Ray v. Blue Alliance Mutual Insurance

594 A.2d 1110, 1991 Me. LEXIS 200

• Court: Supreme Judicial Court of Maine
• Decided: August 6, 1991
• Status: Published

Opinions

ROBERTS, Justice.

Roger B. Ray appeals a judgment of the Superior Court (Cumberland County, Cole, J.) reversing a decision of the District Court (Portland, Goranites, J.) that Ray and his wife, now deceased, were entitled to insurance benefits for acupuncture treatments under the contract they had with the defendant, Blue Alliance Mutual Insurance Company (BAMICO). Because we agree that the contract could not be construed to require payment for the acupuncture treatments, we affirm.

Ray and his wife suffered from osteoarthritis. They received a series of treatments for their arthritis from licensed physicians in Maine for a period of years. Having obtained no relief from conventional therapy, the Rays sought relief through acupuncture treatments. Although a medical doctor recommended that at least Mrs. Ray should receive such treatment, the acupuncturist they saw was not a medical doctor.

The Rays filed insurance claims with BAMICO seeking payment for services rendered by the acupuncturist. BAMICO responded that they felt that the services were “experimental” and denied the claims. In a second letter, BAMICO also stated that the policy limited benefits “to duly licensed doctors of medicine, osteopathy, dentistry, podiatry, or optometry operating within the scope of their licenses.” The Rays then obtained a judgment against BAMICO under their major medical policy in small claims court. BAMICO appealed the decision to the Superior Court on the ground that the insurance contract did not provide coverage for acupuncture treatments. The Superior Court determined that the contract language unambiguously excluded acupuncture from coverage.

The only pertinent issue in this case concerns the language of the policy issued to the Rays. Only two sections of the insurance contract control our decision.¹ The first relevant section entitled “Covered Services,” describes services that the plan covers and includes the statement that:

This policy covers services by physicians. Under this policy, physician means duly licensed doctors of medicine, osteopathy, dentistry, podiatry or optometry operating within the scope of their licenses.

The other relevant section of the insurance contract enumerates a number of services, procedures and situations that the policy does not cover. It specifically states that:

This policy provides benefits only for the services and supplies specified and only to the extent described. All other services and supplies are excluded from coverage.

Because acupuncture is not included specifically in these sections of the policy, the policy excludes acupuncture.

In the past we have made clear that we “will construe conditions and exceptions of the insurance contract ... strictly against the insurer and liberally in favor of the insured.” Patrons-Oxford Mutual Insurance Company v. Dodge, 426 A.2d 888 (Me.1981). In the instant case we find nothing in the contract that arguably supports the Rays’ contention that this contract can be interpreted to pay for services such as acupuncture. The contract specifically delineates which “health care services” it provides for, defining each service in turn. The contract then goes on to exclude “all other services.” We are satisfied that acupuncture must come within this “all other services” exclusion.

The entry is:

Judgment affirmed.

McKUSICK, C.J., and GLASSMAN, CLIFFORD and BRODY, JJ., concur.

1 . We intimate no opinion on BAMICO’s argument that acupuncture treatments are experimental.