Kopp v. Home Mut. Ins. Co.
| Decision Date | 02 January 1959 |
| Citation | 94 N.W.2d 224,6 Wis.2d 53 |
| Parties | Herman KOPP, Respondent, v. HOME MUTUAL INS. CO., Appellant. |
| Court | Wisconsin Supreme Court |
Byrne, Bubolz & Spanagel, Appleton, Wm. S. Pfankuch, Appleton, of counsel, for appellant.
Frank E. Betz, William A. Adler, Eau Claire, for respondent.
The defendant insurance company does not base its refusal to pay the plaintiff anything to apply on the hospital bill upon the ground that the plaintiff should not recover twice for the same expense. On the contrary, it concedes that, if the hospitalization had taken place in a hospital not affiliated with Blue Cross, and the plaintiff had paid the bill and had been reimbursed by Blue Cross, he would be entitled to recover therefor from the defendant, subject to the $500 coverage limit. The defendant's defense is placed upon the very narrow ground that the plaintiff never incurred any expense for his hospitalization. This is because under the plaintiff's contract with Blue Cross, and the contract between Luther Hospital and Blue Cross, Luther Hospital was obligated to furnish such hospitalization free to the plaintiff and to look solely to Blue Cross for payment.
The pertinent provision of the defendant's policy reads as follows:
'Coverage C--Medical Payments
'To pay all reasonable expenses incurred within one year from the date of accident for necessary medical, surgical, X-ray and dental services, including prosthetic devices, and necessary ambulance, hospital, professional nursing and funeral services:
Elsewhere in the policy the amount of medical payments coverage is expressly limited to $500 for each person.
The defendant contends that, under the abovequoted policy provisions, it is a condition precedent to the insured's right of recovery upon the policy for his hospitalization that he shall first have incurred a debt for the same. It is clear from the undisputed facts that no such debt was incurred by the plaintiff to pay for such hospitalization. However, a debt was incurred on the part of Blue Cross to pay such expense to Luther Hospital, and the plaintiff had paid quarterly premiums to Blue Cross as consideration for Blue Cross undertaking so to do. Thus expense was incurred for hospital services furnished 'to or for' the plaintiff insured.
The aforequoted policy provisions do not state who is...
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