Blue Shield of Florida, Inc. v. Woodlief
| Decision Date | 19 May 1978 |
| Docket Number | No. HH-180,HH-180 |
| Citation | 359 So.2d 883 |
| Parties | BLUE SHIELD OF FLORIDA, INC., Appellant, v. Ollie WOODLIEF and Barbara Woodlief, Appellees. |
| Court | Florida District Court of Appeals |
Jeffrey A. Cramer of Carlton, Fields, Ward, Emmanuel, Smith & Cutler, Pensacola, for appellant.
Thomas F. Condon of Holsberry, Emmanuel, Sheppard & Condon, Pensacola, for appellees.
Blue Shield appeals from a circuit court summary judgment awarding appellee Woodlief $205 plus costs and attorney's fees on account of Blue Shield's refusal to pay a $205 dental surgery bill incurred by Mr. Woodlief. Woodlief, whose wife is an employee of Escambia County, is insured under a group contract issued to the Escambia County Board of County Commissioners by Blue Cross of Florida, Inc. and Blue Shield of Florida, Inc. The coverage in dispute is provided by Blue Shield alone. The trial court found the insurance contract and a pamphlet describing it ambiguous in their coverage or exclusion of benefits for dental surgery and so awarded the cost of such surgery under a construction of the documents most favorable to the insured.
Mr. Woodlief's surgery bill included the following items: (1) initial examination, $10; (2) diagnostic panelipse, $20; (3) out-patient general anesthesia, $25; (4) extraction of three teeth, $45; (5) mandibular alveoloplasty, $40; and (6) removal of palatal inflammatory hyperplasia and relining of denture, $75. The charges totaled $215. The trial judge awarded $205 in damages, apparently finding that the fee for the initial examination was not a covered expense. Blue Shield contests coverage for the services rendered, but does not allege that the charges were excessive by the standard set for surgical services in the policy's schedule of benefits.
By affidavit, the treating dentist stated that the extractions were required because of excessive tooth decay and the removal of palatal tissue was made necessary by the growth of malformed tissue caused by ill-fitting dentures. Mr. Woodlief claimed the entire amount under the policy's provision of benefits for doctors' services and its recital that the insurer will pay for minor surgery, diagnostic x-rays, anesthesia, and certain other services up to amounts prescribed in a "schedule of benefits" which has not been included in the record. There follows a list of services for which benefits are not provided, including dental services.
The claimed ambiguity arises on a page of the insurer's descriptive pamphlet which was supplied to inform members of the insured group of coverages and exclusions:
SERVICES BY A NONPARTICIPATING PHYSICIAN.
Should you receive care from one of the few licensed doctors of medicine (MD) or doctors of osteopathy (DO) who are not participating in Blue Shield, the benefits listed in this booklet and your contract will still apply but Blue Shield may elect to make payment directly to you.
Doctors of dental surgery (DDS) and doctors of surgical chiropody (DSC) are also regarded as nonparticipating physicians if they provide...
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...ambiguity only exists when contractual terms are "subject to opposing reasonable interpretations." Blue Shield of Fla., Inc. v. Woodlief, 359 So.2d 883, 884 (Fla. 1st Dist. Ct.App.1978). As both parties here recognize, the fact that a policy endorsement contradicts a provision contained in ......
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