Sistrunk v. Cuna Mutual Insurance Society

733 F. Supp. 1080, 1989 U.S. Dist. LEXIS 16623, 1989 WL 201212
CourtDistrict Court, S.D. Mississippi
DecidedAugust 10, 1989
DocketCiv. A. No. J87-0479(L)
StatusPublished
Cited by1 cases

This text of 733 F. Supp. 1080 (Sistrunk v. Cuna Mutual Insurance Society) is published on Counsel Stack Legal Research, covering District Court, S.D. Mississippi primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Sistrunk v. Cuna Mutual Insurance Society, 733 F. Supp. 1080, 1989 U.S. Dist. LEXIS 16623, 1989 WL 201212 (S.D. Miss. 1989).

Opinion

MEMORANDUM OPINION AND ORDER

TOM S. LEE, District Judge.

This cause is before the court on the motion of defendant CUNA Mutual Insurance Society (CUNA Mutual) for summary judgment or in the alternative, partial summary judgment, pursuant to Rule 56 of the Federal Rules of Civil Procedure. Plaintiff Vinton L. Sistrunk has responded to the motion and the court has considered the memoranda of authorities together with attachments submitted by the parties.

This case represents plaintiffs effort toward recovery under a certain policy of hospitalization insurance issued to plaintiff by CUNA Mutual; defendant has denied payment on the basis that Sistrunk’s claim is for losses not covered under the terms of the policy. The relevant facts, as revealed by the record in this cause, demonstrate that in February 1985, plaintiff, as a member of the USDA Credit Union, received in the mail a sales brochure advertising certain group hospitalization indemnification insurance offered by CUNA Mutual. Sis-trunk completed an enrollment form and was issued a Group Hospital Indemnity Certificate which provided a $50 per day benefit for each day of confinement in a “hospital” as that term was defined in the policy.

From July 1985 through August 14, 1985, Sistrunk was hospitalized at the Veteran’s Administration (VA) Hospital in Jackson, Mississippi for the treatment of alcohol abuse. Though plaintiff, upon his discharge, submitted to defendant a completed claim form as required by his policy, CUNA Mutual denied the claim citing as the reason for denial that the VA Hospital in which he had been confined was not a “hospital” as defined in the policy.

In October 1985, plaintiff was again hospitalized for substance abuse, this time at Doctors Hospital in Jackson, Mississippi.1 Again, plaintiff sought to secure from defendant the payment of policy benefits for his confinement. Initially, CUNA Mutual denied Sistrunk’s claim as one for a pre-ex-isting condition and thus a confinement excluded under the policy. Later, though, it withdrew that as a basis for its denial but nevertheless denied the claim based on its determination that the confinement was not in a “hospital” as defined by the policy.

THE COVERAGE ISSUE

The Group Hospitalization Indemnity Certificate at issue in the case at bar defines the term “hospital” as

an institution which is a short term acute care general hospital. Its main purpose must be to provide medical care and treatment to the injured and sick persons on a resident patient basis. It must have facilities for medical diagnosis and treatment by or under the supervision of one or more Physicians. It must provide 24 hour a day nursing service by or under the supervision of a Registered Nurse. It must have organized departments of medicine. It may not include a rest, convalescent, extended care, rehabilitation, chronic or skilled nursing facility; home for the aged; a place for the care [1082]*1082and treatment of drug addicts or alcoholics, or a mental institution; nor does it include any ward, room, wing or other section of the Hospital that is used for such purposes; whether or not such facility is part of a Hospital, as defined herein, or is an entirely separate facility (emphasis added).

Plaintiff acknowledges that for both of the confinements for which he seeks recovery under the policy, he was hospitalized for alcohol and/or drug abuse. Thus, it cannot be disputed that Sistrunk was, during each hospitalization, confined in a “ward, room, wing or other section of” the VA Hospital and Doctors Hospital, respectively, that is used for the care and treatment of drug addicts and/or alcoholics. Plaintiff has, however, in response to defendant's motion for summary judgment, advanced a number of arguments which he claims mandate the denial of the motion. He first asserts that the policy is ambiguous as to the scope of its coverage. He urges, alternatively, that if, through its definition of the term “hospital,” the policy does exclude treatment for alcoholism, then that provision of the policy is in violation of Mississippi statutory law regarding insurance coverage for alcoholism and is therefore void.

Ambiguity. Though plaintiff claims that the policy is ambiguous, he does not state the basis of the alleged ambiguity. Rather, he merely has directed the court to review Kelly v. Mid-South Insurance Co., 294 S.C. 288, 363 S.E.2d 904 (1988), a case in which the South Carolina Supreme Court found that policy language regarding coverage for alcoholism was ambiguous. In Kelly, though, unlike the present case, the definition of the term “hospital” effectively excluded all coverage for alcoholism whereas the policy affirmatively provided coverage for alcoholism. In the case sub judice, there is in the policy no affirmative statement of nor even an implication of coverage for alcoholism which would render the definition of hospital ambiguous. Indeed, the clarity with which coverage for drug addiction and alcoholism is excluded from coverage by plaintiff’s policy is unmistakable. This narrowly drawn definition of hospital clearly and unambiguously excludes such treatment from coverage.2

Statutory Prohibition. Plaintiff next contends that the definition of hospital, which effectively precludes coverage for treatment of alcohol and drug abuse, runs directly afoul of Miss. Code Ann. § 83-9-27 (Supp.1988), relating to care and treatment for alcoholism. That statute provides as follows:

Notwithstanding any provision of any policy of accident or sickness insurance as defined by section 83-9-1, issued on or after January 1, 1975, whenever such policy provides for the reimbursement for loss resulting from sickness, or from bodily injury by accidental means, or both, said reimbursement shall include health service benefits to any insured or any person covered thereunder, on the same basis as other benefits, for care and treatment of alcoholism.
For purposes of sections 83-9-27 through 83-9-31, alcoholism is defined as a chronic and habitual use of alcoholic beverages, by any person to the extent that such person has lost the power of self-control with respect to the use of such beverages.

Section 83-9-1 defines a policy of accident and sickness insurance as “any policy or contract of insurance against loss resulting from sickness or from bodily injury or death by accident, or accidental means, or both.”

Although section 83-9-27 has been in effect since January 1975, there are no Mississippi cases which have considered the statute or its applicability to particular poli[1083]*1083cies or policy provisions. According to plaintiff's interpretation of the statute, where any policy covers the “sickness” risk, benefits must also extend to the care and treatment of alcoholism. In this court’s opinion, the statute has no application to the policy presently under consideration. By its terms, section 83-9-27 is limited in application to any policy of accident and sickness insurance which provides for “the reimbursement for” loss caused by sickness, bodily injury by accidental means, or both.

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Related

Sistrunk v. Cuna Mutual Ins. Society
915 F.2d 1569 (Fifth Circuit, 1990)

Cite This Page — Counsel Stack

Bluebook (online)
733 F. Supp. 1080, 1989 U.S. Dist. LEXIS 16623, 1989 WL 201212, Counsel Stack Legal Research, https://law.counselstack.com/opinion/sistrunk-v-cuna-mutual-insurance-society-mssd-1989.