Ross v. Western Fidelity Ins. Co.
| Decision Date | 10 August 1989 |
| Docket Number | No. 88-4465,88-4465 |
| Citation | 881 F.2d 142 |
| Parties | Betty and Stanley ROSS, Plaintiffs-Appellants, v. WESTERN FIDELITY INSURANCE COMPANY, Defendant-Appellee. |
| Court | U.S. Court of Appeals — Fifth Circuit |
Appeal from the United States District Court for the Northern District of Mississippi.
ON PETITION FOR REHEARING
(Opinion May 11, 1989, 5th Cir.1989, 872 F.2d 665)
Before GARZA, JOLLY and JONES, Circuit Judges.
We grant the petition for rehearing. We agree that our opinion requires some clarification. We will try. In the process, we hope that we do not make trial on remand any more difficult than it necessarily will be in this hard-to-distill case.
We initially note that most of the issues of interpretation of the insurance policy in this case come down to a blurred amalgam of fact and law that is best resolved after trial when a jury has resolved the factual issues to which the terms of the policy apply. We should therefore make clear that our opinion does not preclude the district court from submitting to the jury the questions whether the second preexisting condition clause or the sickness clause bar the plaintiff from recovering under the policy. We simply reversed the lower court's summary judgment in favor of Western Fidelity. In reviewing the summary judgment, we viewed the facts and made all inferences most favorably to the Rosses, and determined only that the Rosses had a reasonable factual argument that Jennifer's treatment in August was for a heart defect that had never before been treated and therefore was not a "pre-existing condition" under the second clause of the policy's definition of that term. We do not, however, preclude the jury from finding, as a factual matter, that congestive heart failure was a condition for which Jennifer received treatment after birth and again in August, and therefore was a preexisting condition. We clarify that this factual dispute, on the record before us, is a legitimate jury question.
We should also make clear that our case only applied the specific language of the preexisting condition clauses of this policy in determining that summary judgment was inappropriate. Our holding is not to be interpreted to say that diagnosis is always required in order for the underlying condition to be treated, but there is at least a reasonable argument that, under the language of the second clause of the definition of preexisting conditions, treatment for a specific condition cannot be received unless the...
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