Goering v. Choicecare Healthcare Plans, Inc.

Ohio Court of Appeals

Goering v. Choicecare Healthcare Plans, Inc.

735 N.E.2d 936, 136 Ohio App. 3d 22, 1999 Ohio App. LEXIS 5441

CourtOhio Court of Appeals

DecidedNovember 19, 1999

DocketTrial No. A-9800357. Appeal No. C-980962.

StatusPublished

Cited by6 cases

This text of 735 N.E.2d 936 (Goering v. Choicecare Healthcare Plans, Inc.) is published on Counsel Stack Legal Research, covering Ohio Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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Goering v. Choicecare Healthcare Plans, Inc., 735 N.E.2d 936, 136 Ohio App. 3d 22, 1999 Ohio App. LEXIS 5441 (Ohio Ct. App. 1999).

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Opinions

Gorman, Judge.

Plaintiff-appellant, Robert A. Goering, challenges the summary judgment granted by the trial court in favor of defendant-appellee, Choicecare Health Plans, Inc. In two interrelated assignments of error, he contends that the installation of a ramp in his van to transport his son’s wheelchair is covered under his Choicecare health-plan policy.

Goering’s son suffers from a debilitating physical condition that requires him to use a powered wheelchair. Choicecare provides health-maintenance benefits for covered services obtained from approved health providers who participate in its network. Pursuant to the durable medical equipment benefits identified in the policy, in July 1997, Choicecare ultimately provided coverage for the purchase of Goering’s wheelchair.

*24 The record before the trial court, now fully available for review pursuant to an App.R. 9(E) stipulation, reveals that after Choicecare approved the purchase of the wheelchair, Goering purchased a “rampvan package” from Forward Motions, Inc., of Dayton, Ohio. There is no evidence of record indicating that Forward Motions is an approved provider. Including Goering’s July 8, 1997 initial payment of $8,192.50, the cost of the ramp and the modifications to the suspension and air-conditioning systems of Goering’s van exceeds $16,700. In discovery, Goering admitted that he did not obtain approval from Choicecare before purchasing the rampvan package, as required by the policy. In August 1997, Goering sought approval of the ramp installation. This lawsuit followed Choice-care’s denial of coverage.

The purpose of summary judgment is to determine from the evidentiary materials if there is a triable issue. A motion for summary judgment shall be granted if the court, upon viewing the inferences to be drawn from the underlying facts set forth in the pleadings, depositions, answers to interrogatories, written admissions, and affidavits in a light most favorable to the party opposing the motion, makes the following determinations: first, that no genuine issue of material fact remains to be litigated; second, that the moving party is entitled to judgment as a matter of law; and third, that the evidence demonstrates that reasonable minds can come to but one conclusion and that conclusion is adverse to the party opposing the motion. Civ.R. 56(C); Dresher v. Burt (1996), 75 Ohio St.3d 280, 293, 662 N.E.2d 264, 273. Where, as here, the moving party satisfies its burden, the nonmoving party cannot rest on the allegations in the pleadings, but has a reciprocal burden to set forth specific facts demonstrating that there is a triable issue of fact. Id.

Choicecare’s policy, in Section XVI, provides coverage for “Durable Medical Equipment * * * which is primarily medical in nature; can withstand daily use of at least twelve (12) months duration, is appropriate for use in the home; and is generally not useful to a person in the absence of the illness or injury for which it is used.” (Emphasis added.) The policy also states, in Section VII, subsection eighteen, that “travel and transportation expenses, even though prescribed by a physician” are excluded from coverage, except for emergency transportation.

A court must give plain language in an insurance contract its “ordinary meaning.” Miller v. Marrocco (1986), 28 Ohio St.3d 438, 439, 28 OBR 489, 490-491, 504 N.E.2d 67, 69. “[A]n exclusion from liability must be clear and exact in order to be given effect.” Lane v. Grange Mut. Cos. (1989), 45 Ohio St.3d 63, 65, 543 N.E.2d 488, 490. “ ‘[0]nly where a contract of insurance is ambiguous and therefore susceptible to more than one meaning must the policy language be *25 liberally construed in favor of the claimant who seeks coverage.’ ” United States Fire Ins. Co. v. Ohio High School Athletic Assn. (1991), 71 Ohio App.3d 760, 764, 595 N.E.2d 418, 420, quoting Burris v. Grange Mut. Cos. (1989), 46 Ohio St.3d 84, 89, 545 N.E.2d 83, 88.

To avoid the exclusion under the plain and unambiguous language of the policy, Goering’s reciprocal burden was to offer evidentiary material to create, at least, an inference that the van ramp was appropriate for use in the home. As the record is silent in this respect, the granting of summary judgment for Choicecare was appropriate. Goering’s two assignments of error are overruled.

