Matthews v. Standard Life Insurance Company

213 So. 2d 128, 1968 La. App. LEXIS 4546
CourtLouisiana Court of Appeal
DecidedJuly 29, 1968
Docket2396
StatusPublished
Cited by7 cases

This text of 213 So. 2d 128 (Matthews v. Standard Life Insurance Company) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Matthews v. Standard Life Insurance Company, 213 So. 2d 128, 1968 La. App. LEXIS 4546 (La. Ct. App. 1968).

Opinion

213 So.2d 128 (1968)

George F. MATTHEWS, Plaintiff-Appellant,
v.
STANDARD LIFE INSURANCE COMPANY, Defendant-Appellee.

No. 2396.

Court of Appeal of Louisiana, Third Circuit.

July 29, 1968.

*129 Howard N. Nugent, Jr., Alexandria, and McLure & Ford, by William M. Ford, Alexandria, for plaintiff-appellant.

Provosty, Sadler & Scott, by Richard B. Wilkins, Jr., Alexandria, for defendant-appellee.

Before TATE, CULPEPPER and HOOD, JJ.

HOOD, Judge.

Plaintiff, George F. Matthews, instituted this suit to recover benefits, with penalties and attorney's fees, alleged to be due him under the provisions of a health and accident insurance policy. The suit was instituted against Standard Life Insurance Company, the insurer in that policy. On application of defendant, a summary judgment was rendered by the trial court rejecting plaintiff's demands. Plaintiff has appealed.

There is no genuine issue as to any material fact. The record shows that on April 23, 1966, plaintiff sustained a serious injury to his left ankle and foot while working for Texada-Bailey Company, Inc. At that time there was in effect a group policy of insurance which had been issued by defendant to Texada-Bailey Company, Inc., as the employer, in favor of the insured's employees. Plaintiff, as an employee of that company, was insured under that policy. Among other obligations contained in the policy, the defendant agreed to pay plaintiff the sum of $2,500.00 for the loss of one foot as the result of an accident, provided that the loss was sustained within a period of 90 days after the accident occurred.

On the above mentioned date plaintiff fell as he alighted from a horse. He landed on his left lower extremity in or very near a cesspool in the back of a neighbor's home. As a result of this fall he sustained an open fracture, a trimalleolar, of the left ankle. The tibia and fibula were broken, and the foot was dislocated laterally, going up the side of the leg with the broken end of the tibia protruding through the skin and actually sticking down into the cesspool.

He received medical attention almost immediately, and he was treated by Dr. P. M. Davis, Jr., an orthopedic surgeon, for several months after the accident occurred. Dr. Davis cleaned the injured ankle and foot, he fixed the fracture with a screw and he closed the skin, except that a tube was left in the leg to irrigate the wound. An infection set in within two or three days, making it necessary for extensive treatment to be administered over a long period of time. This treatment included the opening of the leg for drainage and allowing it to remain open for several days, surgery on at least four different occasions, the insertion of a pin through the foot into the ankle, the application of a cast and the performance of some skin grafts. After treating the foot, leg and ankle for several months, Dr. Davis concluded on September 29 that the leg would have to be amputated, and on October 4, 1966, he performed the required surgery amputating plaintiff's left leg two or three inches above the ankle. A guillotine type amputation was performed at that time to allow the leg to drain and to recover sufficiently *130 from the infection to permit an ordinary amputation to be accomplished. A few weeks later, and according to the doctor's plan, another amputation was performed on the same leg, five or six inches below the knee. It is apparent from the foregoing review of the facts that the first amputation or severance of the foot took place more than five months after the accident occurred.

After the foot had been severed, plaintiff demanded payment of the benefits provided in the policy for the loss of one foot. Defendant refused to comply with that demand, assigning as reasons therefor that the "loss" of the leg did not occur until more than 90 days after the date of the accident.

The trial judge concluded that the term "loss," as used in the policy with respect to hands and feet, means the loss of such a member by severance, and that plaintiff is not entitled to recover under the policy because the amputation of the foot did not actually occur within 90 days of the date of the accident.

Plaintiff contends that the terms "loss" and "severance," as used in the policy, are not synonymous, that he never regained the use of his foot subsequent to the day of the accident, and that he thus suffered a "loss" of the foot as of that day.

The policy under which plaintiff seeks to recover here contains the following pertinent provisions:

"Upon receipt of notice and due proof, as required herein, that any employee, while insured for Accidental Death, Dismemberment and Loss of Sight Benefits under the policy, shall have sustained any of the losses listed in the following Table of Losses as the direct result of accidental bodily injury and independently of all other causes, as evidenced by a visible contusion or would on the exterior of the body (except in the case of drowning or internal injuries revealed by an autopsy), and the date of occurrence of such injury is not more than ninety days prior to the date such loss was sustained, the Company Agrees to Pay, subject to the terms and conditions hereof, the amount of insurance specified for such loss in the Table of Losses, in accordance with the Full Amount of Insurance applicable to such employee as specified in the Schedule of Benefits.

TABLE OF LOSSES

In the Event of Loss of: .......... One Foot___One Half the Full Amount of insurance. ..........
With respect to hands or feet, "loss" means dismemberment by severance at or above the wrist or ankle joint." (Emphasis added.)

The general rule is that where an accident policy provides indemnity for the "loss" of a member, without any further definition or statement as to what shall constitute such a loss, then the word "loss" will be construed to mean the loss of use of the member. But, where the policy provides indemnity for the "loss" of a member, and it also contains a definition or statement as to what shall constitute a loss of such member, then effect must be given to this qualifying definition or explanation, and the word "loss" must be construed as provided in the policy. Muse v. Metropolitan Life Ins. Co.,193 La. 605, 192 So. 72 (1939); Westenhover v. Life & Casualty Ins. Co. of Tennessee, 27 So.2d 391 (La. App.2d Cir. 1946, cert denied); Appleman, Insurance Law and Practice, Volume 1A, Section 702, pp. 687-689; 45 C.J.S. Insurance § '900b, p. 986; 29A Am.Jur., Insurance, Sections 1510, and 1511, pp. 616-618.

An insurance policy, of course, is the contract between the parties, and, like all other contracts, it is the law between them. Courts are bound to give legal effect to all such contracts according to the *131 true intent of all the parties, and that intent is to be determined by the words of the contract, when these are clear and explicit and lead to no absurd consequences. LSA-C.C. arts. 1901 and 1945; Westenhover v. Life & Casualty Ins. Co. of Tennessee, supra; Rogillio v. Cazedessus, 241 La. 186, 127 So.2d 734 (1961); Paul Foshee Dusting Company v. Byron, 158 So.2d 345 (La.App.3d Cir. 1963).

In Muse v. Metropolitan Life Ins.

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213 So. 2d 128, 1968 La. App. LEXIS 4546, Counsel Stack Legal Research, https://law.counselstack.com/opinion/matthews-v-standard-life-insurance-company-lactapp-1968.