Millstead v. Life Ins. Co. of Va.

• Decision Date: 02 August 1971
• Docket Number: No. 19263,19263
• Citation: 182 S.E.2d 867,256 S.C. 449
• Court: South Carolina Supreme Court
• Parties: Calvin T. MILLSTEAD, Appellant, v. The LIFE INSURANCE COMPANY OF VIRGINIA, Respondent.

Page 867

182 S.E.2d 867

256 S.C. 449

Calvin T. MILLSTEAD, Appellant, v. The LIFE INSURANCE COMPANY OF VIRGINIA, Respondent.

No. 19263.

Supreme Court of South Carolina.

Aug. 2, 1971.

Richard M. Kenan, of Pope & Schumpert, Newberry, for appellant.

W. Croft Jennings, Jr., of Roberts, Jennings & Thomas, Columbia, for respondent.

BUSSEY, Justice.

This is a Declaratory Judgment action in which the plaintiff-appellant seeks construction of a so-called 'anti-duplication provision' of an insurance policy issued by the respondent, and judgment for the benefits allegedly due him.

Plaintiff was employed as a fireman by the City of Newberry and as such covered by a group major medical expense policy issued by the defendant. Plaintiff suffered a cardiac seizure and as a result incurred and continues to incur expenses, properly within the coverage of the policy, all of which the defendant has refused to pay. Plaintiff, at the time of the hearing, had already incurred covered expenses in the amount of approximately $2,000. The plaintiff's wife, Alice R. Millstead, had received certain benefits pursuant to the terms of an insurance plan arranged through her employer, and Travelers Insurance Company, and paid as the result of the expenses incurred by the plaintiff. The parties stipulated as to certain facts, and, inter alia, that the issue made by the pleadings involved an interpretation of the antiduplication provision of the policy. The cause was heard on the merits upon the pleadings and stipulation. The lower court entered judgment in favor of the defendant and plaintiff appeals.

The policy clause involved provides, inter alia, that there shall be deducted from benefits payable '* * * all payments made To or on behalf of the insured individual for medical care or services * * * under any group, franchise, Blue Cross, Blue Shield, or other service prepayment plan * * * arranged through any employer, trustee, union, employee benefit association or other association or organization.' Much of the argument here is devoted to the question of whether or not the term 'any employer', as used in the quoted policy provision, is or is not ambiguous, and the order of the lower court was in a large measure predicated on the conclusion that there was no ambiguity; that the term should not be restricted to mean 'any employer' of the plaintiff; that such term was a broad designation, and included the employer of the wife, with the result that the benefits received by her under her policy on account of her husband's illness precluded his recovery from the defendant. In our view, a proper disposition of the case may be reached without pursuing the inquiry as to whether or not there is, in truth, any ambiguity in the term 'any employer'.

We conclude, independently thereof, that the deductible clause relied upon by the defendant is no bar, under the stipulated facts of this case, to the recovery of benefits by the plaintiff. From the facts of the case, we deem it obvious that no payments for medical care, etc. have been made 'to or on behalf of the insured individual' under the wife's group insurance plan arranged through her employer. It is true that she, not her husband, has received from this plan benefits paid her under the plan as a result of expenses incurred by her husband. Once she received that which she was entitled to, under the plan, she...