Couey v. National Benefit Life Ins. Co.

• Decision Date: 06 March 1967
• Docket Number: No. 8131,8131
• Citation: 424 P.2d 793,1967 NMSC 44,77 N.M. 512
• Parties: William W. COUEY, Plaintiff-Appellee, v. NATIONAL BENEFIT LIFE INSURANCE COMPANY, a corporation, and Continental Casualty Company, a corporation, Defendants-Appellants.
• Court: New Mexico Supreme Court

Page 793

424 P.2d 793

77 N.M. 512

William W. COUEY, Plaintiff-Appellee, v. NATIONAL BENEFIT LIFE INSURANCE COMPANY, a corporation, and Continental Casualty Company, a corporation Defendants-Appellants.

No. 8131.

Supreme Court of New Mexico.

March 6, 1967.

Adams & Pongetti, Albuquerque, for appellants.

Duran & Goodman, Albuquerque, for appellee.

OPINION

MOISE, Justice.

Defendant insurance companies appeal from a judgment in favor of plaintiff assured. The parts of the policy material to the first issue raised in the briefs read:

'NATIONAL BENEFIT LIFE INSURANCE COMPANY

A Legal Reserve Stock Company Home Office Chicago, Illinois

(Herein called the Company)

DOES HEREBY INSURE

and agrees to pay WILLIAM W COUEY (hereinafter called the insured) in the event of hospital residence occurring solely as the consequence of direct bodily injury resulting from any accident and independently of all other causes while this policy is in force (hereinafter called such injury) subject to the provisions of this policy.

PART I

'HOSPITAL CONFINEMENT BENEFIT FOR LIFE--$1,000 PER MONTH. The company will pay at the rate of $1,000 per month for one day to a lifetime beginning with the first day when such injury shall continually confine the insured to a hospital (other than a sanitarium; rest home; or government hospital, unless a charge is made by such a hospital which the insured is legally required to pay).'

Whereas the policy was issued by defendant National Benefit Life Insurance Company, plaintiff alleged and defendants admitted that after the policy had been issued 'defendant Continental Casualty Company absorbed the assets and liabilities of defendant National Benefit Life Insurance Company, or otherwise became responsible for the payment of its claims, * * *.' Judgment was entered against both defendants, and both have appealed.

The several points raised by defendants require that we determine if all the hospitalization for which judgment was granted occurred 'solely as a consequence of direct bodily injury resulting from any accident and independently of all other causes.' The court concluded that it did. The defendants assert error because of a claim that the proof discloses the hospitalization to have been required, partially at least, by causes other than accident.

It appears that on July 8, 1963, while the policy was in force, plaintiff accidentally slipped and fell, injuring his lower back, wrist, shoulder and neck. He was treated at the plant where he worked, and then in the emergency room of the hospital, but was not actually hospitalized until more than a month later--on August 12, 1963. On this occasion he remained in the hospital until October 10, 1963. He was subsequently hospitalized from October 12, 1963 to November 5, 1963; from November 28, 1963 to March 24, 1964; from June 29, 1964 to September 15, 1964, and from September 18, 1964 to November 17, 1964, being a total of three hundred thirty seven days for what defendants describe as 'what appears to be a relatively minor accident,' but which the court found occurred solely as a consequence of direct bodily injury resulting from the accident, independent of all other causes.

It is defendants' position that notwithstanding the accidental fall and injury to plaintiff, the hospitalization did not result 'solely as a consequence' thereof 'independently of all other causes.' Their claim is based on the fact plaintiff had a history of a neck sprain in 1932; a low back injury at the L4--5 level, with a laminectomy in 1958; a spinal fusion at the same level in 1961, and hospitalization for about a week in 1962 because of back trouble. Also, plaintiff, while in the hospital after the July 8, 1963 accident, suffered a heart attack on September 4, 1963. He also developed an infection as a result of surgery performed on his back while in the hospital after August 12, 1963, and this infection caused him to have to return to the hospital on October 12, 1963, after being released on October 10, 1963. Taking into consideration plaintiff's history of back trouble and operations to improve it, as well as the fact of myocardial infarction and infection following surgery after entering hospital on August 12, 1963, is there substantial support in the evidence for the finding of the trial court that each period of hospitalization following the accident 'occurred solely as a consequence of direct bodily injury resulting from the slip and fall on July 8, 1963 and independently of all other causes'? If the answer is in the affirmative, defendants must fail on this portion of their argument.

