold that, under the doctrine of apparent

(1) the hospital, by providing emergency room
authority, a hospital can be held vicariously liable for the
care and by failing to advise patients that they
negligent acts of a physician providing care at the hospital,
were being treated by the hospital’s agent and not
regardless of whether the physician is an independent
its employee, has created the appearance of
contractor, unless the patient knows, or should have known,
agency; and
that the physician is an independent contractor. The
elements of the action have been set out as follows:
(2) patients entering the hospital through the
emergency room, could properly assume that the
For a hospital to be liable under the doctrine of apparent
treating doctors and staff of the hospital were
authority, a plaintiff must show that: (1) the hospital, or its
acting on its behalf.1âwphi1
agent, acted in a manner that would lead a reasonable
person to conclude that the individual who was alleged to be
negligent was an employee or agent of the hospital; (2) In this case, the court considered the act of the hospital of
where the acts of the agent create the appearance of holding itself out as provider of complete medical care, and
authority, the plaintiff must also prove that the hospital had considered the hospital to have impliedly created the
knowledge of and acquiesced in them; and (3) the plaintiff appearance of authority.
acted in reliance upon the conduct of the hospital or its
agent, consistent with ordinary care and prudence.
b. Patient’s reliance
(Emphasis supplied)
It involves an inquiry on whether the plaintiff acted in reliance as moral damages should each earn legal interest at the rate
on the conduct of the hospital or its agent, consistent with of six percent (6%) per annum computed from the date of
104
ordinary care and prudence. the judgment of the trial court. The Court AFFIRMS the rest
of the Decision dated October 29, 2004 and the Resolution
dated January 12, 2006 in CA-G.R. CV No. 56400.
In Pamperin, the court held that the important consideration
in determining the patient’s reliance is: whether the plaintiff is
seeking care from the hospital itself or whether the plaintiff is SO ORDERED.
looking to the hospital merely as a place for his/her personal
105
physician to provide medical care. Thus, this requirement
is deemed satisfied if the plaintiff can prove that he/she
relied upon the hospital to provide care and treatment, rather
than upon a specific physician. In this case, we shall limit the
determination of the hospital’s apparent authority to Dr.
Casumpang, in view of our finding that Dr. Sanga is not
liable for negligence.

SJDH Clothed Dr. Casumpang With Apparent Authority

SJDH impliedly held out and clothed Dr. Casumpang with

apparent authority leading the respondent to believe that he
is an employee or agent of the hospital.

Based on the records, the respondent relied on SJDH rather

than upon Dr. Casumpang, to care and treat his son Edmer.
His testimony during trial showed that he and his wife did not
know any doctors at SJDH; they also did not know that Dr.
Casumpang was an independent contractor. They brought
their son to SJDH for diagnosis because of their family
doctor’s referral. The referral did not specifically point to Dr.
Casumpang or even to Dr. Sanga, but to SJDH.
Significantly, the respondent had relied on SJDH’s
representation of Dr. Casumpang’s authority. To recall, when
Mrs. Cortejo presented her Fortune Care card, she was
initially referred to the Fortune Care coordinator, who was
then out of town. She was thereafter referred to Dr.
Casumpang, who is also accredited with Fortune Care. In
both instances, SJDH through its agent failed to advise Mrs.
Cortejo that Dr. Casumpang is an independent contractor.

Mrs. Cortejo accepted Dr. Casumpang’s services on the

reasonable belief that such were being provided by SJDH or
its employees, agents, or servants. By referring Dr.
Casumpang to care and treat for Edmer, SJDH impliedly
held out Dr. Casumpang, not only as an accredited member
of Fortune Care, but also as a member of its medical staff.
SJDH cannot now disclaim liability since there is no showing
that Mrs. Cortejo or the respondent knew, or should have
known, that Dr. Casumpang is only an independent
contractor of the hospital. In this case, estoppel has already
set in.

We also stress that Mrs. Cortejo’s use of health care plan

(Fortune Care) did not affect SJDH’s liability. The only effect
of the availment of her Fortune Care card benefits is that her
choice of physician is limited only to physicians who are
accredited with Fortune Care. Thus, her use of health care
plan in this case only limited the choice of doctors (or
coverage of services, amount etc.) and not the liability of
doctors or the hospital.

WHEREFORE, premises considered, this Court PARTLY

GRANTS the consolidated petitions. The Court finds Dr.
Noel Casumpang and San Juan de Dios Hospital solidarily
liable for negligent medical practice. We SET ASIDE the
finding of liability as to Dr. Ruby Miranda-Sanga. The
amounts of ₱45,000.00 as actual damages and ₱500,000.00