Scarborough v. Aetna Life Ins. Co.

• Decision Date: 29 March 1978
• Docket Number: No. B-7157,B-7157
• Citation: 572 S.W.2d 282
• Parties: Gail G. SCARBOROUGH, Petitioner, v. AETNA LIFE INSURANCE COMPANY, Respondent.
• Court: Texas Supreme Court

Page 282

572 S.W.2d 282

Gail G. SCARBOROUGH, Petitioner, v. AETNA LIFE INSURANCE COMPANY, Respondent.

No. B-7157.

Supreme Court of Texas.

March 29, 1978.

Roger L. Turner, Dallas, for petitioner.

Woodfin C. Henderson, Dallas, for respondent.

DANIEL, Justice.

The question presented by this case involves the right to benefits under a medical insurance policy.

Gail Scarborough's husband was included in a group accident and health insurance policy issued through his employer by Aetna Life Insurance Company. The policy provided comprehensive medical benefits for Mrs. Scarborough as a member of an insured employee's family. The medical coverage was limited by a continuing treatment exclusion which provided in part:

If, at the time a family member becomes insured under this Title, he has received treatment for a condition resulting from a disease or injury during the three month period just before he became insured under this Title, Covered Medical Expenses for that condition are subject to the limitations described below. Treatment of a condition means receiving either medical services or prescribed drugs or medicines.

1. Any expenses incurred in connection with such condition during the first twelve months while insurance is in force will not be considered Covered Medical Expenses.

The insurance policy went into effect on June 16, 1974. On July 1, 1974 Mrs. Scarborough underwent surgery for a complete hysterectomy and for removal of abdominal adhesions.

While the surgical expenses were covered by the comprehensive medical provisions of the policy, Aetna took the position that the continuing treatment exclusion applied and refused to pay Mrs. Scarborough any benefits. Aetna contends that the surgical expenses were incurred in connection with a condition for which Mrs. Scarborough had been treated during the three-month period prior to the policy's effective date.

The jury found that during the three-month period preceding June 16, Mrs. Scarborough did not receive treatment for a condition which related to her July 1 surgery. Accordingly, the trial court rendered judgment for her in the amount of the medical expenses incurred as a result of the surgery. The Court of Civil Appeals reversed and rendered judgment for Aetna on the ground that the continuing treatment exclusion applied to her surgery. 556 S.W.2d 109. The court held there was no evidence to support the jury's finding of no prior treatment of the condition.

On June 6, 1974, Mrs. Scarborough went to Dr. James Ensey, a gynecologist, for an annual physical examination. That examination revealed abdominal adhesions, an abnormal ovarian function, and that Mrs. Scarborough's ovaries were enlarged. Dr. Ensey testified that nothing revealed at the June 6 examination indicated that surgery was necessary at that time. However, he asked that she return for further examination on June 17 (the day after the insurance policy went into effect). While Dr. Ensey testified that she showed some improvement on that date, his written report compiled as a result of this examination concluded with the recommendation of an ovarian excision.

After she developed abdominal pains, Mrs. Scarborough went to the hospital on June 30 at the direction of Dr. Ensey. After a third examination to verify Mrs. Scarborough's conditions...