Moore v. Prudential Insurance

263 So. 2d 456, 1972 La. App. LEXIS 6301
CourtLouisiana Court of Appeal
DecidedMay 29, 1972
DocketNo. 8848
StatusPublished
Cited by2 cases

This text of 263 So. 2d 456 (Moore v. Prudential Insurance) 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
Moore v. Prudential Insurance, 263 So. 2d 456, 1972 La. App. LEXIS 6301 (La. Ct. App. 1972).

Opinion

LOTTINGER, Judge.

The petitioner, Gerhart Moore, is suing the defendant, The Prudential Ins. Co., on a policy insuring against accidental loss of limb. The Lower Court rendered a summary judgment in favor of the defendant and the petitioner has taken this appeal.

The record discloses that the petitioner was a teacher at the Southeastern Louisiana College and, as such, he was covered by a group policy issued by Prudential Insurance Co. which provides “ . that if the Employee while insured under the Policy, should suffer the loss of life, sight or limb as a result, directly and independently of all other causes, of bodily injuries effected solely through external, violent and accidental means . . . ” ben-. efits would be recoverable under the said policy. The policy, by its express provision, did not cover any loss resulting from or caused “ . . . directly or indirect[457]*457ly, by . disease or bodily . infirmity, or medical or surgical treatment . or bacterial infection”.

While so employed and while the policy of insurance was in full force and effect, petitioner fractured his right femur on July 19, 1969, when he slipped and fell on his kitchen floor, and his right leg was amputated above the knee some 16 days later. Accordingly, the petitioner filed suit for benefits under the said policy of insurance.

Answer was filed by the defendant wherein the claim was denied because of the above quoted clauses of the insurance policy and asserting that the amputation of petitioner’s leg resulted from a disease, bodily infirmity or bacterial infection and was, therefore, not covered by the policy. Consequently, the defendant filed a motion for summary judgment based upon the pleadings, the certificate of insurance, the policy of insurance, the depositions of petitioner as well as that of Dr. F. C. Mc-Mains, the treating physician, based upon the fact that there was no genuine issue as to the material facts insofar as petitioner’s demand against the defendant was concerned. Accordingly, in accordance with the provisions of Articles 966 and 967 of the Louisiana Code of Civil Procedure, the Articles dealing with the rendition of summary judgment, the defendant prayed that the suit be dismissed.

Article 967 provides in part as follows:

“When a motion for summary judgment is made and supported as provided above, an adverse party may not rest on the mere allegations or denials of his pleading, but his response, by affidavits or otherwise provided above, must set forth specific facts showing that there is a genuine issue for trial. If he does not so respond, summary judgment, if appropriate, shall be rendered against him.”

The evidence discloses that the petitioner had sustained a fracture in the same area during about the year 1954 and another about in the year 1962. Because of the presence of osteomyelitis in his right leg, both previous fractures required extensive treatment, including bone grafts, internal fixation and irrigation, over a long period of time, and plaintiff’s leg was left in a weakened and shrunken condition described by Dr. McMains, his treating physician, as a bodily infirmity. The pertinent portions of Dr. McMains’ testimony is as follows:

“It had taken us — this man had really gone from 1952 to the period of 1966 with recurrent episodes of drainage of osteomyletis, bone grafts, operations and things of this nature and now he was back to the same point that he was originally. And after a prolonged discussion with him and considering the fact that he would — this leg was short, decision was made to amputate this extremity rather than • undertake further heroic measures such as further bone grafting, internal fixation and things of this nature which we felt would undoubtedly flare up his osteomyletis again if we did. And in July of 1969, he had a — what we call above-knee amputation on this side.”

Dr. McMains described osteomyelitis as an infection of the bone. He testified that once you have the disease, it is always there and when you add trauma to it whether from a fall or from an operation, or other adverse conditions, the disease will flare up. Although Dr. McMains testified that he would not have amputated this man’s leg except for the injury he says it was an amputation of choice which meant that the patient either had a choice of amputation, which the doctor testified was the best thing for him, or if the patient wanted to try to save the leg, that he could go through this same program that they had attempted for four years before and see if the limb could be saved. The doctor testified that he didn’t promise him that he could save the leg even by going through the bone graft, internal fixation, irrigation, etc. The doctor said “I frankly thought amputation was the better thing for him”.

[458]*458The doctor then went on to testify as follows:

“Q. Now, I take it that amputation is not the usual treatment for a fractured limb.
A. No, sir.
Q. You said if it had not been for the fracture at this particular time there would have not been any necessity for the amputation when it was performed; if it had not been for the infirmity or the condition of his leg at the time of the fracture there would have been no need for the amputation; is that a fair statement ?
A. If I understand you — if I may phrase it a little differently, if he had fractured his opposite leg I would not have for a moment considered an amputation, which a normal extremity.
Q. Well, I guess that means that it was because of the condition of the fractured leg prior to the fracture that was at least indirectly responsible for the amputation.
A. Yes, sir.”

The doctor then went on to explain that by virtue of the amputation, the patient became ambulatory much sooner than he would have been had he followed the procedure followed at the time of the previous fractures.

Now, we are concerned with a policy of insurance against loss of limb directly resulting from accidental injury and independently of all other causes. A loss, therefore, resulting wholly or partly, directly or indirectly, from disease or from bodily infirmity is not included in the coverage.

The jurisprudence is well settled to the effect that the burden of proof in an action on an insurance contract is on the claimant to establish every fact or issue which is essential to his right of recovery including the fact that his claim is covered by the provisions of the policy in the policy coverage. Boyd v. White, La.App., 123 So.2d 835; Macaluso v. Watson, La.App., 188 So.2d 178; King Fin. Co. of La. v. Fireman’s Fund Insurance Co., 247 La. 133, 170 So.2d 111.

An insurance policy is a contract between the parties and they are bound by its terms as written. Civil Code Articles 1901, 1945 and 1946; Gordon v. Unity Life Ins. Co., 215 La. 25, 39 So.2d 812; Oil Well Supply Co. v. N. Y. Life Ins. Co., 214 La. 772, 38 So.2d 777; Harmon v. Lumbermens Mutual & Casualty Co., 247 La. 263, 170 So.2d 646; Rogillio v. Cazedessus, 241 La. 186, 127 So.2d 734; Monteleone v. American Employers’ Ins. Co., 239 La. 773, 120 So.2d 70; Muse v. Metropolitan Life Ins. Co, 193 La. 605, 192 So. 72; Graves v. Traders & General Ins. Co., 252 La. 709, 214 So.2d 116; Theye Y Ajuria v. Pan American Life Ins. Co., 245 La. 755, 161 So.2d 70; Taylor v. State Farm Mutual Automobile Ins. Co., 248 La. 246, 178 So.2d 238.

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Related

Moore v. Prudential Insurance Co. of America
302 So. 2d 381 (Louisiana Court of Appeal, 1974)
Moore v. Prudential Insurance Company of America
278 So. 2d 481 (Supreme Court of Louisiana, 1973)

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263 So. 2d 456, 1972 La. App. LEXIS 6301, Counsel Stack Legal Research, https://law.counselstack.com/opinion/moore-v-prudential-insurance-lactapp-1972.