Therefore, the judgment of the trial court is affirmed.

Judgment affirmed.

Painter, J., concurs. Shannon, J., dissents. Raymond E. Shannon, J., retired, from the First Appellate District, sitting by assignment.

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Gorman, Judge.

Plaintiff-appellant, Robert A. Goering, challenges the summary judgment granted by the trial court in favor of defendant-appellee, Choicecare Health Plans, Inc. In two interrelated assignments of error, he contends that the installation of a ramp in his van to transport his son’s wheelchair is covered under his Choicecare health-plan policy.

Goering’s son suffers from a debilitating physical condition that requires him to use a powered wheelchair. Choicecare provides health-maintenance benefits for covered services obtained from approved health providers who participate in its network. Pursuant to the durable medical equipment benefits identified in the policy, in July 1997, Choicecare ultimately provided coverage for the purchase of Goering’s wheelchair.

*24 The record before the trial court, now fully available for review pursuant to an App.R. 9(E) stipulation, reveals that after Choicecare approved the purchase of the wheelchair, Goering purchased a “rampvan package” from Forward Motions, Inc., of Dayton, Ohio. There is no evidence of record indicating that Forward Motions is an approved provider. Including Goering’s July 8, 1997 initial payment of $8,192.50, the cost of the ramp and the modifications to the suspension and air-conditioning systems of Goering’s van exceeds $16,700. In discovery, Goering admitted that he did not obtain approval from Choicecare before purchasing the rampvan package, as required by the policy. In August 1997, Goering sought approval of the ramp installation. This lawsuit followed Choice-care’s denial of coverage.

The purpose of summary judgment is to determine from the evidentiary materials if there is a triable issue. A motion for summary judgment shall be granted if the court, upon viewing the inferences to be drawn from the underlying facts set forth in the pleadings, depositions, answers to interrogatories, written admissions, and affidavits in a light most favorable to the party opposing the motion, makes the following determinations: first, that no genuine issue of material fact remains to be litigated; second, that the moving party is entitled to judgment as a matter of law; and third, that the evidence demonstrates that reasonable minds can come to but one conclusion and that conclusion is adverse to the party opposing the motion. Civ.R. 56(C); Dresher v. Burt (1996), 75 Ohio St.3d 280, 293, 662 N.E.2d 264, 273. Where, as here, the moving party satisfies its burden, the nonmoving party cannot rest on the allegations in the pleadings, but has a reciprocal burden to set forth specific facts demonstrating that there is a triable issue of fact. Id.

Choicecare’s policy, in Section XVI, provides coverage for “Durable Medical Equipment * * * which is primarily medical in nature; can withstand daily use of at least twelve (12) months duration, is appropriate for use in the home; and is generally not useful to a person in the absence of the illness or injury for which it is used.” (Emphasis added.) The policy also states, in Section VII, subsection eighteen, that “travel and transportation expenses, even though prescribed by a physician” are excluded from coverage, except for emergency transportation.

A court must give plain language in an insurance contract its “ordinary meaning.” Miller v. Marrocco (1986), 28 Ohio St.3d 438, 439, 28 OBR 489, 490-491, 504 N.E.2d 67, 69. “[A]n exclusion from liability must be clear and exact in order to be given effect.” Lane v. Grange Mut. Cos. (1989), 45 Ohio St.3d 63, 65, 543 N.E.2d 488, 490. “ ‘[0]nly where a contract of insurance is ambiguous and therefore susceptible to more than one meaning must the policy language be *25 liberally construed in favor of the claimant who seeks coverage.’ ” United States Fire Ins. Co. v. Ohio High School Athletic Assn. (1991), 71 Ohio App.3d 760, 764, 595 N.E.2d 418, 420, quoting Burris v. Grange Mut. Cos. (1989), 46 Ohio St.3d 84, 89, 545 N.E.2d 83, 88.

To avoid the exclusion under the plain and unambiguous language of the policy, Goering’s reciprocal burden was to offer evidentiary material to create, at least, an inference that the van ramp was appropriate for use in the home. As the record is silent in this respect, the granting of summary judgment for Choicecare was appropriate. Goering’s two assignments of error are overruled.

Therefore, the judgment of the trial court is affirmed.

Judgment affirmed.

Painter, J., concurs. Shannon, J., dissents. Raymond E. Shannon, J., retired, from the First Appellate District, sitting by assignment.

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735 N.E.2d 936, 136 Ohio App. 3d 22, 1999 Ohio App. LEXIS 5441, Counsel Stack Legal Research, https://law.counselstack.com/opinion/goering-v-choicecare-healthcare-plans-inc-ohioctapp-1999.

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