Blue Cross Health Care, Inc. vs. Olivares, G.R. No. 169737

February 12, 2008.

FACTS

Olivares applied for a health care program with petitioner Blue Cross Health Care. In the agreement, ailments due to “pre-existing conditions” were excluded from the coverage. Neomi suffered a stroke and was admitted at the Medical City and incurred hospital expenses amounting to P34,217. Petitioner refused to pay the bills until Olivares attending physician submits a certification that the stroke she suffered was not caused by a pre-existing condition.

         Petitioner argues that respondents prevented Dr. Saniel from submitting his report regarding the medical condition of Neomi.

         Respondents counter that the burden was on petitioner to prove that Neomi’s stroke was excluded from the coverage of their agreement because it was due to a pre-existing condition.

         The METC dismissed the complaint of Olivares for lack of cause of action. RTC reversed the ruling of the MeTC and ordered petitioner to pay respondents. The CA affirmed the decision of the RTC.

ISSUE

WON Blue Cross shall enjoy the presumption that evidence willfully suppressed would be adverse if produced should apply in its favor.

HELD

NO. It is an established rule in insurance contracts that when their terms contain limitations on liability, they should be construed strictly against the insurer. Petitioner never presented any evidence to prove that respondent Neomi’s stroke was due to a pre-existing condition. Respondents’ refusal to present or allow the presentation of Dr. Saniel’s report was justified. It was privileged communication between physician and patient.

Limitations of liability on the part of the insurer or health care provider must be construed in such a way as to preclude it from evading its obligations. Accordingly, they should be scrutinized by the courts with “extreme jealousy” and“care” and with a “jaundiced eye.”

Notes

In Philamcare Health Systems, Inc. v. CA, we ruled that a health care agreement is in the nature of a non-life insurance.

The health care agreement defined a “pre-existing condition” as:

x x x a disability which existed before the commencement date of membership whose natural history can be clinically determined, whether or not the Member was aware of such illness or condition. Such conditions also include disabilities existing prior to reinstatement date in the case of lapse of an Agreement. Notwithstanding, the following disabilities but not to the exclusion of others are considered pre-existing conditions including their complications when occurring during the first year of a Member’s coverage.

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