Clement's Estate, In re
| Decision Date | 26 April 1967 |
| Parties | , 220 Tenn. 114 In re the ESTATE of W. A. CLEMENT, Jr., Deceased. |
| Court | Tennessee Supreme Court |
Tyree B. Harris, Nashville, Hooker, Keeble, Dodson & Harris, Nashville, of counsel, for claimant.
Lan F. MacRae, Dickson, for administratrix.
On July 2, 1961, Mutual of Omaha issued a group insurance policy to the National Association of Retail Druggists.
W. A. Clement, Jr., deceased, a member of the Association, applied for and obtained a health and accident insurance certificate.
The certificate of insurance issued to the deceased contained the following clause: 'If a member has received medical treatment or advice for a sickness within twelve months prior to the effective date of his certificate, and if further treatment is required for such sickness within the first three months after the effective date of his certificate, the maximum benefit payable under any plan of insurance for such sickness shall be limited to $500.00.'
In February and April, 1963, Mr. Clement was hospitalized for 'hypertensive cardiovascular disease' with a finding of arteriosclerotic stenosis of both iliac and common femoral arteries as well as both renal arteries. He filed a claim for this sickness and Mutual paid him benefits amounting to $2,733.61.
During May, 1963, Mr. Clement was hospitalized for the same ailment and filed a claim in the sum of $1,163.72, which Mutual paid.
In August, 1963, Mr. Clement was again hospitalized for the same condition and died shortly after he was discharged from the hospital. Thereafter, the Administratrix of his estate filed a claim with Mutual.
While this claim was pending, claimant learned for the first time that Mr. Clement had received medical treatment from Dr. James T. Allen of Dickson, Tennessee, for 'hypertensive cardiovascular disease, arteriosclerotic heart disease,' within twelve months prior to the effective date of his insurance certificate. At the same time Mutual also learned for the first time that Dr. Allen had treated Mr. Clement on several occasions for the same condition within the first three months immediately following the effective date of his certificate of insurance.
Mutual denied the claim filed by the Administratix of the estate of Mr. Clement. Mutual filed a claim against the estate of Mr. Clement in the amount of $3,397.33, representing the amount of benefits paid to Mr. Clement less the $500.00 maximum provided in the above quoted provision of the certificate of insurance issued to Mr. Clement.
The Administratrix of the estate of the deceased filed exceptions to the claim. The matter was heard by the County Judge on a stipulation of facts which we have hereinabove stated.
Mutual insisted the deceased had required medical attention for his condition within twelve months next preceding the effective date of his certificate of insurance and additional medical treatment for the same condition within three months after the effective date of the certificate; and,...
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