Blue Cross-Blue Shield of Alabama v. Craig

242 So. 2d 398, 46 Ala. App. 352, 1970 Ala. Civ. App. LEXIS 425
CourtCourt of Civil Appeals of Alabama
DecidedDecember 16, 1970
Docket4 Div. 12
StatusPublished
Cited by3 cases

This text of 242 So. 2d 398 (Blue Cross-Blue Shield of Alabama v. Craig) is published on Counsel Stack Legal Research, covering Court of Civil Appeals of Alabama primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Blue Cross-Blue Shield of Alabama v. Craig, 242 So. 2d 398, 46 Ala. App. 352, 1970 Ala. Civ. App. LEXIS 425 (Ala. Ct. App. 1970).

Opinion

BRADLEY, Judge.

Judgment was rendered by the Circuit Court of Covington County on September 19, 1-969 for $467.90 in favor of plaintiffappellee, Cecil Craig (hereinafter referred to as Craig), and against defendant-appellant Blue Cross-Blue Shield of Alabama, A Corporation (hereinafter referred to as Blue Cross), as benefits for hospital and medical services rendered in January 1968.

On October 13, 1969 an amended judgment was rendered by the Circuit Court on behalf of Craig in “the sum of $485.55 less $17.65, the amount of insurance premiums on the policy for the month of January, 1968.”

From the amended judgment an appeal was taken to this court by the filing of a supersedeas bond in the Circuit Court. Blue Cross filed ten assignments of error with the record on appeal.

Suit was commenced by complaint in the Intermediate Court of Covington County for hospital and medical expenses allegedly due under a contract issued by Blue Cross for the hospitalization of Craig’s wife and children during the month of January 1968.

Blue Cross filed a plea in short by consent and the case was submitted to the Intermediate Court on the pleadings and an agreed-on stipulation of facts. Judgment was rendered by said court on April 22, 1969 in favor of Craig in the amount of $467.90.

On appeal to the Circuit Court from the Intermediate Court, the cause was submitted to the Circuit Court, sitting without a jury, on the pleadings and stipulation previously submitted to the Intermediate Court.

The Stipulation of Facts revealed that a “Family Contract” had been issued by Blue Cross to Craig, effective on November 1, 1966, providing benefits which included in-patient hospital service, medical care, and surgical benefits, the terms and conditions of which are set forth in the certificates attached to the stipulation.

The certificates provide that the Hospital Service Certificate (hereinafter referred to as “Certificate”) will govern the availability of benefits, as the medical benefit rider and the surgical benefit rider are valid only so long as the “Certificate” is in full force and effect.

According to Section VI of the “Certificate,” fees (premiums) are:

“* * * due and payable to, and must be received by, the Corporation in advance. ^ * *”

The “Certificate” further provides:

“Term — * * * this contract shall commence and continue in force * * * for the term for which fees have been paid in advance and from term to term thereafter so long as the applicable fees are paid in advance unless terminated as hereinafter provided.”

The fees payable by Craig under the above provision were therefore due and payable to Blue Cross monthly on the first day of each month for one month extending from the first day of each month through the last day of each month.

It is undisputed that such fees were duly paid by appellee for each of the one month terms commencing with the effective date of the contract (November 1, 1966), and ending on December 31, 1967, and that Craig’s contract continued in force and effect through December 31, 1967.

It is also undisputed that the last of such fees paid to Blue Cross by Craig were paid for the one month term commencing on [354]*354December 1, 1967 and ending on December 31, 1967.

Furthermore, the fees for the continuation of Craig’s contract during the month of January 1968 were due and payable to Blue Cross on January 1, 1968, but no fees for the month of January 1968 were ever paid to Blue Cross. Blue Cross subsequently notified Craig that his contract was terminated effective January 1, 1968 for non-payment of dues (premiums), as provided for by Section VII.A.5 of the “Certificate.”

However, Section VI.3 of the “Certificate” provides for a “grace period” of thirty days for the payment of delinquent fees, but it also provides that if such fees are not paid to and received by Blue Cross within the “grace period” of thirty days, the “* * * Contract shall terminate * * * as of the date such fees were due, and the Corporation shall not be liable for, and this Contract shall not cover, any benefits furnished to any Member during the grace period.”

Section V.3 of the “Certificate” also provides:

“Exclusions. No Benefits Shall Be Provided Hereunder With Respect To:
* * * * * * “Hospital services rendered or received during the grace period * * * if actual payment of fees then due is not received * * * within such grace period. Receipt by a Member of Hospital Service during the grace period shall not constitute payment of fees.”

The hospital service and other services on which Craig’s action rests were not furnished until the second week in January 1968 (the hospitalizations commencing January 6 and 7, 1968), which was during the month for which the fees were never paid to Blue Cross and subsequent to the effective date of the termination of Craig’s contract according to the terms of the contract.

Each of the ten assignments of error is predicated on the alleged erroneous judgment, as amended, entered by the Circuit Court permitting Craig to recover under his contract with Blue Cross.

Assignment of error three provides:

“The trial court erred in rendering in favor of the plaintiff and against the defendant its judgment of September 10, 1968, and its amended judgment of October 13, 1967.”

The issue, as presented by the assignments of error, seems to us to be whether, under the terms and conditions of the contract, coverage is provided for service furnished to a member during the grace period specified in the contract when fees which are due are not paid to Blue Cross during such grace period.

Blue Cross says that the contract benefits claimed by Craig were based solely on services rendered during January 1968, after the contract’s termination because the contract was terminated automatically according to the provisions of the “Certificate” when Craig failed to make his payment for the one-month term from January 1 to January 31, 1968.

Blue Cross concedes, however, that the contract provides for a thirty day grace period within which the fees may be paid after their due date; yet vigorously contends that the contract explicitly excludes any coverage of benefits for hospital service received during such grace period if actual payment of the fees is not made to it during that period.

To support this position, Blue Cross argues two provisions found in the “Certificate,” which provide, in Section VI.3, that if such fees are not paid within such grace period, the contract shall terminate as of the due date and shall not cover any benefits furnished during the grace period; and, in Section V.3, that no benefits shall be provided if actual payment of fees then due is not received within the grace period.

As we interpret the argument made by Blue Cross, it is saying that while Craig has the right to make payment during this [355]*355grace period and be covered, that if he does not make payment during said grace period, normal coverage is explicitly excluded.

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Related

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Cite This Page — Counsel Stack

Bluebook (online)
242 So. 2d 398, 46 Ala. App. 352, 1970 Ala. Civ. App. LEXIS 425, Counsel Stack Legal Research, https://law.counselstack.com/opinion/blue-cross-blue-shield-of-alabama-v-craig-alacivapp-1970.