It is clear that, notwithstanding a history of back trouble suffered by plaintiff prior to the spinal fusion in 1961, after that date he was free of symptoms and back pain and except for the brief hospitalization in 1962 was able to work without discomfort until the accident of July 8, 1963. If we assume that the fall in 1963 re-damaged an old injury or condition and the surgery performed to repair it, can it be said that the July, 1963 fall was the sole cause of the hospitalization? Stated differently--does liability arise if the proximate efficient cause of hospitalization is an accident which requires hospital residence, even though a pre-existing condition which may have been triggered or touched off thereby, or a latent, but theretofore unknown condition makes necessary a longer hospital stay than would normally result from the accident alone? We recognize the presence of cases which would support a negative answer. However, we think the better reasoning is found in those decisions which would answer in the affirmative. We do not propose to discuss the cases at any great length. Rather, we will limit ourselves to a relatively small number. The conclusions reached vary, according to the language of the particular policies being considered and the factual situations presented. Many of them are reviewed and discussed in the annotation at 84 A.L.R.2d 176.

Our problem is not as difficult as that presented in most of the cases, since the attending physician and surgeon here testified that in their opinions the accidental injury and the treatment necessarily given contributed to the infection and heart attack, and that the hospitalization did not result from any antecedent condition. In other words, there is direct evidence of a substantial character to support the court's findings and conclusion that the accident was the sole cause of the numerous hospitalizations, notwithstanding the prior history and intervening untoward occurrences. We do not overlook a concession by one doctor, in his testimony, that the previous condition of the back 'was at least a contributing cause.' In these circumstances, if the question is one of fact, we do not ordinarily disturb the finding made by the trial court. Board of County Com'rs of Dona Ana County v. Vargas, 76 N.M. 369, 415 P.2d 57 (1966); State ex rel. State Highway Commission v. Tanny, 68 N.M. 117, 359 P.2d 350 (1961).

In our view of the case, every injury or disease suffered by a person from his birth to the date of a particular injury contributes to some degree to the condition then present. Necessarily, by the words used in the policy it could not have been intended that payment would be due only when the accident was literally the sole cause of hospitalization. If a person had suffered a broken leg which had healed perfectly five years before, and a second accident wherein the leg had broken at the same place, could it be said that the condition resulting from the first break did not in any way contribute to the second break? We think the answer is obvious and, under defendants' theory, plaintiff would not be entitled to recover. In our view, this application of the language of the policy is entirely too restrictive and would be unreasonable. Other courts have agreed. See Freeman v. Mercantile Mut. Acc. Ins. Ass'n, 156 Mass. 351, 30 N.E. 1013 (1892); Cramer v. John Hancock Mut. Life Ins. Co. of Boston, Mass., 18 N.J.Misc. 367, 13 A.2d 651, 657 (1940); Prudential Ins. Co. of America v. Carlson, 126 F.2d 607, 610 (10th Cir. 1942); 25 Mich.L.R. 467 (1927). We think the following oft-quoted language of Chief Justice Cardozo in Silverstein v. Metropolitan Life Ins. Co., 254 N.Y. 81, 171 N.E. 914, 915, is pertinent:

'* * * In a strict or literal sense, any departure from an ideal or perfect norm of health is a disease or an infirmity. Something more, however, must be shown to exclude the effects of accident from the coverage of a policy. The disease or the infirmity must be so considerable or significant that it would be characterized as disease or infirmity in the common speech of men. Eastern Dist. Piece Dye Works v. Travelers' Ins. Co., 234 N.Y. 441, 453, 138 N.E. 401, 26 A.L.R. 1505. 'Our guide is the reasonable expectation and purpose of the ordinary business man when making an ordinary business contract.' Bird v. St. Paul Fire & Marine Ins. Co., 224 N.Y. 47, 51, 120 N.E. 86, 87, 18 A.L.R. 875; Goldstein v. Standard Accident Ins. Co. 236 N.Y. 178, 183, 140 N.E. 235, 236; Van Vechten v. American Eagle Fire Ins. Co., 239 N.Y. 303, 146 N.E. 432, 38 A.L.R. 1115. A policy of insurance is not accepted with the thought that its coverage is to be restricted to an Apollo or a Hercules.

'A distinction, then, is to be drawn between a morbid or abnormal condition of such qualify or degree that in its natural and probable development it may be expected to be a source of mischief, in which event it may fairly be described as a disease or an infirmity, and a condition abnormal or unsound when tested by a standard of perfection, yet so remote in its potential mischief that common speech would call it not disease or infirmity, but at most a predisposing tendency. Leland v. Order of United Commercial Travelers of America, 233 Mass. 558, 564, 124 N.E. 517; Collins v. Casualty Co. of America, 224 Mass. 327, 112 N.E. 634, L.R.A. 1916E, 1203; Mutual...