National Family Care Life Insurance Co. v. Kuykandall

705 S.W.2d 267, 1986 Tex. App. LEXIS 12439
CourtCourt of Appeals of Texas
DecidedJanuary 15, 1986
DocketNo. 04-84-00459-CV
StatusPublished
Cited by2 cases

This text of 705 S.W.2d 267 (National Family Care Life Insurance Co. v. Kuykandall) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
National Family Care Life Insurance Co. v. Kuykandall, 705 S.W.2d 267, 1986 Tex. App. LEXIS 12439 (Tex. Ct. App. 1986).

Opinion

[269]*269OPINION

REEVES, Justice.

Appellant, National Family Care Life Insurance Company, seeks reversal of this case on the grounds that the hospitalization of Frank R. Kuykendall, Jr., appellee, fell within a noncompensable exception to the policy.

Appellant insured appellee, contracting to pay $300.00 per day in the event he was hospitalized in an intensive care unit.

Appellee became ill and was first confined in the Intensive Care Unit (ICU) at the Medical Center Hospital where he was diagnosed as suffering from a pulmonary embolus.1 The payment of this portion of appellee’s hospitalization is not contested. After three days in the Medical Center Hospital’s ICU, appellee’s doctor ordered his transfer to an equivalent unit at the San Antonio Community Hospital. Appel-lee was placed in a part of the hospital designated as the Coronary Care Unit (CCU) where he remained for 27 days. The area designated as the ICU is contiguous to the CCU.

Appellant refused to pay for the $300.00 per diem rate, contending that confinement in the San Antonio Community Hospital fell within an exception enumerated in the insurance policy. A jury found to the contrary and the trial court granted judgment to appellee for the time he was confined to the CCU.

Appellant asserts the trial court erred in the following:

1. in entering judgment for appellee because, as a matter of law, the confinement in the CCU was expressly excluded from the contract;
2. the undisputed evidence displays that appellee was not confined in a medical care unit covered under the contract;
3. there was no evidence or insufficient evidence to support appellee’s claim to medical payment coverage; and
4.in overruling appellant’s objections to the jury charge and failing to submit appellant’s requested issues and instructions.

The standard of review for a “no evidence” assertion requires that the court consider only evidence tending to support the finding, viewing it in the most favorable light in support of the finding, giving effect to all reasonable inferences that may properly be drawn therefrom and disregarding all evidence which is conflicting or contrary. Glover v. Texas General Indemnity Co., 619 S.W.2d 400, 401 (Tex.1981).

The standard of review for an insufficient evidence assertion requires that the court consider and weigh all the evidence and set aside the judgment if we conclude that the finding is clearly wrong and unjust. In re King’s Estate, 150 Tex. 662, 244 S.W.2d 660, 661 (1951).

If the insurance contract is ambiguous or uncertain, it will be construed liberally in favor of the insured and strictly against the author of the contract, the insurer. United States Fidelity & Guaranty Co. v. Bimco Iron & Metal Corp., 464 S.W.2d 353, 355 (Tex.1971); Zimmerman v. National Home Life Assurance Co., 517 S.W.2d 842, 845 (Tex.Civ.App.—Waco 1974, writ ref’d n.r.e.). Our Supreme Court in Hardware Dealers Mutual Insurance Co. v. Berglund, 393 S.W.2d 309, 314 (Tex. 1965) stated:

The language used in the policies must be construed according to the evident intent of the parties, to be derived from the words used, the subject matter to which they relate, and the matters naturally or usually incident thereto, and it is only when the words admit of two constructions, that one will be adopted most [sic] favorable to the insured. [Citations and emphasis omitted.]

It is undisputed that appellant’s contract of insurance excepts from coverage confinement by the insured in a CCU. The contract provides, in pertinent part:

[270]*270COVERED CONFINEMENT: Covered Confinement shall mean the occurrence or all of the following conditions:
1. The Covered Person is necessarily confined in a Hospital Intensive Care Unit (Hospital ICU).
EXCLUSIONS AND LIMITATIONS: This policy does not cover confinement in coronary care units, neonatal intensive care units, or step-down units such as progressive care, sub-acute intensive care, intermediate care units, private monitored rooms, observation units or other facilities which do not meet the standards of ‘Hospital ICU’ as defined above.

It is also undisputed that appellee was receiving treatment in ICU at the Medical Center Hospital, and his doctor, Raymond P. Harle, ordered that he be placed in a like environment when transferred to the San Antonio Community Hospital. The doctor was evidently satisfied with the care received in the area designated CCU as his patient remained there for 27 days. Appel-lee’s problem was diagnosed pulmonary embolus. The CCU and the ICU were side by side and Dr. Harle said the treatment in both units was comparable. He testified as follows:

Q: And did you undertake his care and treatment at that time?
A: That’s correct.
Q: What did you recommend be done for him?
A: Be transferred to an equivalent unit at Community Hospital.
Q: What was that equivalent unit?
A: In this case it was the coronary care unit.
Q: And what was it specifically — did you intend to specifically put him in a coronary care unit or looking for intensive care unit, whatever was available at the hospital?
A: At that time he had to go into intensive care unit and in other words these were back to back at Community Hospital and one is interchanga-ble with the other in my opinion.

The hospital staff originally billed appel-lee for confinement in the CCU but changed the billing to care in ICU because of the diagnosis and because appellee was not listed as a coronary patient. The cost of the care is the same in either facility.

Appellant has not defined “coronary care unit” in its insurance contract. It is apparent, however, that at the time appellant authored that portion of its contract excluding confinement in a CCU, it considered care in that type of unit inferior to care in a “Hospital ICU.” The absence of a comma following the word facilities indicates that the clause following it, “which do not meet the standards of ICU as described above,” is a restrictive clause modifying facilities and limiting its meaning to only those facilities which do not meet the standards of ICU as described above. The use of “other” in combination with the restrictive clause indicates that all the specifically listed units are considered “facilities which do not meet the standards of ICU as described above.” Appellant did not choose to define “coronary care unit” more specifically, but it did define “Hospital Intensive Care Unit” as:

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Pleasant v. Regence BlueShield
325 P.3d 237 (Court of Appeals of Washington, 2014)

Cite This Page — Counsel Stack

Bluebook (online)
705 S.W.2d 267, 1986 Tex. App. LEXIS 12439, Counsel Stack Legal Research, https://law.counselstack.com/opinion/national-family-care-life-insurance-co-v-kuykandall-texapp-1986.