Bunk v. Blue Cross & Blue Shield of Utica-Watertown, Inc.

170 Misc. 2d 416, 648 N.Y.S.2d 291, 1996 N.Y. Misc. LEXIS 373
CourtNew York Supreme Court
DecidedSeptember 26, 1996
StatusPublished
Cited by4 cases

This text of 170 Misc. 2d 416 (Bunk v. Blue Cross & Blue Shield of Utica-Watertown, Inc.) is published on Counsel Stack Legal Research, covering New York Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bunk v. Blue Cross & Blue Shield of Utica-Watertown, Inc., 170 Misc. 2d 416, 648 N.Y.S.2d 291, 1996 N.Y. Misc. LEXIS 373 (N.Y. Super. Ct. 1996).

Opinion

OPINION OF THE COURT

John T. Buckley, J.

This is an action for payment of medical bills pursuant to a contract of health care insurance. Faye Bunk was a covered person under a medical and hospital insurance policy purchased from the defendant on November 11, 1993 and effective as of December 1, 1993 except with respect to any "pre-existing condition” for which there existed a 330-day waiting period. Plaintiff, diagnosed with Burkitt’s lymphoma on December 8th, was denied coverage upon a claim by defendant that her treatment was for an excluded preexisting condition. Defendant has moved for summary judgment based upon the preexisting condition exclusion; plaintiff has cross-moved for summary judgment. After receiving various written materials, the court entertained oral argument on May 13, 1996.

[418]*418CPLR 3212 authorizes this court to grant summary judgment in favor of the moving party if it is satisfactorily demonstrated that there are no disputed issues of material fact which would preclude awarding the movant the relief for which a prima facie claim or defense has been made. Although as a method of accelerated judgment such a technique deprives the opponent of trial, the Court of Appeals has underscored the need for judicial economy and the rights of other litigants since "when there is no genuine issue to be resolved at trial, the case should be summarily decided, and an unfounded reluctance to employ the remedy will only serve to swell the Trial Calendar and thus deny to other litigants the right to have their claims promptly adjudicated.” (Andre v Pomeroy, 35 NY2d 361, 364 [1974].)

Summary judgment is the "procedural equivalent of a trial” (Falk v Goodman, 7 NY2d 87, 91 [1959]), and, as such, summary judgment is a "drastic remedy” and should not be granted where there is any doubt as to the existence of a triable and "bona fide” issue of fact. (Rotuba Extruders v Ceppos, 46 NY2d 223, 231 [1978].) When movant has made a prima facie showing which demonstrates that summary judgment is warranted, it is then incumbent upon the opposing party to show by evidentiary facts that a claim is real and can be established at trial. (Zuckerman v City of New York, 49 NY2d 557, 562-563 [1980]; Indig v Finkelstein, 23 NY2d 728 [1968]; Borrman v Bogold, 229 AD2d 949.) "The purpose of the motion is to sift out evidentiary facts and determine from them whether an issue of fact exists. As such, the testimony of the nonmoving party appellant must be accepted as true and a decision on the motion must be made on the version of the facts most favorable to her.” (Strychalski v Mekus, 54 AD2d 1068, 1069 [4th Dept 1976].) This court is not supposed to determine any facts at this stage of litigation but rather ascertain that there exist material disputes of fact. This court is to find issues, not facts.

Mindful of the foregoing, the court has carefully reviewed the parties’ submissions which reveal that there exists no dispute over any material fact; the dispute involves the interpretation and application of a contract clause. If the preexisting condition exclusion does not apply to Mrs. Bunk, the defendant is responsible for providing coverage under the contract. If the preexisting condition exclusion is given effect by this court, the defendant will be granted summary judgment and Mrs. Bunk will have no recourse under her health insurance [419]*419contract. The court has been asked to ascertain whether the "pre-existing condition” exclusion contained in defendant’s health insurance policy bars plaintiff’s reimbursement for otherwise covered health care expenses. Coverage or exclusion under an insurance contract is a dispute particularly and appropriately suited for resolution by the court as a matter of law. (Mannino v Agway Group Trust, 192 AD2d 131 [2d Dept 1993]; see also, Hartford Ins. Co. v Halt, 223 AD2d 204 [4th Dept 1996].)

Although counsel for the parties characterize the chronology somewhat differently, the essential facts which emerge from the affidavits are undisputed. Faye Bunk was diagnosed with Hodgkin’s disease and successfully treated in 1988 with chemotherapy and radiation by Dr. Levy of New Haven, Connecticut. George Bunk became self-employed in 1992 and early in November of 1993 obtained a medical and hospital insurance policy from the defendant. Faye Bunk went to the Little Falls Hospital emergency room on November 20th complaining of pain from a back problem unrelated to Burkitt’s lymphoma. On November 29th, Faye Bunk went to her treating physician who assessed her as suffering from abdominal and back pain which he believed traceable to many possibilities, none of which were Burkitt’s lymphoma or Mrs. Bunk’s prior disease. On December 1st and 2nd, Faye Bunk’s treating physician dealt with her complaints of persisting pain and she was advised to increase her medication and use suppositories for constipation. On December 4th, she was admitted to the Little Falls Hospital and was treated for constipation while she was being evaluated. On December 6th, a CT scan revealed a condition "consistent with Hodgkin’s disease” and she was admitted to Yale New Haven Hospital on December 8th where a diagnosis of Burkitt’s lymphoma was made. Prior to December 1st, Mrs. Bunk was not diagnosed as having Burkitt’s lymphoma, had no symptom specific to Burkitt’s lymphoma and was not treated for Burkitt’s lymphoma.

The Blue Cross and Blue Shield comprehensive contract contains a "waiting period” for "pre-existing conditions” which is defined as follows: "With the exception of benefits for services in connection with pregnancy and complications (paragraph A above), you must wait 330 days before benefits are available for services in connection with any disease, illness, ailment, or other condition where, within 6 months before your coverage under contract began:

"Medical or surgical advice or treatment was received or suggested; or

[420]*420"You had symptoms that would usually cause a prudent person to seek medical or surgical advice or treatment, even if you did not seek it.”

Although the defendant appeared to rely upon the "prudent person with a symptom” clause in the initial motion papers, the defendant correctly recognized in its memorandum of law that this dispute does not involve that clause since Mrs. Bunk actually sought out medical treatment. There is no claim, much less evidence in this record, which would support a view that Mrs. Bunk had symptoms other than those which are reflected in the records or statements of her treating physician, Little Falls Hospital, or her treating oncologist. Mrs. Bunk experienced back and abdominal pain in the latter part of November and appropriately sought out medical advice and treatment. The question now is whether Mrs. Bunk is trying to obtain insurance coverage in connection with any disease, illness, ailment, or other condition for which she either received or had suggested medical or surgical advice or treatment within six months before her coverage under contract began on December 1, 1993.

Before further analysis of Mrs. Bunk’s claim or Blue Cross and Blue Shield’s defense as applied to the facts of this case, it is necessary to briefly consider the evolution of New York law with respect to preexisting conditions. Despite defendant’s characterization of the current State statute as evidence of "legislative recognition of the grammatical gymnastics applied by the courts”, the case law is straightforward and the legislative enactment clear.

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Bluebook (online)
170 Misc. 2d 416, 648 N.Y.S.2d 291, 1996 N.Y. Misc. LEXIS 373, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bunk-v-blue-cross-blue-shield-of-utica-watertown-inc-nysupct-1996.