Connors v. Mutual Benefit Health & Accident Ass'n

49 Misc. 2d 776, 268 N.Y.S.2d 154, 1966 N.Y. Misc. LEXIS 2130
CourtNew York County Courts
DecidedMarch 7, 1966
StatusPublished
Cited by7 cases

This text of 49 Misc. 2d 776 (Connors v. Mutual Benefit Health & Accident Ass'n) is published on Counsel Stack Legal Research, covering New York County Courts primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Connors v. Mutual Benefit Health & Accident Ass'n, 49 Misc. 2d 776, 268 N.Y.S.2d 154, 1966 N.Y. Misc. LEXIS 2130 (N.Y. Super. Ct. 1966).

Opinion

Carrollton A. Roberts, J.

The plaintiff brought this action to recover from the defendant insurance company the sum of $3,958.76, which represents 75% of the plaintiff’s expenses incurred during her confinement in the infirmary section of St. Ann’s Home for the Aged between February 1, 1963, and January 22, 1964.

The policy of insurance in question was issued to the plaintiff while she was employed and when she was 77 years of age.

On January 13, 1963, the plaintiff fell and fractured her hip. She was immediately hospitalized at St. Mary’s Hospital where she remained under the care of an orthopedic specialist until February 1,1963. She was completely incapacitated and was in need of and had nursing care around the clock. The defendant paid, under the terms of its policy, for her expenses for which defendant was liable while she was in St. Mary’s Hospital. On February 1, 1963, the plaintiff was confined to the infirmary section of St. Ann’s Home for the Aged, and continued there from that date until January 22,1964.

St. Ann’s Home for the Aged is a modern brick building, 10 stories in height, and is subdivided functionally into three areas —full infirmary, ambulant floor and area for intermediate care. Each floor comprises 46 beds with a core in the center of the building that houses not only the elevators and stairways, but a nursing unit from which the charge nurse on the floor performs her duties. There are subnursing units in each of the wings and a utility room. The rooms are primarily private rooms, although there were two double rooms on each floor. The entire building contains 354 patient rooms of which 165 are infirmary beds. The building also contains a lobby, administrative offices, private offices for the doctors, and kitchen facilities.

There is a medical wing which comprises an operating room, X-ray suite, a laboratory, a dental suite, a physical medicine suite and an eye room. There is also a room used by urologists and podiatrists.

The hospital is staffed by sisters of the Catholic Diocese most of whom are registered nurses, and the home also employs lay nurses. There is a sister who is Director of Nursing, and sisters who are nursing supervisors and staff nurses, as well as nurse’s aides. Lay people are also employed in these various duties. The sisters reside on the tenth floor of the home and provide 24-hour nursing service and care for the patients.

The infirmary section of the home comprises four floors, each of the rooms contains a hospital-type bed, bedside stand, a floor light, a dresser, a chair and toilet facilities. Each of the rooms [778]*778is also equipped with a light-button call system which lights a signal in the nursing station and summons the nurses to the patient’s room.

As part of the infirmary section there is an acute medical room for any of the patients who are acutely ill and require intensive nursing care and supervision.

The health and accident policy issued to the plaintiff provides : “ PART A. The term ‘ hospital ’, means a place, other than a convalescent, nursing or rest home, having accommodations for resident bed patients, a laboratory, a registered nurse always on duty and an operating room where surgical operations are performed by legally qualified physician or physicians.”

The sole issue to be determined is whether or not St. Ann’s Home for the Aged, in which the plaintiff was confined is a “ hospital ” as defined in PART A of the policy.

The defendant concedes that if St. Ann’s Home for the Aged is a hospital falling within the scope of the definition as contained in the policy, then the plaintiff is entitled to recover from the defendant for hospital room and board and other hospital furnished medical services and supplies under the provisions of PART C of the policy.

In order to determine the rights and liabilities of the parties under the policy, it is first necessary to determine whether or not there is an ambiguity in the wording of PART A of the policy.

The policy excludes convalescent, nursing or rest homes, and does not exclude a home for the aged. The policy contains a specific definition of the word “ hospital ”, but does not contain any specific definition of the words ‘ ‘ convalescent, nursing or rest home.”

The words convalescent, nursing or rest home ” contained in the exelusory clause are very broad terms. Facilities exist in this State and in other States which provide a wide variety of medical, surgical, hospital and nursing services to the public. What one person may consider a hospital may indeed be considered by others to be a convalescent home. On the other hand, what others may consider to be a convalescent or nursing home might provide more hospital facilities and services than some institutions which are called hospitals.

We are in an age of constantly expanding and more completely equipped institutions for the care of the sick, the infirm and the aged. The institution in this case is a home for the aged, but it is not such a home as one might always associate with an old-age home. It is a large, modern, superbly equipped and staffed medical facility. In fact, it is so well equipped and so well staffed that it meets each and every one of the standards speci[779]*779lied by the insurer as being necessary to constitute a hospital by its own definition contained in PART A of the policy.

The terms ‘ ‘ convalescent home “ nursing home ”, or ” rest home ’ ’, are, under varying circumstances, capable of more than one meaning. Whether or not a building or home or hospital is or is not a convalescent, nursing or rest home depends upon the facilities and services provided in each instance.

The insurer in this case by its policy sought to exclude from coverage convalescent, nursing or rest homes. The insurer, however, did not give any specific definition of these terms. The result is that the term 1 ‘ hospital ’ ’ as defined in the policy is clearly unambiguous, but the terms of exclusion are general, broad and capable of more than one meaning or definition.

This doubt, or ambiguity in the meaning of the exclusory clause of the policy, must, of course, be resolved in favor of the insured. The burden is on the defendant insurer to establish that one of the terms “ convalescent ”, “ nursing ” or “ rest home ’ ’ is susceptible of being defined by an average man so as to exclude St. Ann’s Home for the Aged as being such an institution. But further, the defendant has the burden of establishing that such a definition of one of these terms is the only one that could be fairly placed thereon. (Bronx Sav. Bank v. Weigandt, 1 N Y 2d 545.) It is not sufficient for the defendant to demonstrate that the plaintiff purchaser of the policy, or a physician or a hospital administrator might construe or might have construed the terms “ convalescent, nursing or rest home ” to include an institution such as St. Ann’s Home for the Aged. The defendant, to derive any benefit from the exclusory clause, was obliged to show: (1) that it would be unreasonable for the average man reading the policy to conclude that St. Ann’s Home for the Aged was anything but a convalescent, nursing or rest home; and, (2) that its own construction of these terms was the only one that could be fairly placed thereon.

The defendant has not sustained this burden. Where there is an ambiguity in an exclusory clause such as this, the rule that such ambiguity must be resolved in favor of the insured has particular application. (Sincoff v.

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Bluebook (online)
49 Misc. 2d 776, 268 N.Y.S.2d 154, 1966 N.Y. Misc. LEXIS 2130, Counsel Stack Legal Research, https://law.counselstack.com/opinion/connors-v-mutual-benefit-health-accident-assn-nycountyct-1966.