Dungan v. Travelers Insurance

476 P.2d 915, 257 Or. 511, 1970 Ore. LEXIS 459
CourtOregon Supreme Court
DecidedNovember 25, 1970
StatusPublished
Cited by1 cases

This text of 476 P.2d 915 (Dungan v. Travelers Insurance) is published on Counsel Stack Legal Research, covering Oregon Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Dungan v. Travelers Insurance, 476 P.2d 915, 257 Or. 511, 1970 Ore. LEXIS 459 (Or. 1970).

Opinions

HOWELL, J.

Plaintiff brought this action to recover benefits under a group medical insurance policy which insured employees and eligible dependents of employees of Pacific Northwest Bell Telephone Company. Plaintiff sought to recover charges incurred by him as a result of his son’s institutionalization at Fairview Hospital and Training Center in Salem. At the close of the trial both parties moved for a directed verdict. The court, however, submitted the case to the jury and a verdict [513]*513was returned in plaintiff’s favor. The defendant appeals from the judgment in plaintiff’s favor.

Plaintiff’s son, Daniel, who was born in 1945, began to show manifestations of diabetes mellitus at age 15. Between 1961 and 1965 Daniel was admitted to Good Samaritan Hospital in Portland on many occasions for emergency treatment for a diabetic coma or for insulin reaction. In November, 1965, Daniel suffered another severe attack. His arrival at the hospital was delayed when the ambulance broke down. He was unconscious in the hospital for 27 hours with a very high temperature and consequently suffered severe brain damage. Later, he was admitted to Dammasch State Hospital for approximately six months. He returned home for several months on a trial visit and in 1967 was admitted to Holladay Park Hospital. Subsequently he was again transferred to Dammaseh and then to Pairview. At the time of his admission to Pairview his mentality was reduced to that of a 5-year-old child, due to the brain damage. His condition was described as moderate to severe mental retardation complicated by diabetes mellitus.

Por its first assignment of error, the defendant contends the trial court erred in denying its motion for a directed verdict. The defendant argues that plaintiff failed to prove certain policy requirements: that Pair-view was a “hospital” within the terms of the policy; that any of the charges incurred were for “medical services * * * for treatment of injury or sickness”; that Pairview was a “legally constituted hospital”; and that Daniel was an “eligible dependent” under the policy.

Defendant’s argument that plaintiff faded to prove Daniel was an eligible dependent under the [514]*514policy is without merit.- The policy defined an eligible dependent as one who is dependent on his father for support and whose total income does not exceed $1200 per year including Social Security benefits. The defendant contends since Daniel was employed prior to his brain damage he was probably covered by Social Security, which could have paid Daniel in excess of $1200 per year. The defendant has overlooked a document signed by plaintiff at the time Daniel was admitted to Fairview. In addition to other general information, the document states that Daniel has no income from Social Security, the Veterans Administration, the State Industrial Accident Commission, the Railroad Retirement Board; owns no real estate; and has no trust fund. There is a blank space on the form following the question dealing with income from other sources, which reasonably indicates Daniel has no other income. The information on this form and the evidence in general concerning Daniel’s age and physical and mental condition clearly established that he qualified as an eligible dependent of his father under the terms of the policy.

The policy provides for the payment of covered medical expenses, including room and board, “in a legally constituted hospital.” The policy defines a “hospital” as follows:

“ ‘Hospital’ means only an institution which meets fully every one of the following tests, namely,
(a) it is primarily engaged in providing — for compensation from its patients and on an inpatient basis — diagnostic and therapeutic facilities for the surgical and medical diagnosis, treatment, and care of injured and sick persons by or under the supervision of a staff of physicians, and
(b) it continuously provides twenty-four hour-[515]*515a-day nursing service by registered graduate nurses, and
(c) it is not, other than incidentally, a place for rest, a place for the aged, a place for drug addicts, a place for alcoholics, a nursing home, a hotel or the like.
However, general hospitals operated by the Armed Forces or the Public Health Service of the United States Government will be deemed to be hospitals for the purposes of this Policy.”

The facts regarding Fairview Hospital and Training Center, the medical hospital located at Fairview, and Daniel’s physical and mental condition plus the treatment he is receiving at Fairview are undisputed.

Fairview Hospital and Training Center is a state-owned institution “for the care and training of such mentally deficient persons as are assigned to its care by the Mental Health Division or who have previously been committed to its custody.” OHS 427.010. While mental retardation is the primary criterion for admission to Fairview, it is generally necessary that the person have other complicating physical maladies, such as diabetes, cerebral palsy, or emotional or psychological complications. The institution occupies 640 acres of land with several dozen buildings, including living facilities, a school building complex, and a physical rehabilitation center. Fairview also has a 48-bed hospital including a surgery room, an emergency room, and X-ray and laboratory services. The staff consists of 12 full-time physicians, with graduate nurses on duty 24 hours per day. Generally, all types of surgery except brain and chest surgery are performed at the hospital.

The defendant’s argument that the evidence did [516]*516not establish Fairview as a “legally constituted hospital” is completely without merit. Whether it is licensed or not is immaterial. Hospitals are required to be licensed by the State Board of Health because of the interest which the state has in the “health and safety of individuals to be cared for therein.” ORS 441.022. The fact that Fairview was created by an act of the Oregon legislature and is operated under the supervision of the State Mental Health Division should satisfy this requirement.

A number of courts have liberally construed the term “hospital” as it appears in medical expense insurance policies.

In Travelers Ins. Co. v. Esposito, 171 So 2d 177 (Fla App 1965), the group medical policy insured the employee and his dependents. Travelers contended a private psychiatric treatment center was not a hospital. The definition of a hospital was for all practical purposes identical to the definition in the instant ease, and the policy was issued by Travelers, the defendant herein. The center provided medical, physical and psychological care, nursing care on a 24-hour basis, and it was affiliated with another hospital for use of diagnostic and surgical facilities. The court found the psychiatric treatment center qualified as a hospital under the policy.

The decision in Esposito was followed by the Florida Court of Appeals in Mutual Life Ins. Co. v. Young, 211 So 2d 599 (Fla App 1968).

For a contrary holding, see Burk v. Prudential Ins. Co., 7 NC App 209, 172 SE 2d 67 (1970), where the court held that the same psychiatric school and center with trained teachers did not qualify as a hospital because it had no diagnostic and surgical facilities as required by the policy.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cullop v. Rogue Valley Physicians' Service, Inc.
503 P.2d 699 (Oregon Supreme Court, 1972)

Cite This Page — Counsel Stack

Bluebook (online)
476 P.2d 915, 257 Or. 511, 1970 Ore. LEXIS 459, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dungan-v-travelers-insurance-or-1970.