Blue Cross & Blue Shield of Mississippi, Inc. v. Campbell
| Decision Date | 19 December 1984 |
| Docket Number | No. 54744,54744 |
| Citation | 466 So.2d 833 |
| Parties | BLUE CROSS & BLUE SHIELD OF MISSISSIPPI, INC., et al. v. William T. CAMPBELL. |
| Court | Mississippi Supreme Court |
Blue Cross & Blue Shield of Mississippi, Inc., appeals from a judgment of the Circuit Court of Washington County in favor of William T. Campbell for $10,000 damages beyond his policy coverage with Blue Cross.
Finding no conduct by Blue Cross which would justify a claim for damages in excess of the policy provisions, we reverse and render judgment for Blue Cross.
Campbell made application on October 2, 1980, for a non-group insurance policy with Blue Cross. In answer to the question of whether he had ever been treated for, or had known indication for (among other things) "alcoholism," he marked "No." He was likewise asked about "ulcer" and the answer was "No."
The face of the application signed by Campbell in bold face type states:
I agree, that in the event illness, disease or infirmity for which I or my dependents, if any, receive care or treatment during the first twelve months after the effective date of the contract, has resulted from causes existing prior to the effective date of the contract, then no benefits shall be provided during or on account of such illness, disease or infirmity.
On October 16, 1980, Blue Cross issued a non-group policy to Campbell. It contained an exclusion for, or as a result of, any ailment or disease or physical condition existing at or before the effective date of the contract. The contract further provided that after the policy had been in force twelve months this exclusion would not apply, except for a congenital defect.
On December 3, 1980, six weeks later, Campbell appeared at the Emergency Room of Delta Medical Center in Greenville, a local hospital (Delta Medical). He was discharged December 19, 1980.
Delta Medical in due course sent a claim to Blue Cross for Campbell's hospitalization, showing the total hospital charges to be $8,210.87. The claim form gave as Campbell's diagnosis: "acute alcoholic pancreatitis."
Of the total hospital charge of $8,210.87 for this first hospitalization in December, 1980, $4,555.75 was for drugs.
The claim form also contained the following statement signed by Campbell:
AUTHORIZATION TO PAY INSURANCE BENEFITS:
I hereby authorize payment directly to the above-named hospital of the Hospital Benefits, herein specified and otherwise payable to me but not to exceed the hospital's regular charges for this period of hospitalization. I understand that I am financially responsible to the hospital for charges not covered by this authorization.
The medical staff of Blue Cross questioned this claim (hereinafter detailed), and on February 19, 1981, sent a form letter to the medical records librarian of Delta Medical requesting Campbell's history and physical, and Discharge Summary. The final paragraph of this form letter states the following:
Payment of this claim will be delayed pending receipt and review of the above information. This information must be received within 20 days from the date of this request in order to avoid a denial due to lack of medical information. Please attach a copy of this request to the information to insure prompt handling.
Your assistance and cooperation are appreciated.
This form letter shows that a copy was mailed to Campbell at his Greenville address.
Apparently, Blue Cross received no reply from Delta Medical, and again on March 2, 1981, sent the same form letter to Delta Medical.
Following receipt of this information Delta Medical sent the requested hospital information. The following are sentences extracted from Campbell's Discharge Summary:
... he stated that he had been drinking alcohol excessively on the week end and after that for an extended period of time.
* * *
His past history further revealed that he had been treated in the past due to duodenal ulcer and he was a known alcohol abuser.
* * *
After the 5th hospital day the patient showed signs of alcohol withdrawal, became disoriented, combative. This was managed with Haldol 5 mgs. given every 4 hours unless the patient was over sedated.
The following sentences are extracted from Campbell's History:
HPI (History of Present Illness):
This patient was brought to the Emergency Room service with abdominal pain, nausea and vomiting of one day's duration. He denied any diarrhea and stated that he had been drinking alcohol too much on the week end and every week end for quite an extended period of time.
* * *
PH (Past History):
He has been treated in the past due to duodenal ulcer.... He states that he has had a very heavy drinking habit, especially on the week ends for the past several years. [Emphasis added]
From Campbell's Physical Examination the following diagnosis is quoted:
DIAGNOSIS:
Acute pancreatitis possibly due to alcoholism.
