Preferred Risk Life Ins. Co. v. Sande

421 So. 2d 566
CourtDistrict Court of Appeal of Florida
DecidedSeptember 29, 1982
Docket81-1083
StatusPublished
Cited by22 cases

This text of 421 So. 2d 566 (Preferred Risk Life Ins. Co. v. Sande) is published on Counsel Stack Legal Research, covering District Court of Appeal of Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Preferred Risk Life Ins. Co. v. Sande, 421 So. 2d 566 (Fla. Ct. App. 1982).

Opinion

421 So.2d 566 (1982)

PREFERRED RISK LIFE INSURANCE COMPANY, an Iowa Corporation, Appellant,
v.
Carl E. SANDE, Individually and As Natural Guardian of Kimberly Lynn Sande, Appellee.

No. 81-1083.

District Court of Appeal of Florida, Fifth District.

September 29, 1982.
Rehearing Denied November 8, 1982.

*567 Russell K. Dickson, Jr., of Akerman, Senterfitt & Eidson, Orlando, for appellant.

R.K. Roberson of Roberson & Roberson, DeLand, for appellees.

COBB, Judge.

The issue in this case is whether the trial court erred by allowing recovery under a major medical insurance policy. We hold it did and reverse.

On July 19, 1976, Mrs. Marsha Sande took her daughter Kimberly to Dr. George Wiggins for a routine physical. Dr. Wiggins found a urinary tract infection which was confirmed after tests on July 23, 1976. In April 1977, Mrs. Sande again took Kimberly to Dr. Wiggins with a high fever. Dr. Wiggins again found that a urinary tract infection was present, and recommended that Mrs. Sande take her daughter to a urologist for a complete evaluation. Mrs. Sande took her daughter to a specialist on November 22, 1977, complaining of recurrent kidney infections, as well as problem bed wetting. The specialist, Dr. Lankford, admitted Kimberly to the hospital on December 1, 1977, where it was found she had a mild urethal stenosis and an ectopic left ureter. This was an anatomical defect which was present at birth, and which was causing her urinary tract infection. This condition was corrected by surgery on January 24, 1978.

On October 6, 1977, appellee, Carl Sande, applied for a major medical expense policy for his family with appellant, Preferred Risk Life Insurance Company. The Preferred Risk agent filled out the application after asking Sande the questions that appeared on it. Of particular importance is question number 7(j), which asked:

Have you, or any person named in question 1, ever had, to the best of your knowledge or belief:
(j) gall bladder, liver, kidney or bladder trouble.

The answer to this is marked "yes" and in the space provided below for explanation, the only mention of any problem in this area is of a kidney infection his wife had in 1972. No mention is made of the problems that Kimberly had or of her visits with Dr. Wiggins.

On January 16, 1978, Mrs. Sande completed and signed a claim form for benefits relating to her daughter's treatment from Dr. Lankford. Initially, Mrs. Sande had left blank question number 5, which asked, "Have you ever been treated for this condition at any time previous to this? If yes, when?" Upon receipt of this, Preferred sent it back and requested the form be completed. Mrs. Sande did so and answered "yes" and added April 15, 1977, as the date of treatment.

Appellant then reviewed the claim and denied it on the basis that the condition was treated previous to the policy, and was therefore excluded. Preferred sent a letter to the Sandes to this effect. The policy was later terminated following no response from the Sandes as to the letter and a failure to pay the required premiums. The Sandes then instituted this litigation to recover under the policy by filing a complaint on March 11, 1980.

Prior to the non-jury trial, depositions of Drs. Wiggins and Lankford were taken. Dr. Wiggins acknowledged seeing Kimberly in July of 1976 and April of 1977, and stated that he informed Mrs. Sande to get a specialist to examine Kimberly, and advised her of the possibility of an anatomic disorder. He stated he felt the disorder for which Kimberly was operated on became symptomatic in 1976, and was recurring since, with the condition being present since birth. Dr. Lankford testified that while other disorders could cause urinary tract infections of the type Kimberly was having, the true cause was the anatomic disorder, and further there was no way of knowing of such a disorder conclusively without the tests he ultimately performed in December of 1977.

At the trial, Mr. Sande testified that he was unaware of Kimberly's urinary tract *568 infections at the time he applied for the policy, but had answered all the questions asked of him, and stated that all the answers given were recorded by the agent. Mrs. Sande testified that she had never told her husband about the persistent urinary tract infections, and that he would not have been aware of it.

An underwriter for Preferred, William Gates, testified that it was company policy for the agents to ask the questions and fill out the forms, and it was properly done here. He further testified that at the time the policy was approved he was unaware that Kimberly had been treated for urinary tract infections, and that if he had known, the policy would not have been issued in the manner it was. Gates stated that had the company been aware of the condition, they would have issued a specific exclusion rider, which would have excluded the impairment from coverage. He further testified that in a juvenile a recurring urinary tract infection is looked at more closely than in an adult.

Following the hearing, the judge entered final judgment for the Sandes in the total sum of $2,215.66. No explanation for the finding is seen in the judgment itself, but in a letter to counsel, the judge stated that he felt there was not a material misrepresentation in the filling out of the application, and found that the infection was indeed a "covered sickness" within the meaning of the policy, since it was possible that it was caused by more than one illness.

The first issue on appeal is whether Kimberly's illness is in fact covered by the policy. The policy defines "covered sickness" as: "sickness first manifested while this policy is in force." Appellant claims the trial court erred since Kimberly's illness is not covered, as it manifested itself prior to the policy becoming effective and was therefore excluded by the policy terms.

While the Florida courts have never specifically defined what "manifested" means, the accepted definition seems to center around the symptoms:[1]

That point in time when the sickness or disease becomes symptomatic and not necessarily when the exact nature of sickness or disease is diagnosed by a physician after extensive testing.

McDaniel v. State Farm Mut. Ins. Co., 3 Kan. App. 2d 174, 591 P.2d 1094 (1979).

In McDaniel, the insured had the symptoms of the illness some two months before the policy was bought, but it was not actually diagnosed until a month after purchase. The court held that the condition was pre-existing, since the symptoms would have led a physician to diagnose the illness; the insured's unawareness as to the exact cause of the disease was unimportant. The court noted that if the insured had gone for the tests prior to the purchase of the policy, when the symptoms first began, she would have gotten the same diagnosis as she received following the tests.

Florida courts have not dealt with the definition of the word "manifest" as directly as McDaniel. In Continental Casualty v. Gold, 194 So.2d 272 (Fla. 1967), the court held that sickness meant a disabling illness, as opposed merely to disease, thereby seemingly prohibiting a disease from being seen here, unless Kimberly was disabled by it.[2] However, the court notes that the insurer may protect itself and limit liability by stipulating in the policy that it did not cover a sickness whose symptoms appear prior to the effective date of the policy.

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Bluebook (online)
421 So. 2d 566, Counsel Stack Legal Research, https://law.counselstack.com/opinion/preferred-risk-life-ins-co-v-sande-fladistctapp-1982.