Gilliland Estate

48 Pa. D. & C.2d 69, 1969 Pa. Dist. & Cnty. Dec. LEXIS 109
CourtPennsylvania Court of Common Pleas, Washington County
DecidedJune 11, 1969
Docketno. 208 of 1967
StatusPublished

This text of 48 Pa. D. & C.2d 69 (Gilliland Estate) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, Washington County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Gilliland Estate, 48 Pa. D. & C.2d 69, 1969 Pa. Dist. & Cnty. Dec. LEXIS 109 (Pa. Super. Ct. 1969).

Opinion

MARINO, P. J.,

We here consider the claim of the Metropolitan Life Insurance Company (Metropolitan) against the Estate of Willard R. Gilliland, deceased. The claim is for the repayment of medical and hospital expenses paid by Metropolitan, some payments being made directly to the said estate and others to the doctors and the hospital concerned. The payments were made by Metropolitan under the provisions of a group insurance policy issued by said company to Aluminum Company of America (Alcoa) [70]*70decedent’s employer, insuring eligible salaried employes of Alcoa and providing, inter alia, for payment of benefits to an employe on account of medical and hospital services rendered to the employe and his dependents.

Decedent was killed on July 17, 1963, in an automobile accident in which three of his minor children were injured and two others were also killed. The injured minors were taken to St. Clair Memorial Hospital, where they were admitted and stayed for varying lengths of time and received various medical and surgical attention.

Metropolitan’s group policy had attached a supplementary agreement that set forth the provisions covering what is termed “extended medical expense benefits.” Briefly stated, it called for the payment to an insured employe of expenses, therein defined as covered medical expenses, incurred for the employe, and also provided benefits payable to the employe on account of covered medical expenses incurred for a dependent of the employe. Section 7 of the supplementary agreement provides, in material portion, as follows:

“All benefits provided in this Supplementary Agreement shall be paid to the Employee as they accrue upon receipt of written proof that the medical expenses for which claim is made were actually incurred. . . .”

The insuring clause, section 5(A), reads, in material portion, as follows:

“If an Employee or a Dependent of an Employee suffers an injury or contracts a sickness and as a result thereof the Employee incurs on account of himself while insured under this Supplementary Agreement for Personal Insurance, or on account of the Dependent while the Employee is insured under this Supplementary Agreement on account of such Dependent

[71]*71“(a) Covered Medical Expenses during any one Medical Expense Period which are in excess of

“(b) the Deductible Amount with respect to such Medical Expense Period, then, upon receipt of proof of claim as required herein, the Insurance Company shall pay benefits, subject to the terms and limitations hereof, in an amount equal to the Insured Proportion, as specified in the schedule in subsection (C) below, of such excess of (a) over (b), provided that ...” the applicable maximum benefit limits are not exceeded. The definitions of personal insurance and dependent insurance are set forth in section 1 and are as follows:

“The term ‘Personal Insurance’ means insurance providing benefits payable to an Employee on account of Covered Medical Expenses incurred for the Employee, subject to the terms and limitations hereof.

“The term ‘Dependent Insurance’ means insurance providing benefits payable to an Employee on account of Covered Medical Expense incurred for a Dependent of the Employee, subject to the terms and limitations hereof.”

Covered medical expenses are detailed in section 5(D), which contains a number of exceptions, including the one designated (j), which is material in this case. The pertinent portion of this part of section 5 reads as follows:

“Exceptions: — Expenses incurred for any of the following shall in no event be considered Covered Medical Expenses: . . .
“(j) Any expenses for which payment or reimbursement is received by or for the account of the Employee or Dependent as a result of a legal action or settlement, . . .”

Because there were two other cars involved in the automobile accident, there was a distinct possibility that the medical and hospital expenses incurred on [72]*72account of decedent’s three minor children might well come within the above-quoted exception (j), if one of the other drivers in the accident were later to be held hable for, or to make a compromise settlement of, the claims for the personal injuries sustained by the minors.

During the Gilliland daughters’ hospitalization, claim was made with Metropolitan for payment of those hospital, medical and surgical expenses covered by a group insurance policy issued by the Aluminum Company of America to Willard R. Gilliland, decedent. This policy provided hospital, medical and surgical coverage within specified limits for the named employe and his dependents as hereinbefore set forth. Following submission of these claims, Metropolitan drew checks payable to the estate on August 21, 1963, which were then accepted and cashed by the executors of the estate. The entire proceeds of these checks went to the appropriate physicians, surgeons and St. Clair Memorial Hospital. Later payments by Metropolitan of additional claims made under this policy passed directly to St. Clair Memorial Hospital, physicians and surgeons by checks drawn to their orders, but only after Mrs. June Gilliland had executed the requested reimbursement agreements.

From the evidence submitted at the hearing, and from the admitted pleadings, we make the following

FINDINGS OF FACT

1. Decedent, Willard R. Gilliland, was killed on July 17, 1963, in an automobile accident in which three of his minor children were injured and two others were also killed. The injured minors were taken to St. Clair Memorial Hospital, where they were admitted and stayed for varying lengths of time and received various medical and surgical attention.

[73]*732. At his death, decedent was a salaried employe of Aluminum Company of America and as such was insured under Metropolitan Life Insurance Company Group Policy No. 12345-G, inter aha, for medical and hospital expense benefits for the three injured minor children as his dependents.

3. Metropolitan’s group policy had attached a supplementary agreement that set forth the provisions covering what is termed “extended medical expense benefits.” Briefly stated, it called for the payment to an insured employe of expenses, therein defined as covered medical expenses, incurred for the employe, and also provided benefits payable to the employe on account of covered medical expenses incurred for a dependent of the employe. Section 7 of the supplementary agreement provides in material portion as follows:

“All benefits provided in this Supplementary Agreement shall be paid to the Employee as they accrue upon receipt of written proof that the medical expenses for which claim is made were actually incurred. . . .”

4. The insuring clause in the group policy, section 5(A), reads, in material portion, as follows:

“If an Employee or a Dependent of an Employee suffers an injury or contracts a sickness and as a result thereof the Employee incurs on account of himself while insured under this Supplementary Agreement for Personal Insurance, or on account of the Dependent while the Employee is insured under this Supplementary Agreement on account of such Dependent,
“(a) Covered Medical Expenses during any one Medical Expense Period which are in excess of

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Cite This Page — Counsel Stack

Bluebook (online)
48 Pa. D. & C.2d 69, 1969 Pa. Dist. & Cnty. Dec. LEXIS 109, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gilliland-estate-pactcomplwashin-1969.