Mutual Benefit Health & Accident Ass'n v. Reed

242 S.E.2d 731, 144 Ga. App. 853, 1978 Ga. App. LEXIS 1822
CourtCourt of Appeals of Georgia
DecidedFebruary 3, 1978
Docket54703
StatusPublished
Cited by1 cases

This text of 242 S.E.2d 731 (Mutual Benefit Health & Accident Ass'n v. Reed) is published on Counsel Stack Legal Research, covering Court of Appeals of Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mutual Benefit Health & Accident Ass'n v. Reed, 242 S.E.2d 731, 144 Ga. App. 853, 1978 Ga. App. LEXIS 1822 (Ga. Ct. App. 1978).

Opinion

McMurray, Judge.

In 1970 Frank B. Reed operated a service station in Adel, Georgia. He had previously purchased a policy of insurance from Mutual Benefit Health & Accident Association (Mutual of Omaha) which was an accidental benefit policy paying for total and partial disability. Thereafter, as contended by Mr. Reed, on or about August 15, 1970, he sustained a personal injury by accidental [854]*854means which resulted in permanent disability since May 10.1971. Mr. Reed contends the injury occurred when he was pushing an automobile into the service station which started suddenly thereby causing him to fall upon the pavement. Mr. Reed contends he was unable to work thereafter due to a hiatal hernia in the upper region of his chest. After examination by his doctor on or about May 10, 1971, Reed began contacting the insurance company seeking to make a claim for permanent and total disability. A written report of disability was made to the insurance company on July 14,1971. A representative of the company contacted him and paid him $800 "for being sick.” Mr. Reed did not sign a release, but that is all the insurance company ever paid him. Mr. Reed then contacted a lawyer in November or December, 1974, and filed suit against Mutual Benefit Health & Accident Association on the 7th day of May, 1975, contending therein that he had been permanently disabled since May 10.1971, seeking judgment against the defendant for the sum of $8,400 (later amended to $15,400) plus $2,100 in attorney fees. The defendant answered denying., the averments of the complaint and admitting only the averments as to the residence of plaintiff and as to the accident insurance policy attached.

At the trial plaintiff offered evidence generally showing the above facts and that although he had fallen in August of 1970 and had been disabled since that time, he did not contact the defendant insurance company until after he had seen the doctor in May of 1971. He testified he had received a check from Mutual of Omaha for $800. Plaintiff submitted in evidence the policy owner’s report of disability, dated "7-14-71,” a supplemental report dated "8-25-71,” and a copy of the policy, as well as a claim form dated "3-5-75,” and copies of correspondence. The defendant submitted in evidence copies of correspondence, one dated "6-23-71” and also one dated July 2, 1971.

The policy owner’s report of disability dated "7-14-71,” as well as other correspondence it had had with Mr. Reed, including the report of disability dated "3-5-75” and a copy of a statement of benefits for $800 paid Mr. Reed on September 3,1971. The defendant also submitted [855]*855the testimony of a claims representative of "Mutual of Omaha Insurance” who had testified that he had worked on Mr. Reed’s claim, but that he had never contacted him personally, that a claim draft had been issued to Mr. Reed in the amount of $800 for one month confining sickness disability plus three months nonconfining sickness disability, contending that this was all he was entitled to.

After the close of the evidence defendant Mutual of Omaha moved for a directed verdict contending that a clause in the policy stated that "if the Insured because of such injury shall be totally and continuously disabled and shall suffer a total loss of time, the Association will pay benefits from one day or more (benefits begin on the date of the first medical treatment during disability) during the period of such disability at the rate of the Monthly Benefit per month if such disability commences prior to age 60 or at the rate of 50% of the Monthly Benefit per month if such disability commences on or after Insured’s 60th birthday; provided the Insured is under the professional care and regular attendance of a legally qualified physician, other than himself, and such injuries do not result in any of the specific losses mentioned below”; and under provision 5 of the policy written notice of the claim must be given to the association within 20 days after the occurrence or commencement of any loss covered by the policy or as soon thereafter as is reasonably possible and that if insured suffers loss of time on account of disability for which indemnity may be payable for at least two years he shall at least once every six months after having given notice of claim give the association notice of continuance of said disability, except in the event of legal incapacity; that the period of six months following any filing of proof by the insured or any payment by the association shall be excluded in applying this provision; that delay in giving such notice shall not impair the insured’s right to any indemnity which would otherwise have accrued during the period of six months "proceeding [sic] the date on which said notice is actually given”; that Mr. Reed had given notice apparently on June 23, 1971, and that paragraph 7 of the policy requires written proof of loss to be furnished "within ninety days after the termination of the period for which the Association is [856]*856liable and in case of claim for any other loss within ninety days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate [nor] or reduce any claim if it was not reasonably possible to give such proof within such time, provided, such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.” Movant contends that the payment was made in 1971 under the paragraph 6 provisions as to sickness or disability and that no further action had been taken by the plaintiff himself and "[n]o such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished”; that this provision was required by Code Ann. § 56-3004 (Ga. L. 1960, pp. 289, 717) and that this action by the plaintiff was barred, citing Darnell v. Fireman’s Fund Ins. Co., 115 Ga. App. 367 (154 SE2d 741) and McIntyre v. Shield Ins. Co., 128 Ga. App. 480 (197 SE2d 160). This motion was denied.

The jury returned a verdict for the plaintiff in the amount of $15,400. The judgment followed the verdict, whereupon defendant moved for judgment notwithstanding the verdict, or in the alternative for new trial. The latter motion was amended and after a hearing denied. Defendant appeals. Held:

1. Defendant’s main argument is to the alleged error in the denial of its motion for directed verdict and judgment notwithstanding the verdict, based upon such cases as McIntyre v. Shield Ins. Co., 128 Ga. App. 480, supra; Darnell v. Fireman’s Fund Ins. Co., 115 Ga. App. 367, supra; Johnson v. Ga. Farm Bureau Mut. Ins. Co., 141 Ga. App. 859 (234 SE2d 693). However, the evidence here shows an issue of fact for jury determination as to whether or not a waiver of or proper proof of loss was required in that the insurance company had investigated the claim and had paid this insured plaintiff the sum of $800 as well as the other conduct testified to by the plaintiff with reference to his conversations with various officials of said company. Plaintiff did present to the defendant, on forms of the defendant, a "Policyowner’s Report of Disability,” dated July 14,1971, a supplemental report on August 25, 1971, and again on March 5,1975. See in this connection [857]*857such cases as to conduct amounting to waiver or estoppel of the insurer. Norfolk & Dedham Mut. Fire Ins. Co. v. Cumbaa, 128 Ga. App. 196 (1) (196 SE2d 167); Travelers Fire Ins. Co. v. Robertson, 103 Ga. App. 816 (120 SE2d 657);

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Cite This Page — Counsel Stack

Bluebook (online)
242 S.E.2d 731, 144 Ga. App. 853, 1978 Ga. App. LEXIS 1822, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mutual-benefit-health-accident-assn-v-reed-gactapp-1978.