National Am. Life Ins. Co. of Baton Rouge, La. v. Williams, 44551

• Decision Date: 13 November 1967
• Docket Number: No. 44551,44551
• Citation: 204 So.2d 174
• Parties: NATIONAL AMERICAN LIFE INSURANCE COMPANY OF BATON ROUGE, LOUISIANA v. Mrs. Ann (Leland) WILLIAMS.
• Court: Mississippi Supreme Court

Page 174

204 So.2d 174

NATIONAL AMERICAN LIFE INSURANCE COMPANY OF BATON ROUGE, LOUISIANA v. Mrs. Ann (Leland) WILLIAMS.

No. 44551.

Supreme Court of Mississippi.

Nov. 13, 1967.

Huff, Williams, Gunn, Eppes & Crenshaw, Meridian, Walter J. Gex, III, Satterfield, Shell, Williams & Buford, Jackson, for appellant.

Pigford & Hendricks, Meridian, for appellee.

BRADY, Justice:

This case is based on a claim for benefits under a group insurance policy issued by appellant to the City of Meridian Police Department. From an order and judgment in favor of the claimant, this appeal is prosecuted.

Under this group policy, certificate number 65 was issued to appellee's husband, Mr. Leland Williams Covering the appellee as one of his dependents. The effective date of coverage for appellee was November 1, 1964. The appellee claimed benefits for hospitalization from December 11, 1964, to January 8, 1965, which was necessary for It was stipulated between the litigants that the aggregate of appellee's claim was $1,237.92, less $500 which had already been paid by appellant, leaving the blance, if any, owed to appellee of $737.92. It was further stipulated that only one witness would be examined by either of the parties, namely, Dr. John Lindley, the physician who treated appellee. On October 27, 1966, the court, sitting without a jury, awarded appellee $737.92.

surgery performed on appellee for the excision of ovarian fragments, endometriem implants and adhesions. It is the contention of appellant that the disease, endometriosis, which precipitated the surgery, existed and was discovered in an active stage approximately one and a half months prior to the effective date of appellant's policy of November 1, 1964. Appellant contends that it was diagnosed as such at that time and that the endometriosis continued and progressed until surgery ultimately resulted.

Dr. John E. Lindley first saw appellee on September 22, 1964, at which time he found an oval mass in the right posterior pelvis, which was diagnosed as endometriosis. The appellee was seen again on October 6, 1964, at which time the same mass was present but was smaller and less tender. The diagnosis was still endometriosis. When he saw appellee again on December 11, the mass on the right side was still present, but he also discovered another mass on the left side. The mass on the left side was of the same type as that which had existed in September on the right side and was considered a continuing process of the endometriosis. On December 13, 1964, appellee was admitted to the hospital, and surgery was performed on December 15. Hospitalization was necessary for a week or ten days until she was discharged on January 8, 1965.

The record discloses that a hysterectomy was performed on appellee prior to September 22, 1964, the date she was first examined by Dr. Lindley.

There is one basic issue in this cause, namely: Was the illness or condition for which appellee was hospitalized on December 13, 1964, contracted prior to November 1, 1964, the effective date of appellant's policy? Under the general definitions of the policy we find this language:

GENERAL DEFINITIONS

The following words and phrases shall have the stated meanings when used in these provisions for dependents insurance for Major Medical Expense Benefits:

'Illness' means a bodily disorder or disease, mental infirmity or bodily injury; all bodily injuries sustained by an individual in a single accident, or all illnesses which are due to the same or related cause or causes shall be deemed one illness.

DEFINITION OF EXCLUDED CHARGES

The following 'excluded charges' are specifically excluded from coverage:

All charges which are not specifically included in the definition of eligible charges for personal insurance and in addition any charges:

(6) in excess of a payment hereunder of $500 incurred in connection with an illness of the employee contracted prior to the effective date of his personal insurance for Major Medical Expense Benefits unless incurred after a period of three consecutive months or longer, ending after such effective date, during which period he has not incurred any charges which, except for this limitation, would otherwise be eligible charges in connection with such illness; * * *.

At the outset, the disease or illness from which appellee was suffering was diagnosed as endometriosis or endometrium implant. Dr. Lindley's explanation of endometriosis establishes that the disease is caused by the menstrual flow going back through the tubes rather than out through the opening of the womb. It is apparent that if appellee had a hysterectomy with removal of the tubes prior to the time she first saw Dr. Lindley, the disease was an antecedent fact to her hysterectomy.

Appellee contends that Dr. Lindley testified that the mass on the right side which he discovered on September 22 was not present on December 11 when a mass was found on the left side. This conclusion is incorrect because the record discloses that Dr. Lindley did find the mass present on the right side on December 11. The thrust of appellee's contention is that she had a condition which caused both of said masses, but the condition for which she was operated on was the mass on the left side of her body discovered on December 11, 1964, forty-one days after the effective...