Medical Serv. Of District of Columbia v. Llewellyn, 3637.

• Decision Date: 12 April 1965
• Docket Number: No. 3637.,3637.
• Parties: MEDICAL SERVICE OF the DISTRICT OF COLUMBIA and Group Hospitalization, Inc., bodies corporate, Appellants, v. Mary Isabelle LLEWELLYN, Appellee.
• Court: D.C. Court of Appeals

208 A.2d 734

MEDICAL SERVICE OF the DISTRICT OF COLUMBIA and Group Hospitalization, Inc., bodies corporate, Appellants, v. Mary Isabelle LLEWELLYN, Appellee.

No. 3637.

District of Columbia Court of Appeals.

Argued March 1, 1965.

Decided April 12, 1965.

Charles J. Steele and Warren E. Magee, Washington, D. C., for appellants.

Downey Rice, Washington, D. C., with whom John 0. Harper, Washington, D. C., was on the brief, for appellee.

Before HOOD, Chief Judge, and QUINN and MYERS, Associate Judges.

MYERS, Associate Judge

On May 1, 1962, appellee entered into contracts with appellants pursuant to which the latter were to pay certain monetary allowances to hospitals and doctors in the event of her illness or hospitalization.¹ Each contract contained the following similar provision:

"WAITING PERIOD

"Subject to the provisions of [the paragraph dealing with Exclusions], benefits under this Contract will be available for the following only after the Contract has been in effect for a waiting period of ten consecutive calendar months * * *:

"(1) Pre-existing conditions: namely, any condition, disease or ailment which existed on the Effective Date * * *, whether known or not known by the Subscriber; or any condition, disease or ailment for which medical or surgical treatment or advice has been rendered within one year prior to the date on which this Contract became effective * * *;

"(2) Complications resulting from preexisting conditions;" [Emphasis supplied.]

Appellee's claims for medical and hospital expenses incident to the surgical removal of gallstones on September 20, 1962, were rejected by appellant companies on the ground that the condition for which she was operated upon was in existence on the effective date of the policies and therefore came within the above exclusion. After hearing on her suit to recover these expenses, the trial judge ruled that appellee's "existing physical condition on the effective date of the contracts did not disqualify her under the pertinent exclusionary provisions from recovery" and found in her favor for the stipulated amounts. This appeal by the insurers followed.

Miss Llewellyn testified that although she had suffered some pain and flatulence, it was not until September 1962 that x-rays revealed the presence of stones in the gallbladder. Although an operation was not absolutely necessary Atthat time, appellee underwent a cholecystectomy, at which time 77 gallstones "of the uniform size of a pea" were removed. No further testimony was offered on behalf of appellee.

A medical expert for appellants, after detailing his qualifications, testified, in substance, that 77 gallstones the size of a pea could not have been formed between May and September of the same year but could have formed only over a period of many years; that an accumulation of stones causing no pains or symptoms could be present for many years; that the presence of gallstones in the gallbladder would eel.: tainly constitute a "diseased state," a "pathological condition," synonymous with disease or diseased condition; that gallstones are sufficiently uncommon as to constitute a disease; that after removal of gallbladder and stones, microscopic examination always discloses chronic inflammation in the gall bladder tissue; that the presence of 77 gallstones in appellee's gallbladder on September 20, 1962, necessitated the conclusion that on May 1, 1962, "there was disease present." Admitted information from the hospital records disclosed a diagnosis of "chronic cholecystitis with lithiasis," a medical term for long-standing inflammation of the gallbladder with the formation of gallstones.

Appellee contends that the words "disease" and "condition," as used in the contracts, were validly interpreted by the trial judge. We are at a loss to ascertain the factual support for the...