Ex parte Blue Cross-Blue Shield of Alabama.

• Decision Date: 10 July 1981
• Docket Number: CROSS-BLUE
• Citation: 401 So.2d 783
• Parties: Ex parte BLUESHIELD OF ALABAMA. (Re Margaret L. HAGGARD v. BLUESHIELD OF ALABAMA). 80-68.
• Court: Alabama Supreme Court

Page 783

401 So.2d 783

Ex parte BLUE CROSS-BLUE SHIELD OF ALABAMA (Re Margaret L. HAGGARD v. BLUE CROSS-BLUE SHIELD OF ALABAMA).

80-68.

Supreme Court of Alabama.

July 10, 1981.

Byrd R. Latham for Patton, Latham, Legge & Cole, Athens, for petitioner.

Jimmy E. Alexander for Steele, Alexander, Corder & Plunk, Athens, for respondent.

ADAMS, Justice.

We granted petitioner's request for writ of certiorari to the Court of Civil Appeals to review their decision on what we considered a material question of first impression in Alabama. That material question is whether the terminology "not medically necessary" which appears in the plaintiff's policy with the defendant Blue Cross-Shield of Alabama is terminology which is exclusively within the knowledge of expert witnesses (doctors) so that if such a witness is uncontradicted in his statement that it was not medically necessary for the plaintiff to be hospitalized, the case should not go to the jury. Although not treated in the Court of Civil Appeals opinion, the petitioner also argues that the terminology "domiciliary care" provided in plaintiff's policy is exclusively within the knowledge of expert witnesses (doctors) and if such a witness testifies that plaintiff was admitted solely because of lack of such care at home, the case should not be submitted to the jury. We will address both questions.

The trial court granted a directed verdict in favor of Blue Cross-Blue Shield, thereby answering these questions in the affirmative. The Court of Civil Appeals, 401 So.2d 781 reversed and remanded, answering the question it decided in the negative. We affirm.

There has been no contest of the factual statement of the Court of Civil Appeals and, therefore, we adopt its statement of facts. That court says the following incidents occurred:

Plaintiff, having been released from a period of hospitalization only six days before, suffered a blackout and a fall. She fell across a coffee table while alone at night. The next day she went to the emergency room of the hospital where her physician found her to have recently fractured lumbar and sacral vertebrae and her pubis ramus. She was in much pain and unable to bear her weight without crutches. Her physician knew from his past attendance that plaintiff had weak bones, "osteoporosis," and a nervous problem causing blackouts. She had had previous falls and fractures. He knew or was told that she had no one to care for her at home. She did not request hospitalization. Plaintiff's physician admitted her to the hospital and prescribed specific courses of medication and treatment.

Plaintiff suffered much pain for which she was given medication. She was confined to bed and given a regimen of physical therapy and exercise to relieve pain and strengthen her body. Her physician visited her twice each day, checking her condition and entering additional daily orders for her care and treatment. She remained in the hospital for more than two weeks and was released upon the order of her physician. She filed her claim for insurance benefits. The physician filed a claim for his services. A portion of plaintiff's claim was paid. The claim of the physician was paid. Subsequently, the physician was notified by defendant to return his payment and he did. Plaintiff, after several inquiries about payment, was notified her claim was denied because of policy exclusions.

The physician testified that though he admitted plaintiff to the hospital and kept her there for two weeks, he did not consider such hospitalization "medically necessary." He said that she could have stayed at home if she had someone to care for her, and he admitted her because he knew, or she told him, she had no one at home to care for her.

Under the Exclusions section, plaintiff's Blue Cross-Blue Shield policy carries the following statements:

Not medically necessary i. e., when in the judgment of the Carrier the medical services did not require the acute hospital bedpatient (overnight) setting, but could have been provided in a physician's office, the outpatient department of a hospital, or in a lesser facility without adversely affecting the patient's condition or the quality of medical care rendered....

....

Domiciliary care Provided because care in the home is not available or is unsuitable.

The Court of Civil Appeals said in Ford Life Insurance Company, Inc. v. Smith, 369 So.2d 808 at 809 (Ala.Civ.App.1979):

It is well settled in Alabama that the opinion testimony of an expert witness is not binding on the jury unless (1) such testimony concerns a subject which is exclusively within the knowledge of experts and (2) the testimony is uncontroverted.

If there ever was a phrase that would be exclusively within the knowledge of an expert, it would seem that the phrase "medically necessary" would meet the test. On closer scrutiny, however, it seems that which would appear to be obvious is not obvious. The first stumbling block we run into is the defendant's own view of what the term "not medically necessary" means. Although Blue Cross argues to us that we should take the word of Dr. Pendleton that plaintiff was hospitalized for non-medical reasons, Blue Cross is not required to accept doctors' opinions on this subject, absolutely. The policy says "not medically necessary" means "when in the judgment of the Carrier the medical services did not require the acute hospital bedpatient (overnight) setting." (Emphasis added.) In Van Vactor v. Blue Cross Association, 50 Ill.App.3d 709, 8 Ill.Dec. 400, 365 N.E.2d 638 (1977), plaintiffs filed a class action suit to...