Meade v. Prudential Ins. Co. of America, 83-678.
| Decision Date | 27 June 1984 |
| Docket Number | No. 83-678.,83-678. |
| Citation | 477 A.2d 726 |
| Parties | John P. MEADE, Appellant, v. The PRUDENTIAL INSURANCE COMPANY OF AMERICA, Appellee. |
| Court | D.C. Court of Appeals |
John P. Meade, pro se.
Charles H. Fleischer, Washington, D.C., with whom Randall C. Smith, Washington, D.C., appeared on the brief, for appellee.
Before FERREN and BELSON, Associate Judges,* and KERN,** Associate Judge, Retired.
This appeal concerns interpretation of an exclusion provision in a medical insurance contract. The trial judge ruled that the provision excluded from coverage certain charges for crowns and inlays the insured incurred.
The parties did not dispute the facts before the trial court. Appellant suffered from temporomandibular joint syndrome (TMJS), an inflammation of the jaw joint due to improper alignment of the upper and lower jaws. A dentist, an oral surgeon, treated appellant's TMJS in two stages. First, the dentist inserted a plastic splint in appellant's mouth. The splint brought appellant's jaws into the correct alignment. In order to make the new alignment permanent, the dentist, at the second stage, could have installed either a steel splint or crowns and inlays. Appellant and his dentist chose the latter. The treatment was successful.
Prudential reimbursed appellant for the cost of the splint, but denied liability for the costs of the crowns and inlays. The company said that the charges for the crowns and inlays fell within the "Mouth Conditions Charges" exclusion in the policy. That exclusion reads:
Generally Excluded Charges:
. . .
Mouth Conditions Charges — charges for Physicians' services or x-ray examinations in connection with mouth conditions due to periodontal or periapical disease, or involving any of the teeth, their surrounding tissue or structure, the alveolar process or the gingival tissue; unless the charges are in connection with the treatment or removal of malignant tumors and would, except for this part (6), be covered under the coverage.
Appellant sued the company in Superior Court for the charges, arguing that the exclusion's language did not cover the $4,075.10 at issue. On cross-motions for summary judgment, the trial court ruled that as a matter of law the company's construction of the exclusion's language was more reasonable than appellant's. He granted summary judgment for the company.
or
[2)] involving any of the teeth, their surrounding tissue or structure, the alveolar process or the gingival tissue.
or
[2)] involving any of the teeth, their surrounding tissue or structure, the alveolar process or the gingival tissue.
Because insertion of crowns and inlays is a service involving the teeth, the company's reading would exclude charges for that service.
Appellant's construction appears to us the more reasonable. We are not persuaded by the company's argument that the exclusion must link "involving" with "charges" because all the policy exclusions focus on charges. The mouth conditions exclusion's general concern with charges does not dictate the interpretation of the detailed language defining what sorts of charges will be excluded. Indeed, appellant's construction preserves the focus on charges; charges for services connected with mouth conditions will be excluded, with one sort of mouth...
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