Aetna Life Ins. Co. v. Evins, 44466

Decision Date29 May 1967
Docket NumberNo. 44466,44466
PartiesAETNA LIFE INSURANCE COMPANY, Defendant-Appellant, v. George Stanley EVINS, Plaintiff-Appellee.
CourtMississippi Supreme Court

Elizabeth Hulen, Watkins & Eagar, Jackson, for appellant.

Lancaster, Baxter & Seale, Tallulah, La., Teller, Biedenharn & Rogers, Vicksburg, for appellee.

PATTERSON, Justice:

This appeal is prosecution by Aetna Life Insurance Company from a judgment non obstante veredicto of the Circuit Court of the First Judicial District of Hinds County entered after a trial jury had returned a verdict for Aetna and against the insured appellee, George Stanley Evins.

Evins had brought suit for benefits under a policy of health and accident insurance issued by Aetna. The policy provided for monthly benefits of $200 for total disability from sickness. It was issued on May 2, 1962, and by November 1962 appellee had become totally disabled from multiple sclerosis.

The policy called for payment of benefits for five years. Aetna paid benefits for one year and stopped further payments on the ground that a rider attached to the policy contract limited indemnity to twelve months for total disability 'resulting from any affection of the brain.'

In his January 1962 application for insurance, Evins noted that he previously had been treated for a brain concussion. Aetna's medical director, Dr. John O. Alden, sent a 'Skull Questionnaire' regarding the injury to Evins' attending physician, Dr. Frank Padberg. Aetna issued the policy on May 2, 1962, with the following rider attached.

IMPAIRED CONDITION COVERAGE RIDER

In consideration of the payment of the special class premium stated below, it is hereby agreed that:

1. Part II of this Policy entitled 'Total Disability', as it pertains to Sickness, is modified so that in no event shall the maximum period for which monthly indemnity is payable for any one period of total disability resulting from any affection of the brain exceed 12 months.

2. No claim for benefits under this Policy on account of loss resulting from accidental bodily injuries sustained or from sickness contracted and commencing on or after the effective date of the Policy shall be reduced or denied on the grounds that the Insured contracted or suffered from brain disorder before the Policy Date, except as stated in this Rider.

3. The special class 1 Month premium is $1.52 which is included in the premium stated in the Policy.

Both appellant and appellee requested and were refused peremptory instructions.

Appellant assigns as error the circuit court's action in setting aside the jury verdict and entering judgment for appellee notwithstanding the verdict of the jury, and in failing to grant appellant a directed verdict.

It is Aetna's contention that the rider was attached, not because of Evins' April 1960 brain concussion, but because of Dr. Alden's recommendation, which he said was prompted by the bizarre neurological symptoms reported by Dr. Padberg in the questionnaire.

The appellant argues that there was not only ample evidence to sustain a verdict for the defendant, but that the great weight of the evidence was to the effect that the appellee was totally disabled from an affection of the brain and that this was a jury issue.

The appellee maintains that the policy provided coverage for disability resulting from the disease of multiple sclerosis for a period of five years and that the 'impaired condition coverage rider' which reduces the indemnity period when disability results from 'brain affection' is not applicable. He contends that multiple sclerosis is a spontaneous disease of unknown origin and this disease resulted in the disability suffered by appellee; that multiple sclerosis is not produced by an 'affection of the brain' and that under the policy the producing and responsible cause of the disability is the determinative factor. He contends, apart from the foregoing, that the evidence conclusively shows that appellee was totally disabled due to nerve damage in his spinal cord resulting from multiple sclerosis independent of 'any affection of the brain.'

The parties admit and the evidence reflects that the appellee is totally disabled from multiple sclerosis.

This disease was defined by Dr. Alden, an assistant medical director for the appellant, in his deposition, as being 'an affection of the brain.' This definition was not elaborated upon by question or answer to determine if the disease also included the spinal cord.

Dr. Robert Currier, a neurologist and witness for the appellant, defined multiple sclerosis as follows:

This is a disease of the central nervous system, the brain and the spinal cord, of unknown cause, but due to defects in the myelin coverings of the central nerves, the nerves in the brain and the spinal cord. These coverings normally, most people believe, act like insulation, and once these coverings deteriorate or degenerate, then the nerve fibers that go through the coverings don't work any more, so you have areas of poor function of the body that is run by these parts of the nervous system. It's a demyelinating disease, if that explains anything.

He defined the brain as being that part of the central nervous system contained within the skull, which includes the cerebral hemispheres, the cerebellum, and the brain stem.

Dr. Richard W. Naef, a neurologist and witness for the appellee, testified that no one knows the actual cause of multiple sclerosis. 'It gets its name because there are multiple areas of scarring. * * * There is no other disease process which you might term an affection of the brain which causes multiple sclerosis. Multiple sclerosis is a spontaneous disease of itself, not coming from any other disease or any affection of the brain,' and 'It involves the central nervous system.' Later he testified that the central nervous system consists of the brain and the spinal cord.

Multiple sclerosis is defined as:

A disease of the brain and spinal cord. The spinal cord is the 'cable' of nerves in the spinal column. In this condition, various parts of the brain and spinal cord are subjected to a type of deterioration called sclerosis. (Schmidt, Attorneys Dictionary of Medicine and Word Finder (1965).

and

A demyelinating disease involving the central nervous system. By 'demyelination' is meant that there is a loss of the myelin insulating sheaths about the nerve fibers in the tract of the brain and spinal cord. (3 Gray, Attorney's Textbook of Medicine, Sec. 88.68(4) 1965).

The record reflects the following uncontroverted facts: (1) the issuance to the insured of the policy with the attached rider which excludes disability payments for a period longer than 12 months when such disability results from 'any affection of the brain,' and (2) the disability of the insured from multiple sclerosis, the same having become manifest after the issuance of the policy.

The primary question to be determined is whether the exclusionary provision of the rider is limited to an affection of the brain, meaning a disease of that organ which is located within the skull, or whether the language thereof is broad enough to exclude coverage for a disability resulting from a disease of the central nervous system which is composed of both the brain and the spinal cord. The rider did not exclude multiple sclerosis by name or specific description although the rider was attached, as contended by appellant, as the result of the bizarre neurological symptoms (headaches, altered coordination, and weakness of the right leg) reported to it in the questionnaire at the time of the issuance of the policy.

Under the undisputed evidence, an 'affection' of the brain is the same as a disease of the brain. It is difficult to define precisely what is meant by 'any affection...

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