Richard v. Board of Trustees

411 So. 2d 491, 1982 La. App. LEXIS 6865
CourtLouisiana Court of Appeal
DecidedMarch 2, 1982
DocketNo. 14496
StatusPublished
Cited by2 cases

This text of 411 So. 2d 491 (Richard v. Board of Trustees) 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
Richard v. Board of Trustees, 411 So. 2d 491, 1982 La. App. LEXIS 6865 (La. Ct. App. 1982).

Opinion

LEAR, Judge.

Plaintiff, Oscar G. Richard, III, a state employee and a member of the State Employees Group Benefits Program, sued to recover medical expenses incurred by his wife, Billie G. Richard, who is a covered dependent under this benefit plan. Plaintiff also seeks statutory penalties and attorney’s fees. Defendant, Board of Trustees of the State Employees Group Benefits Program alleged that it had paid all eligible expenses on claims submitted by plaintiff, and that the obligation sued upon was therefore extinguished by payment. Judgment was rendered in the trial court in favor of plaintiff, awarding him the benefits sued for and statutory penalties and attorney’s fees. Defendant then appealed.

On or about July 4,1978, Dr. Jere Melilli, a licensed physician practicing in Baton Rouge, Louisiana, suggested that Mrs. Richard receive acupuncture treatments for pain following a cervical laminectomy. Dr. Melilli referred her to Dr. Li Chang Wang1, who was then practicing acupuncture within Dr. Melilli’s office and allegedly, under his supervision.

Mrs. Richard received a number of acupuncture treatments beginning on July 4, 1978. Defendant first paid for these acupuncture treatments, as they were billed as subcutaneous nerve stimulation and the claim forms were signed by Dr. Melilli. At a later date, however, it was determined that these claims were for acupuncture treatments rendered by Dr. Li, at which time defendant denied coverage for these previously paid acupuncture claims and deducted the cost of these acupuncture treatments from subsequently submitted eligible claims.

As the trial court’s judgment was based on its finding that these acupuncture treatments were covered under the program, we must initially determine whether this conclusion of the trial court is correct.

The dispute in this case is governed by the contract of insurance existing between plaintiff and defendant. The principles of law in this area are set forth in the case of Fontenot v. New York Life Insurance Company, 357 So.2d 1185 (La.App.3d Cir. 1978), in which the court stated: [493]*493See also W. H. Franks v. Louisiana Health Services and Indemnity Company, 382 So.2d 1064 (La.App.2d Cir. 1980); Hall v. National Life and Accident Insurance Company, 383 So.2d 74 (La.App.3d Cir. 1980).

[492]*492“It is well settled law that a policy of insurance is a contract between the Insured and the Insurer and has the effect of law on the parties. LSA-C.C. Art. 1901; Smith v. North American Companies for Life, Accident and Health Insurance Company, 295 So.2d 483 (La.App.3d Cir. 1974), writ granted, 299 So.2d 360, reversed on other grounds, 306 So.2d 751. It is equally well settled law that insurers are at liberty to limit their obligations so long as such conditions and limitations do not conflict with statutory law or offend public policy. When such conditions and or limitations are clear and unambiguous they must be given effect as written. Muse v. Metropolitan Life Insurance Company, 193 La. 605, 192 So. 72 (1939); Andrus v. Police Jury of Parish of Lafayette, 270 So.2d 280 (La.App.3d Cir. 1972); Cormack v. Prudential Insurance Company of America, 259 So.2d 340 (La. App. 4th Cir. 1972) writ refused, 261 La. 824, 261 So.2d 230.”

[493]*493The law of this case, the insurance contract between the parties, is found in a brochure entitled “State of Louisiana Employees Uniform Group Benefits Program”, which was introduced as “joint exhibit 1”. The parties agree that plaintiff’s claim for payment for the acupuncture treatments is governed by the policy provisions entitled “Benefits” and “Eligible Expenses”, which are contained on pages D-2 through D-4 of the contract. These provisions, in pertinent part, read as follows:

“BENEFITS
“When accidental bodily injury or sickness, as a result of other than alcoholism or a mental or nervous disorder, requires the covered person to incur expense for any of the Eligible Expenses defined herein, and such service or treatment is performed or prescribed by a Physician while this coverage is in force as to such person, the program will pay .... [emphasis added]
“ELIGIBLE EXPENSES
“The following shall be considered eligible expenses under major medical benefits;
9. Services of a Physician
10. Services of a Physiotherapist duly licensed under the laws of the state where the service is rendered” [emphasis added]

For an expense incurred for service or treatment to be covered by the program it must not only be performed or prescribed by a Physician, but such service or treatment must be contained in the list of Eligible Expenses. In determining this issue, the trial court found that, because these acupuncture treatments were “prescribed by a Physician” they were covered by the program and plaintiff was entitled to be reimbursed for them. The trial court erred, however, in failing to initially determine if these acupuncture treatments were in fact listed as an Eligible Expense.

These acupuncture treatments were not “services of a Physician”. The evidence clearly shows that Dr. Melilli, plaintiff’s physician, did not himself actually perform these acupuncture treatments. They were performed by Dr. Li, in a building adjacent to Dr. Melilli’s office. Dr. Melilli was not present when these treatments were performed, nor did he in any way direct Dr. Li in performing these treatments.

The term “Physician” is defined by the policy, in pertinent part, as follows:

“DEFINITIONS
“(B) Physician as used herein, means the following: A duly licensed Medical Doctor (M.D.), Doctor of Dental Surgery (D.D.S.), (D.M.D.), Doctor of Osteopathy (D.O.), licensed Podiatrist, licensed Psychologist meeting the requirements of the National Register of Health Service Providers in Psychology or licensed Chiropractor, legally entitled to practice their specialties in the state in which the service is performed. Such persons must be engaged in private practice, and render a charge to the Covered Person for his professional services.”

As noted above, Dr. Li is not licensed as a Medical Doctor under the laws of Louisiana. Nor could he in any sense be included in the term “physician” as defined by the policy.

Plaintiff next argues that acupuncture is in fact a form of physical therapy and, under certain circumstances, a person is allowed by law to practice physical therapy in Louisiana without being licensed. The question before us is not whether a person can practice physical therapy without a license, but whether such services are an eligible expense under the contract of insurance.

Plaintiff then concludes that these treatments should be considered as physical therapy and they should be paid for by the Program under subparagraph 10 of Eligible Expenses (quoted above). It is not necessary for us to decide the question of whether acupuncture is or can be equated with physical therapy, and we decline to do so here. Even assuming that these treatments [494]*494could be classified as physical therapy ar.d/or Dr.

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Miller v. Duthu
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Bluebook (online)
411 So. 2d 491, 1982 La. App. LEXIS 6865, Counsel Stack Legal Research, https://law.counselstack.com/opinion/richard-v-board-of-trustees-lactapp-1982.