Simpson v. National Casualty Co.

851 S.W.2d 665, 1993 Mo. App. LEXIS 340, 1993 WL 59374
CourtMissouri Court of Appeals
DecidedMarch 9, 1993
DocketNo. 61832
StatusPublished
Cited by2 cases

This text of 851 S.W.2d 665 (Simpson v. National Casualty Co.) is published on Counsel Stack Legal Research, covering Missouri Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Simpson v. National Casualty Co., 851 S.W.2d 665, 1993 Mo. App. LEXIS 340, 1993 WL 59374 (Mo. Ct. App. 1993).

Opinion

AHRENS, Presiding Judge.

In this declaratory judgment action, plaintiff Andrew Simpson appeals from the trial court’s judgment in favor of defendant National Casualty Company (National) on both plaintiff’s petition and National’s counterclaim. We affirm in part, reverse in part, and remand.

In August 1981, National issued three insurance policies to plaintiff; two are in issue: an Individual Hospital Policy, and an Individual Major Hospital and Surgical Expense Policy. National renewed those policies each year until October 1986. On October 21, 1986, National issued to plaintiff a Major Medical Policy (Conversion Policy) incorporating into one agreement the coverage provided under the three existing policies. Plaintiff paid premiums to renew the policy each January beginning in 1987.

On December 14, 1988, the Social Security Administration awarded plaintiff Medicare Part A hospital insurance benefits retroactive to December 1984.

Plaintiff paid, and National accepted, the premium to renew plaintiff’s policy for the period January 21, 1989, to January 21, 1990. In the subsequent months of 1989 and 1990, plaintiff was hospitalized. Plaintiff submitted proof of claim forms to National; he did not, however, complete the space on those forms to indicate “Date Eligible for Medicare.”

In August 1989, National became aware of plaintiff’s Medicare eligibility when a hospital refunded National’s payment on plaintiff’s account, due to Medicare’s payment on that account. In a letter dated October 2,1989, National informed plaintiff the company would not renew his policy on January 21,1990. National also refused to pay those claims plaintiff submitted which Medicare covered. In a letter dated February 13, 1990, National informed plaintiff that his policy had “been non-renewed retroactive to 1984,” and that National was “negotiating with Medicare regarding all claims paid since 1984.”

[668]*668Plaintiff filed this two count action. Under count one, plaintiff sought a declaratory judgment that National is required to pay plaintiff under the Conversion Policy “for costs and expenses incurred by or charged to [pjlaintiff relating to his stay and treatment and care received” at hospitals in 1989 and in January and February 1990. Plaintiff also sought a judgment declaring “a sum certain which [National] was and is responsible to pay [pjlaintiff under the said policy[,J including the expenses incurred” at a hospital in January and February 1990. Plaintiff sought interest on that amount, together with attorney’s fees and costs. Under count two, plaintiff sought damages for National’s alleged vexatious refusal to pay the amounts sought under count I.

National filed a counterclaim seeking $78,787.90 which, it alleged, “represents the amount paid by [National] on claims made by plaintiff since he became eligible for Medicare from June 14, 1985 through August 28, 1988.” The evidence showed that since December 1984, National paid plaintiff $78,787.90 in benefits for expenses related to plaintiff’s medical care and treatment, consisting of $56,228.32 paid under the Conversion Policy, $4,400.00 paid under the Individual Hospital Policy, and $18,-159.58 paid under the Individual Major Hospital and Surgical Expense Policy.

The trial court entered judgment against plaintiff on his claim and on National’s counterclaim. In its order, the trial court found that the language in the insurance policies which were in effect from December 1984 to December 1989, “relieve the defendant of any obligation to reimburse plaintiff for expenses of medical care and treatment during the period, since plaintiff has been found to be eligible for Medicare retroactive to December 1984.” The trial court further found National was entitled to recover $78,739.59 from plaintiff for payments made “to plaintiff for claims covered by Medicare....”

Point I.

In the first of his two points, plaintiff asserts the trial court erred in entering judgment in favor of National on plaintiff’s cause of action, “in that as a matter of law the court misconstrued or misinterpreted the obligations of [National] to [plaintiff] under the provisions of [the Conversion Policy] of insurance and denied [plaintiff] his legal right to obtain benefits under the policy” in 1989 and 1990.

Murphy v. Carron, 536 S.W.2d 30 (Mo. banc 1976) governs our review of this court-tried case. The judgment must be affirmed “unless there is no substantial evidence to support it, unless it is against the weight of the evidence, unless it erroneously declares the law, or unless it erroneously applies the law.” Further, “[i]t is a fundamental rule of construction that words used in a contract are to be understood in their ordinary meaning, unless a different meaning is indicated by the context of the instrument or by the circumstances of the case.” Steffen v. Pacific Mut. Life Ins. Co., 442 S.W.2d 142, 145 (Mo.App.1969).

National argues that the trial court properly ruled plaintiff is not entitled to payment of expenses covered by Medicare, because the Conversion Policy terms provide only for payment of “Eligible Expenses.” The policy refers to “Eligible Expenses” as “Charges Incurred” and “Fees charged.” National asserts that under Missouri law and the law applicable to Medicare, plaintiff was not charged for any services or expenses covered by Medicare. National further argues the policy by its terms states its purpose is to provide benefits for “loss” and plaintiff has not suffered a loss. In support of this assertion, National relies on Research Medical Center v. Safir, 616 S.W.2d 553 (Mo.App.1981), and Steffen, 442 S.W.2d 142.

In Steffen, the insured under a “Medical Expense Insurance Policy” became Medicare eligible while he was hospitalized. Id. at 143-44. The insurance policy in question provided: “ ‘Nothing in the group policy shall be construed to mean that any benefits which are contingent on charges made to the Employee shall be payable by the Insurance Company ... with respect to a hospital confinement or any surgical, [669]*669medical, or other treatment for which no charge is made that the Employee is required to pay.’ ” Id. at 143. From that language, the Steffen court concluded, “it was the intent of the parties that the contract of insurance was meant to indemnify the insured against obligations they were by law compelled to pay, and unless such a charge is made there can be no liability under the policy.” The Steffen court concluded the insurance company was not liable under the policy for services rendered the insured and paid for by Medicare, because neither the insured or “his personal representative could be required to pay said services.” Id. at 145.

In Research Medical, the policy excluded from benefits those expenses “ ‘furnished under any circumstances where no charge is made to the insured.’ ” Research Medical, 616 S.W.2d at 554. Further, the Research Medical court noted that the policy defined the term “deductible amount” as “ ‘The amount of Covered Charges which the Insured must incur before benefits are payable under this benefit....’” Id.

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Bluebook (online)
851 S.W.2d 665, 1993 Mo. App. LEXIS 340, 1993 WL 59374, Counsel Stack Legal Research, https://law.counselstack.com/opinion/simpson-v-national-casualty-co-moctapp-1993.