Mutual Hosp. Ins., Inc. v. Hagner
| Citation | 475 N.E.2d 32 |
| Decision Date | 27 December 1984 |
| Docket Number | No. 2-1183A414,2-1183A414 |
| Parties | MUTUAL HOSPITAL INSURANCE, INC. and Mutual Medical Insurance, Inc., d/b/a Blue Cross and Blue Shield of Indiana, Appellants (Defendants), v. George HAGNER and Carol Hagner, Appellees (Plaintiffs). |
| Court | Indiana Appellate Court |
Donald C. Trigg, Wallace T. Gray, Indianapolis, for appellants (defendants).
Robert M. Bly, McIntyre & Bly, Kokomo, for appellees (plaintiffs).
Defendants-appellants Mutual Hospital Insurance, Inc. and Mutual Medical Insurance, Inc., doing business as Blue Cross and Blue Shield of Indiana [hereinafter referred to as Insurance Companies], appeal from a judgment entered in favor of plaintiffs-appellees George and Carol Hagner (Hagners) that ordered the Insurance Companies to pay Hagners $744.25 under a contract of health insurance and an additional $5,000 as punitive damages, claiming the trial court erred in concluding that the treatment rendered to Hagners' son was not an excluded dental service under the contract of medical insurance and in awarding punitive damages when the record did not disclose clear and convincing evidence of conduct justifying such an award.
We affirm in part and reverse in part.
This litigation arose from an action on a contract of medical insurance between Insurance Companies and General Motors. The action was brought by George Hagner, an employee of General Motors and a beneficiary under the medical insurance program, and his wife Carol for payment of treatment rendered to their son Christopher Hagner (Christopher). The case was tried to the bench, and the evidence included discovery materials, stipulated items, and testimony.
Christopher, a child of two and one-half years of age, fell and broke several front teeth at the gum line. Christopher suffered from the pain of this injury, quit eating, lost weight, and ran the risk of severe infection. On October 7 and 8, 1979, Christopher was treated at St. Mary's Health Center in Jefferson City, Missouri. A dentist placed Christopher under a general anesthetic, removed the dead pulp from each tooth, filled the open wounds, and then covered the broken teeth with steel crowns. The total cost incurred by Hagners for Christopher's treatment was $1,178.28.
The Hagners then became involved in correspondence with the Insurance Companies which lasted almost two years. The initial claim for hospital expenses, received by the Insurance Companies on October 9, 1979, was immediately paid. But when Hagners submitted a claim to the Insurance Companies for the remaining $744.25 in medical expenses, the Insurance Companies requested, during January of 1980, that Hagners refund the amount previously paid toward hospital services and refused payment of the $744.25. The Insurance Companies' terse denial of the claim was based on the opinion that no "concurrent medical hazard" existed.
About May of 1980, Hagners requested a review of their insurance claim and submitted to the Insurance Companies a letter by Dr. Busby, the hospital staff physician at the time of Christopher's treatment, that attested to the related health problems suffered by Christopher as a result of his injuries. In response to this letter, the Insurance Companies withdrew their refund request and stated the hospital insurance claim was payable because it was accident related. The Hagners, convinced that if hospital services for Christopher were provided then medical services should also be covered, resubmitted their claim for the doctor's services. In August of 1980, Hagners' request was again denied, and again the Insurance Companies made a refund Further correspondence of this type was carried on for several months by Hagners, the General Motors insurance office, and the Insurance Companies. In frustration, Hagners wrote, in January of 1981, to the president of the Insurance Companies, explaining their problem and asking for help. The Insurance Companies indicated that they would again review the claim. Finally, in June of 1981, the Insurance Companies responded with a letter detailing at some length the basis of their refusal of the Hagners' claim for medical treatment and dropping their request for a refund of the payment for hospital services. The Insurance Companies also offered to pay an additional $32.00 for first aid for Christopher.
request, this time through General Motors' insurance office.
This lawsuit ensued, and the trial court found the treatment rendered to Christopher was medically necessary and covered by the medical insurance policy under which Christopher was a beneficiary. The trial court also found the exceptions to coverage asserted by the Insurance Companies were inapplicable. In addition to an award of $744.25, the trial court awarded Hagners $5,000.00 in punitive damages. The trial court based the punitive damages award on the finding that the Insurance Companies had deliberately avoided payment of a covered claim, such conduct amounting to bad faith, oppressive conduct, fraud or malice.
The Insurance Companies raise two issues for our review:
1. Whether the trial court erred when it concluded, as a matter of law, that the Hagners' claim was not excepted from coverage under the insurance contract?
2. Whether the trial court erred when it found the evidence to be clear and convincing that the Insurance Companies' conduct amounted to bad faith, oppressive conduct, fraud or malice?
ISSUE ONE--Whether the trial court erred when it concluded, as a matter of law, that the Hagners' claim was not excepted from coverage under the insurance contract?
PARTIES' CONTENTIONS--The Insurance Companies argue that the treatment rendered to Christopher was clearly excepted from coverage under the contract of medical insurance.
Hagners contend that Christopher's treatment was not subject to exceptions under the insurance contract.
CONCLUSION--The trial court did not err when it concluded that the treatment provided to Christopher was covered under the contract of medical insurance because the Insurance Companies failed to prove that such treatment was excepted from the general provisions of the medical insurance policy.
Because this case involves a mixed question of fact and law, the trial court was required to determine, as a matter of law, the effect of the insurance contract. The court also needed to determine the facts of the case and examine them according to its decision regarding the insurance contract. Christopher's injury and need for treatment were undisputed.
Hagners presented the expert testimony of Dr. William Leyda, Doctor of Dental Medicine specializing in oral and maxilofacial surgery, who characterized Christopher's condition as a traumatic bodily injury. Record at 434. The treatment of such injury, by excision of the dead pulp under a general anesthetic, fits the plain meaning of the Insurance Companies' contract provision for surgery, the latter defined as "operative and cutting procedures for the necessary ... treatment of ... injury." Record at 373.
The burden of proving an exception to this general provision was on the Insurance Companies. 13 J.A. Appleman & J. Appleman, Insurance Law and Practice Sec. 7387 (1976) (citations omitted). "[A] common rule of contract and insurance law states that when performance is promised in general terms, followed by specific exceptions and limitations, the obligor has the burden of proving that the case falls [within] the exception." Zebrowski & Assoc. v. City of Indianapolis (1983), Ind.App., 457 N.E.2d 259, 262 (citations omitted). Because the Insurance Companies are appealing from a negative judgment on the issue of whether Christopher's treatment was excepted from the contract of insurance, an affirmative defense on which the Insurance Companies carried the burden of proof, we will reverse only if the evidence reasonably leads to only one conclusion which is contrary to that of the trial court. Ross v. Ross (1979), Ind.App., 397 N.E.2d 1066.
The burden was on the Insurance Companies to prove that Christopher's treatment was subject to...
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