Philamcare Health Systems, Inc. v.

Court of Appeals
G.R. No. 125678, [March 18, 2002], 429 PHIL 82-95
Doctrine:
A health-care agreement may be considered as an insurance contract.
Facts:
Ernani Trinos, was issued a Health Care Agreement for health coverage with
petitioner Philamcare Health Systems, Inc. Ernani suffered a heart attack and was
confined in the hospital. Julita, his wife, tried to claim the benefits under the
health care agreement, but Philamcare denied her claim, therefore, Julita paid the
hospitalization expenses herself.
Julita filed an action for damages against Philamcare and its president, Dr.
Benito Reverente. The trial court ruled in favor of Julita and awarded damages.
On appeal, the Court of Appeals affirmed the decision of the trial court but
deleted all awards for damages and absolved Dr. Reverente. Philamcare brought
the case to the Supreme Court, arguing that a health care agreement is not an
insurance contract.
Issue:
Whether a health-care agreement is considered an insurance contract.
Ruling:
The Supreme Court ruled that a health care agreement is considered a non-
life insurance contract.
An insurance contract exists when certain elements are present, including
the insured having an insurable interest, being subject to a risk of loss, the insurer
assuming the risk, the assumption of risk being part of a general scheme to
distribute losses, and the insured paying a premium.
In a health-care agreement, if the member incurs hospital, medical, or any
other expense arising from sickness, injury, or other stipulated contingencies, the
health care provider must pay for the same to the extent agreed upon under the
contract. The health care agreement, therefore, met the elements given in the
preceding paragraph, and thus be considered a non-life insurance contract.