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Philamcare vs. Trinos: Insurance Claim Ruling

Philamcare denied Julita Trinos' claim for her deceased husband's health care benefits, claiming concealment in his application regarding his medical history. The Supreme Court ruled that Philamcare's denial was unjustified. Ernani answered the health questions in good faith based on his own understanding, not as a medical expert. Answers made in good faith will not void an insurance policy. The health care agreement was a contract of indemnity, so Philamcare was obligated to pay covered expenses Ernani incurred.

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Jarvin David Resus
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110 views2 pages

Philamcare vs. Trinos: Insurance Claim Ruling

Philamcare denied Julita Trinos' claim for her deceased husband's health care benefits, claiming concealment in his application regarding his medical history. The Supreme Court ruled that Philamcare's denial was unjustified. Ernani answered the health questions in good faith based on his own understanding, not as a medical expert. Answers made in good faith will not void an insurance policy. The health care agreement was a contract of indemnity, so Philamcare was obligated to pay covered expenses Ernani incurred.

Uploaded by

Jarvin David Resus
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Philamcare Health Systems, Inc., petitioner, v.

Court of Appeals and


Julita Trinos, respondent
G.R. No. 125678, March 18, 2002
FACTS: Respondent Julita Trinos' deceased husband, Ernani Trinos, applied for
a health care program with petitioner Philamcare Health Systems (Philamcare).
In his application form, he was asked if he was ever been treated for high blood
pressure, heart trouble, diabetes, cancer, liver disease, asthma or peptic ulcer and
he answered no. The application was approved and during the period of its
effectivity, Ernani suffered a heart attack resulting in confinement in Manila
Medical Center. Julita Trinos tried to claim from Philamcare the benefits under
the health care agreement. Philamcare denied her claim saying that the health
care agreement was void because there was concealment in his application
regarding his medical history.
ISSUE: Whether Philamcare was justified in denying Julita Trinos’ claim.
RULING: NO. The health care agreement entered into by Ernani with
Philamcare is a non-life insurance which is covered by the Insurance Law. An
insurance contract is a contract of indemnity. Once the member incurs hospital,
medical, or any other expenses arising from sickness, injury, or other
contingency, the health care provider must pay for the same to the extend agreed
upon in the contract. There was no concealment on the part of Ernani because he
answered the question with good faith. He was not a medical doctor hence his
answer in his application is his personal opinion and not a fact. Answers made in
good faith will not void the policy.
KEY CONCEPTS:
Contract of Indemnity
-The insured is entitled to recover only the amount of total loss sustained, and the
burden is upon him to prove the amount of such loss. The purpose of insurance is
to leave the insured in the same financial position as he was in immediately prior
to the incident loss, damage, or liability.
Contingent or unknown event
-Section 3 of the Insurance Code states that any contingent or unknown event,
whether past or future, which may damnify a person having an insurable interest
against him, may be insured against. Every person has an insurable interest in
the life and health of himself.
Concealment / Misrepresentation as a defense
-The fraudulent intent on the part of the insured must be established to warrant
rescission of the insurance contract. Concealment as a defense for the health care
provider or insurer to avoid liability is an affirmative defense and the duty to
establish such defense by satisfactory and convincing evidence rests upon the
provider or insurer.

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