Rosinia v. Board of Trustees

526 So. 2d 467, 1988 La. App. LEXIS 1204, 1988 WL 49406
CourtLouisiana Court of Appeal
DecidedMay 17, 1988
DocketNo. CA 87 0514
StatusPublished
Cited by1 cases

This text of 526 So. 2d 467 (Rosinia 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
Rosinia v. Board of Trustees, 526 So. 2d 467, 1988 La. App. LEXIS 1204, 1988 WL 49406 (La. Ct. App. 1988).

Opinion

ALFORD, Judge.

The defendant, Board of Trustees, State Employees Group Benefits Program, State of Louisiana, appeals from a judgment in the trial court that reversed a decision by the Claims Review Committee, denying the plaintiff, Mary N. Rosinia, medical benefits under the State Employees Group Benefits Program. The defendant alleges that the trial court erred in failing to affirm the Claims Review Committee finding of a preexisting illness justifying denial of coverage under the terms of the Plan.

The following facts are not in dispute. Mary Rosinia became an employee of the state on March 14, 1983; at that time she did not apply for health insurance under the state program, State Employees Group Benefits Program. On September 14, 1983, Mary Rosinia was examined by Dr. O’Quinn at the Tulane Medical Center Hospital and Clinic; the plaintiff had visited Dr. O’Quinn for a routine annual examination. Dr. O’Quinn diagnosed Mary Rosinia as having the following conditions: third degree prolapse, mild cystocele, and a significant rectoeele. At that time, Dr. O’Quinn recommended to the plaintiff that she have a hysterectomy with posterior repair. Mary Rosinia elected not to undergo surgery as she was suffering from no symptoms. On December 19, 1983, Ms. Rosinia submitted an application for medical benefits coverage to the State Employees Group Benefits Program. Coverage for Ms. Rosinia became effective on June 1, 1984. On September 14, 1984, exactly one year after the diagnosis made by Dr. O’Quinn, Mary Rosinia visited Dr. Ivker for another annual examination; however, at that time, she presented several complaints. Dr. Ivker diagnosed her condition as: first (approaching second) degree prolapse, second degree cystocele, and a recto-cele. Dr. Ivker subsequently performed a hysterectomy, suspension of the bladder, and posterior repair, in a January 3, 1985, operation.

Ms. Rosinia submitted medical bills totaling $10,505.31, incurred as a result of the surgery, to the State Employees Group Benefits Program, for payment under her medical benefits policy; of which the Program claims only $9,299.81 would have been payable had Ms. Rosinia been eligible for coverage. The Program paid $1,580.00, leaving a balance of $7,719.81. Further coverage was denied by the Program, the reason being given that the September 14, 1983, diagnosis by Dr. O’Quinn evidenced a pre-existing condition preventing coverage under the following policy exclusion:

[469]*469c. Medical expenses incurred during the first 24 months that coverage for the Employee and/or Dependent is in force under this contract will not be considered as covered medical expenses if they are in connection with a disease, illness, accident or injury for which the Covered Person received Treatment or services, or was prescribed drugs, during the 12 month period immediately prior to the effective date of such coverage.

The policy defines “treatment” as follows:

EE. The term Treatment as used herein shall mean all steps taken to effect the cure of a disease, illness, accident or injury and shall include, but not be limited to consultations, examinations, diagnoses, and any application of remedies.

An appeal was made by Ms. Rosinia to the Claims Review Committee and a hearing was held on December 18, 1985. The Committee concluded that the examination, diagnosis and consultation by Dr. O’Quinn constituted “treatment” of Ms. Rosinia which occurred within the twelve months prior to the effective date of coverage. Mary Rosinia filed suit seeking payment of the medical expenses together with statutory penalties and attorney fees. The administrative record was filed in accordance with La.R.S. 49:964(F) and the trial court rendered judgment for the plaintiff, Mary Rosinia, on the record, in the amount of $7,719.81; penalties and attorney fees were denied.

Judicial review of an administrative governmental agency adjudication is limited by La.R.S. 49:964(G)1. In reviewing a committee’s factual determinations, the manifest error standard is applied, while the arbitrariness standard is used when the committee’s exercise of discretion is at issue. Hay v. South Central Bell Telephone Co., 475 So.2d 1052 (La.1985). However, as the Hay court points out, “whether undisputed circumstances or events constitute a particular legal status is a question of law, and the court is free to decide such a question with little or no deference to the decision of the fiduciaries.” Hay, 475 So.2d at 1056. It is undisputed in the case sub judice that Mary Rosinia was diagnosed on September 14,1983, as having a prolapse, a cystocele and a rectocele; and that this date was within the twelve month period prior to the effective date of medical coverage referred to in the pre-existing condition exclusion under the Plan. The disputed issue is whether that diagnosis constituted “treatment” under the policy exclusion.

Ms. Rosinia claims that the definition of treatment under the terms of the Plan is ambiguous, arguing that the reference to “consultations, examinations, diagnoses” may be read as applying only to the “cure” process. Ms. Rosinia reasons that since no steps were taken to effect a cure subsequent to the diagnosis by Dr. O’Quinn that no treatment was given within the meaning of the exclusion.

It is well established that courts are bound to give legal effect the terms of an insurance agreement according to the true intent of the parties, and that intent is to be determined from the words of the contract when they are clear and explicit and lead to no absurd consequences. Miller v. Duthu, 470 So.2d 500 (La.App. 1st Cir.), writ denied, 474 So.2d 1310 (La.1985). It is equally well established that any ambi[470]*470guity in the contract of insurance is to be construed in favor of the insured. Credeur v. Luke, 368 So.2d 1030 (La.1979). However, in order to be held ambiguous, the policy term must be suspectible of two or more interpretations, which are equally reasonable. Elmer v. Washington National Ins. Co., 308 So.2d 312 (La.App. 3rd Cir.1975). The interpretation propounded by Ms. Rosinia cannot be considered reasonable; clearly, the verb phrase, “shall include, but not be limited to consultations, examinations, diagnoses, and any application or remedies”, refers back to the noun, “treatment”.

Ms. Rosinia acknowledges the fact that the present definition of “treatment” in the Plan was drafted in response to the case of Posey v. Board of Trustees, State Employees Group Benefits Program, 426 So.2d 705 (La.App. 1st Cir.1982), writ denied, 429 So.2d 139 (La.1983), but she argues that the amendment was not successful in accomplishing its purpose. We disagree. In Posey, the plaintiff was denied medical benefits coverage by the Program for a June 16, 1980, hysterectomy where she was diagnosed on April 29, 1980, with a second degree uterine prolapse and second degree uterine retroversion, even though no other service or cure was provided until after the effective date of coverage, May 1, 1980. At the time of that dispute the Plan terms did not define the word “treatment” and the major point of contention in the Posey case was whether a diagnosis could be considered “treatment”. The court held that “at the very least the term ‘treatment’ was ambiguous and required a construction which afforded coverage.” Posey, 426 So. 2d at 708.

After Posey,

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Bluebook (online)
526 So. 2d 467, 1988 La. App. LEXIS 1204, 1988 WL 49406, Counsel Stack Legal Research, https://law.counselstack.com/opinion/rosinia-v-board-of-trustees-lactapp-1988.