Jefferson v. State Farm Ins. Companies

551 A.2d 283, 380 Pa. Super. 167, 1988 Pa. Super. LEXIS 3635
CourtSupreme Court of Pennsylvania
DecidedDecember 8, 1988
Docket1143
StatusPublished
Cited by36 cases

This text of 551 A.2d 283 (Jefferson v. State Farm Ins. Companies) is published on Counsel Stack Legal Research, covering Supreme Court of Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jefferson v. State Farm Ins. Companies, 551 A.2d 283, 380 Pa. Super. 167, 1988 Pa. Super. LEXIS 3635 (Pa. 1988).

Opinion

CIRILLO, President Judge:

This is an appeal from a summary judgment entered by the Court of Common Pleas of Philadelphia County in favor of appellee Blue Cross of Greater Philadelphia and against appellant Mary Jefferson.

Mary Jefferson was hit by a van in February of 1984. Because of injuries she allegedly sustained to her left shoulder and hip, she underwent extensive medical and hospital treatment. At the time of her injury, Jefferson was insured for hospitalization expenses under a group insurance policy between her employer, the Philadelphia School District, and Blue Cross of Greater Philadelphia, and for medical expenses by Equitable Life Assurance Society. Shortly before the accident, Jefferson had voluntarily terminated her coverage with Blue Cross and Equitable, and had switched her insurance coverage to an HMO plan provided *169 by Health America. The termination was to become effective on March 15, 1987.

Jefferson submitted claims for her hospital and medical expenses to Blue Cross, Equitable, and Health America, as well as State Farm Insurance Company, her No-Fault automobile insurer. State Farm refused payment of the claims, contending that her primary insurers should pay her medical and hospital expenses. Blue Cross, Equitable, and Health America also refused to pay the claims. Blue Cross, the only appellee here, claimed that Jefferson was not insured for any expenses arising after March 15, 1987, the date upon which her termination became effective. Further, it noted that it had never received any notification from the health care providers of the services in question, only a letter from Jefferson’s attorney, and therefore, in any case, it was unable to determine which of the claims made by Jefferson were for expenses covered under the insurance policy.

The parties agreed to arbitrate the matter, and the arbitrator found for the defendant insurers. Jefferson appealed the arbitrator’s decision to the Court of Common Pleas of Philadelphia County. Appellee Blue Cross moved for summary judgment, denying that there was any issue of material fact, and arguing that as a matter of law, it was not liable for any expenses arising after the termination date. Jefferson argued that an issue of material fact did exist, although she did not state what that issue was, and also argued that if no factual dispute did exist, she, rather than Blue Cross, was entitled to judgment as a matter of law. She contended that the policy was an occurrence policy, and that therefore, the insurer was liable for all expenses arising out of any injury occurring during the policy period. The trial court granted summary judgment for Blue Cross, finding that the policy covered expenses arising during the policy term, rather than injuries occurring during that period. Jefferson then appealed to this court.

*170 Jefferson argues the same issues to us on appeal as she argued in her motion contesting summary judgment. In reviewing a grant of summary judgment, the appellate court must accept as true all well-pleaded facts in the non-moving party’s pleadings, and give to him or her the benefit of all reasonable inferences to be drawn therefrom. To uphold the trial court’s grant of summary judgment, not only must there be no genuine issue of material fact, but the moving party must have been entitled to summary judgment as a matter of law. Curry v. Estate of Thompson, 332 Pa.Super. 364, 368, 481 A.2d 658, 659 (1984).

Here, Jefferson argues that the case involves genuine issues of material fact with regard to the termination clause included in her policy which should have resulted in the denial of Blue Cross’ motion for summary judgment. Jefferson is not, however, explicit on what those material issues of fact are. Rather, she seems to argue that the trial court erred as a matter of law in granting summary judgment because the policy provision upon which it relied in ruling for Blue Cross was ambiguous. She argues that the provision in question could have reasonably led her to believe that her coverage would continue after the policy terminated on March 15, 1987, because the injury which gave rise to those expenses occurred during the policy term.

The interpretation of an insurance policy is a question of law for the court to consider. Adelman v. State Farm Mutual Automobile Insurance Co., 255 Pa.Super. 116, 123, 386 A.2d 535, 538 (1978). The policy must be read in its entirety, and the words must be given their plain and proper meaning. It should be read to avoid ambiguities if possible, and the language should not be tortured to create them. Monti v. Rockwood Insurance Co., 303 Pa.Super. 473, 476, 450 A.2d 24, 25 (1981). A provision is ambiguous only if reasonably intelligent persons considering it in the light of the entire policy could honestly differ as to its meaning. Adelman, 255 Pa.Super. at 123, 386 A.2d at 538. Any truly ambiguous term must be given a construction favorable to the insured. Id.

*171 The policy provision in question is entitled, “Termination Without Claim Prejudice,” and reads as follows:

When this agreement is terminated, except for termination by incorrect information or misrepresentation, and a Subscriber is receiving in-patient benefits on the date of such termination, benefits will continue to be provided only to the date of discharge or expiration of eligible benefit days, whichever is earlier.

Jefferson argues that the title of the policy creates an ambiguity; she claims it could be read to state that the expiration of the insurance policy will not terminate benefits, and that this could lead a reasonable person to believe that entitlement to insurance benefits are governed by whether the date of the accident falls within the policy period. We disagree.

According to a Michigan court analyzing the somewhat sparse and divergent case law on this subject, courts have come to decisions in these situations by analyzing the risk insured in each case. See Auto-Owners Insurance Co. v. Blue Cross & Blue Shield of Michigan, 182 Mich.App. 800, 349 N.W.2d 238 (1984). Courts have found coverage to extend beyond the policy period in cases in which the risk insured could have been construed as expenditures arising out of an accident. Id. at 817, 349 N.W.2d at 246. In those cases, the benefit is held to have vested when the accident occurred. See Myers v. Kitsap Physicians Service, 78 Wash.2d 286, 474 P.2d 109 (1970). We agree with the Michigan court that the policy considerations behind permitting benefits under a policy which insures loss related to accident, injury, illness, and so forth, to continue past the effective date of the policy, are not the same as those governing a situation in which medical and hospital expenses are the risks insured.

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Bluebook (online)
551 A.2d 283, 380 Pa. Super. 167, 1988 Pa. Super. LEXIS 3635, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jefferson-v-state-farm-ins-companies-pa-1988.