Seguin v. Continental Service Life & Health Insurance

89 So. 2d 113, 230 La. 533, 55 A.L.R. 2d 1014, 1956 La. LEXIS 1441
CourtSupreme Court of Louisiana
DecidedJune 11, 1956
Docket42724
StatusPublished
Cited by37 cases

This text of 89 So. 2d 113 (Seguin v. Continental Service Life & Health Insurance) is published on Counsel Stack Legal Research, covering Supreme Court of Louisiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Seguin v. Continental Service Life & Health Insurance, 89 So. 2d 113, 230 La. 533, 55 A.L.R. 2d 1014, 1956 La. LEXIS 1441 (La. 1956).

Opinions

HAWTHORNE, Justice.

On October 15, 1952, plaintiff obtained a policy of insurance, of a type commonly called a health and accident policy, which provided for the payment of hospital and medical expenses in the event of illness or accident. On June 10, 1953, within one year from the date of the issuance of the policy and while it was in full force and effect,-, plain tiff, developed a condition diagnosed as diaphragmatic hernia: The herniation consisted of the projection of the stomach .into the thpracic cavity through the opening. ;in .the .diaphragm normally occupied by the esophagus, and in plaintiff’s case the opening was large enough to permit the stomach freely to enter into the thoracic cavity. He was operated on for this condition on June 29, and as a result incurred surgical and hospital expenses in the amount of $489.97. Payment of these expenses was refused by the insurance company, and plaintiff instituted suit to recover the amount of these expenses together with the penalties provided by R.S. 22:657 and attorney’s fees. The district court rendered judgment in his favor for the amount of expenses incurred plus penalties in a like amount and $200 attorney’s fees. The Court of Appeal, First Circuit, by a divided court reverséd this judgment and dismissed plaintiff’s suit. See 83 So.2d 789 (on rehearing). On application of plaintiff to this court writs were granted.

As a defense to plaintiff’s claim the insurance company relies on the following exclusion clause in the policy of insurance:

“Article IV — Waiting Periods: “Twelve (12) consecutive months of continuous membership under this certificate before LPS will assume liability for payment of surgical or' medical services, or hospital care for pre-existing conditions, tonsils, adenoids, hemorrhoids, and hernia.”

The'Court of Appeal, rélying'Oir Article 1947__ of the Louisiana Civil Code, which provides .that technical jphpases are to be in[537]*537terpreted according to their received meaning with those who profess the art or profession to which they belong, concluded that the word “hernia” as used in the exclusion clause is a technical medical term and according to the medical profession includes ■diaphragmatic hernia, and that such disability is excluded from coverage under the policy of insurance for the first year, and that consequently plaintiff cannot recover.

The question here presented is whether the unqualified word “hernia” as used in the health and accident policy should be technically construed under Article 1947, or whether the word should be construed in its plain, ordinary, popular sense under Article 1946, which provides that the words of a ■contract are to be construed, like those of a law, in the common and usual signification.

In a strict, technical, and medical sense, a hernia is any protrusion consisting of an organ or part projecting through some natural or accidental opening in the walls of its natural cavity. See Webster’s New International Dictionary (2nd ed. Unabridged). According to the evidence, inguinal, femoral, umbilical, epigastric, and diaphragmatic hernias are a few that are associated with the abdomen. However, in its technical sense the word includes also ruptured intervertebral disc, cerebral hernia, hernia of the eye, hernia of the lung, and, in fact, any protrusion through an abnormal opening. On the other hand, in its ordinary, popular sense, the word “hernia”' means simply a rupture or noticeable protrusion from some part of the abdominal cavity. See 39 C.J.S. p. 896.

In the instant case the Court of Appeal in the majority opinion says [83 So.2d 792]:

“ * * * All of the doctors testified that the most common hernia was the type which protruded through the front, or anterior, abdominal wall, however, in medical terminology, a diaphragmatic hernia, which protruded through the upper wall was a true hernia. The medical experts agreed that the layman’s common conception of the term ■hernia was a protrusion through the front abdominal wall." (Italics ours.)

The Courts of Appeal of this state 6n numerous occasions have been called upon to interpret and construe the meaning of the terms and provisions of health, accident, and sickness insurance policies. For instance, in Miley v. Fireside Mut. Ins. Co., La.App. 1st Cir., 200 So. 505, 507, the court said:

“ * * * In Corpus Juris, vol. 1, p. 417, in treating the topic ‘Accident Insurance’, the text states that the language of the contract in policies of that class of insurance ‘should be construed as a whole and should receive a reasonable interpretation,’ and further, that the terms ‘should be understood in their plain, ordinary, popular sense, rather than in a philosophical or scientific sense.’ ”

Again, in Beard v. Peoples Industrial Life Ins. Co. of Louisiana, La.App. 2d Cir., 5 So.2d 340, 342, it was stated:

[539]*539“In the construction and interpretation of contracts of insurance, just as with other contracts, the intention of the parties is of paramount importance. This intention is determined in accordance with the plain, ordinary and popular sense of the language which they have used in the agreement, and by giving consideration, on a practical, reasonable and fair basis, to the instrument in its entirety.”

See also McKinney v. American Security Life Ins. Co., La.App. 2d Cir., 76 So.2d 630.

It must be remembered that a contract of insurance is prepared by the insurance company, and that the company contracts through its agents with ordinary laymen who do not know the technical meaning of medical words and phrases. No doubt this is one of the reasons why the courts in construing the meaning of medical words and phrases found in health, accident, and sickness policies have consistently said that such words and phrases should be understood in their plain, ordinary, and popular sense rather than in their scientific sense. In the instant case we do not think the parties intended that the word “hernia” should include, for instance, a hernia of the brain or a hernia of the lung or a hernia of the eye. We think it is proper that their intention should be determined in accordance with the plain, ordinary, and popular sense of the language which the parties used in the contract, that the Court of Appeal improperly applied the provisions of Article 1947 in denying plaintiff recovery, and that the court should have properly construed the exclusion clause under the provisions of Article 1946 of the Civil Code and should have found that the word “hernia” means simply a rupture or noticeable protrusion of part of the viscera through the front abdominal wall, which is the common, ordinary,, accepted meaning of the word.

Respondent contends that the word “hernia” in its customary usage is generally-identified with that group of hernias relating to the abdomen, which, as we have-pointed out, includes inguinal, femoral, umbilical, epigastric, and diaphragmatic hernias. Respondent then argues that since-diaphragmatic hernia is a hernia of the abdominal group, such a hernia falls within the common and customary use and meaning-of the word “hernia”. We cannot agree-with this contention, and, as we have already stated, a diaphragmatic hernia is not a hernia within the common and ordinary meaning of that word.

In permitting the plaintiff to recover the penalty provided by R.S. 22:657 together with attorney’s fees in the sum of $200, the trial judge in his reasons for judgment tells us:

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Bluebook (online)
89 So. 2d 113, 230 La. 533, 55 A.L.R. 2d 1014, 1956 La. LEXIS 1441, Counsel Stack Legal Research, https://law.counselstack.com/opinion/seguin-v-continental-service-life-health-insurance-la-1956.