Active duodenal ulcer.
General debility due to the above. 1
All of the above hospital records are signed by J.B. Yeldell, M.D.
Based on the hospital records transmitted to them, Blue Cross denied the claim.
On March 26, 1981, Campbell signed a Discharge Payment Agreement with Delta Medical. The agreement recited his hospitalization from December 3 to December 19, 1980, and that the total bill was $8,180.87. In the agreement Campbell promised to pay this account at the rate of $50 a month, with no provision for interest, beginning May 1, 1981. The agreement does provide that in the event of a default Delta Medical could charge a collection fee of 15 percent upon the amount due.
Campbell was again hospitalized in Delta Medical on April 28, 1981, and discharged May 11, 1981. The claim to Blue Cross dated May 13, 1981, showed charges for hospitalization to be $2,823.28. The diagnosis on this claim states:
DIAGNOSIS:
Acute Pancreatitis along with acute gastritis UTI (urinary tract infection), etiology undetermined--possible duodenal ulcer, active.
This form, also signed by Campbell, likewise authorizes the payment of all benefits directly to the hospital. Also, across the face of the statement for hospital transmitted to Blue Cross there is stamped the following: "INSURANCE BENEFITS ASSIGNED TO DELTA MEDICAL CENTER." The History signed by Dr. Yeldell in this second hospitalization states that the past history revealed Campbell "has been treated in the past due to pancreatitis, gastritis, duodenitis and peptic ulcer disease," and because of this he was readmitted for further evaluation and treatment. The history showed that he had been treated in December for pancreatitis, and a duodenal ulcer.
In the Discharge Summary, the doctor stated: The Discharge Summary also stated that Campbell had a small active duodenal ulcer.
The Physical Examination of Campbell gave the following diagnosis:
DIAGNOSIS:
Acute pancreatitis along with acute gastritis.
Urinary tract infection, etiology undetermined.
Possible duodenal ulcer active.
Again, the Physical Examination, history and Discharge Summary are all signed by Dr. Yeldell.
On May 21, 1981, Blue Cross received from Delta Medical a copy of the original claim submitted for the December hospitalization. It is the same as the original transmitted, except a barely discernible line is drawn through, or at the bottom of "Acute alcoholic," and further over on the form there is typed: "Acute Pancreatitis," and there is printed in someone's handwriting the following statement across the face of this copy:
CORRECTIVE BILLING
Wrong diagnosis
Submitted
________________________ Al
Because there had been no correction of the hospital records, Blue Cross still denied the claim. Campbell was hospitalized again on June 16, 1981, to June 22, 1981. Again Delta Medical sent a claim form to Blue Cross with the diagnosis of "Acute Pancreatitis and small duodenal ulcer." This claim form also contains the signed authorization to pay all benefits to Delta Medical. Also, there is stamped on the face of the statement: "INSURANCE BENEFITS ASSIGNED TO DELTA MEDICAL CENTER." The total hospital charges were $1,514.50.
The final diagnosis for this hospitalization gave "acute pancreatitis, Small Duodenal Ulcer."
The secondary diagnosis or complications gave "alcohol Abuse."
Dr. Yeldell's history stated in part:
The Physical Examination gave a diagnosis of "acute pancreatitis, with a possible active duodenal ulcer." These are signed by Dr. Yeldell.
In July, 1981, Campbell employed a Greenville attorney, Leslie D. King, who wrote a letter to Blue Cross dated July 31, 1981, requesting reconsideration of, and payment of the claim. King's letter enclosed a handwritten note from Dr. Yeldell stating that Campbell's was not a pre-existing condition. This letter with the doctor's statement was received by Blue Cross on August 7, 1981. Blue Cross responded to King's letter by letter dated August 27, 1981, the following:
Dear Mr. King:
In response to your correspondence, we have again reviewed the medical records pertaining to Mr. Campbell's admissions on December 3, 1980, April 28, 1981, and June 16, 1981, to Delta Medical Center.
Your correspondence included a letter from Dr. Yeldell. Based on the information supplied by Dr. Yeldell, it has been determined that benefits can be provided for these confinements. Therefore, payment will be made toward the previously denied charges in the near future.
Should there be any questions, please do not hesitate to contact us.
S/Ms. Linda Guenin, R.N.
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