Blue Cross & Blue Shield of Mississippi, Inc. v. Mosley

• Decision Date: 04 August 1975
• Docket Number: No. 48147,48147
• Citation: 317 So.2d 58
• Parties: BLUE CROSS & BLUE SHIELD OF MISSISSIPPI, INC. (formerly Mississippi Hospital & Medical Service) v. Mrs. Edna MOSLEY.
• Court: Mississippi Supreme Court

Page 58

317 So.2d 58

BLUE CROSS & BLUE SHIELD OF MISSISSIPPI, INC. (formerly Mississippi Hospital & Medical Service) v. Mrs. Edna MOSLEY.

No. 48147.

Supreme Court of Mississippi.

Aug. 4, 1975.

McDavid & Rimmer, Jackson, for appellant.

William R. Barnett, Jackson, for appellee.

Before PATTERSON, INZER, and WALKER, JJ.

INZER, Justice.

This is an appeal by Blue Cross & Blue Shield of Mississippi, Inc. from a judgment of the Circuit Court of the First Judicial District of Hinds County awarding appellee Mrs. Edna Mosley $1,408.25 in benefits allegedly due under the terms of a medical insurance contract issued by the appellant.

The insurance contract in question was issued on February 1, 1971, and a major medical endorsement was added to the contract on August 1, 1971. In September 1971 Mrs. Mosley was hospitalized and underwent surgery for which she filed claims for benefits alleged to be due under the policy. Appellant denied liability on the ground that the ailment, disease, or physical condition for which the claims were submitted was contracted prior to the effective date of the policy. Mrs. Mosley then brought this suit.

Appellant admits that the contract was in full force and effect at the time these claims arose, but urges that the disease, ailment or physical condition was contracted, commenced, manifested and actually diagnosed prior to the effective date of the contract, and under the express terms of the contract was not covered thereby. The pertinent provision of the contract reads as follows:

B. NO BENEFITS WILL BE PROVIDED FOR:

1. Any services rendered or supplies provided for, or as the result of, any ailment, disease or physical condition existing at or before the effective date of this contract.

By agreement of the parties this cause was tried before the trial judge without the intervention of the jury. The only witnesses were Mrs. Mosley and the treating physician and surgeon. Mrs. Mosley testified that in 1960 she went to Dr. Blanche Lockard because of excessive bleeding following the birth of her fourth child. After an examination by Dr. Lockard, she was advised that she needed surgery. Because of her financial condition, she said she requested Dr. Lockard to refer her to the University Hospital. There she was examined by doctors whose names she did not remember, who advised her that she did not need surgery.

From that time until August 1971 Mrs. Mosley worked as a waitress, except for time off to have her fifth child in 1961. She said she had no physical difficulty except for occasional excessive bleeding that was more pronounced at times than at others.

During the first part of August 1971, while on vacation, Mrs. Mosley engaged in strenuous activity by working in her garden and painting her house. About the middle of August she experienced heavy bleeding and pain accompanied by 'dropping out or falling out feeling' in the lower part of her body. She said she had never experienced this feeling before.

Because of this condition appellant saw Dr. Lockard on September 15, 1971, who after an examination told her she needed an operation. On October 1, 1971, Dr. Lockard performed the operation for which these claims are submitted.

Dr. Lockard, whose specialty is gynecology, testified that she first saw Mrs. Mosley in March 1960 and at that time Mrs. Mosley's chief complaint was excessive vaginal bleeding. At that time she made a gynecological examination that disclosed a prolapse of the pelvic organs, which in layman's terms means a falling down of the bladder, uterus and rectum. The doctor described it as follows:

I described it as a two degree cystourethrocele, which means a falling down of the bladder; a two degree descensus of the uterus, which means a dropping of the uterus; and a two degree rectocele, which means a bulging of the rectum through the posterior wall of the vagina. . . . The uterus was directed three degrees retrodisplaced. And so I diagnosed her entire condition as prolapsed pelvic organs with hyperemia, which menas excessive bleeding.

Dr. Lockard advised Mrs. Mosley that she needed an operation to correct the prolapse. Mrs. Mosley informed her that she was not financially able to pay for the operation. Dr. Lockard then referred her to the University Hospital to have a workup in the gynecology clinic, a D. and C., which means a dilatation and curettage of the uterus, and a possible vaginal hysterectomy with anterior-posterior repair.

Dr. Lockard said she did not see Mrs. Mosley again until September 15, 1971, at which time Mrs. Mosley's chief complaint was a falling out feeling of the pelvic organs, soreness in the lower abdomen, and flooding. Dr. Lockard said she then made an examination of Mrs. Mosley and testified:

On pelvic examination again I noted there was a two degree cystourethrocele, or a falling down of the bladder; a two degree retroflexion and a two degree rectocele, with good perineal support. She had had an infant between these times, her fifth child; and I assume that she had some good perineal support because the repair...