Aetna Life Ins. Co. v. Bocanegra, 15933
| Decision Date | 13 September 1978 |
| Docket Number | No. 15933,15933 |
| Parties | AETNA LIFE INSURANCE CO., Appellant, v. Janie P. BOCANEGRA, Appellee. |
| Court | Texas Court of Appeals |
The Plaintiff, Janie P. Bocanegra, filed this suit against the defendant, Aetna Life Insurance Company, seeking to recover on a group health insurance policy that provided coverage for the plaintiff for medical expenses incurred in a non-occupational injury or disease while she was an employee of the Clegg Company. Trial was held before a jury, and it found that the medical services received by plaintiff resulted from a non-occupational disease and that the reasonable medical expenses amounted to $4,500.00 and for attorney's fees.
Prior to filing this suit, plaintiff filed a claim with the Industrial Accident Board for the same injury. We quote from the statement of facts in plaintiff's brief:
At all times material to this incident, she was employed at the Clegg Company, where she had worked since October of 1965. The employees of the Clegg Company, at all times material, were covered by a group health insurance policy issued by Aetna Insurance Company. During her hospitalization, in mid-August, 1975, Plaintiff filed a Notice of Injury or Occupational Disease and Claim for Compensation with the Texas Industrial Accident Board. She did this in the belief that the acute pain she suffered on or about June 3, 1975 was the result of a work related injury. This belief was based on the information she received from her doctor and friends at the time of her admission to the hospital, and during her stay there.
Fireman's Fund Insurance Company was the Clegg Company's worker's compensation insurer. Although it disputed liability on this claim based on the belief that it was not a job related injury, on October 27, 1975, it agreed to enter into a Compromise Settlement Agreement, paying the Plaintiff Twelve Thousand & No/100 ($12,000.00) Dollars for lost wages and future impaired earning capability. This settlement specifically provided no compensation for a past or future medical or hospital expenses, but was solely for lost wages and future impaired earning capacity. Fireman's Fund maintained that 'Liability is Disputed'.
Defendant's contention, as stated in its brief, is as follows:
Appellant says that by virtue of the Appellee's filing such claim with the Industrial Accident Board of the State of Texas and securing workmen's compensation benefits from the Fireman's Fund, which was the workmen's compensation carrier for The Clegg Company, she is estopped to make a claim against Appellant for medical expenses under the group policy which would only cover expenses if the claim were to arise out of a non-occupational injury and/or disease. 1
We sustain this contention.
Plaintiff took the position in her workmen's compensation claim that her injury was in the course of her employment with the Clegg Company and originated in her work with the company. She now takes the opposite view that her medical expenses were the result...
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