Travelers Insurance Co. v. Brown

750 S.W.2d 916, 1988 Tex. App. LEXIS 1202, 1988 WL 51621
CourtCourt of Appeals of Texas
DecidedMay 25, 1988
Docket07-87-0124-CV
StatusPublished
Cited by14 cases

This text of 750 S.W.2d 916 (Travelers Insurance Co. v. Brown) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Travelers Insurance Co. v. Brown, 750 S.W.2d 916, 1988 Tex. App. LEXIS 1202, 1988 WL 51621 (Tex. Ct. App. 1988).

Opinion

COUNTISS, Justice.

This is a suit to recover on an insurance contract. Appellant The Travelers Insurance Company, after a non-jury trial, was ordered to reimburse appellee Ronnie Brown for medical expenses, attorney’s fees and costs, and to pay interest and a penalty. Travelers contends, by seven points of error, that there is no or insufficient evidence to support the award for medical expenses and attorney’s fees, and that assessment of a penalty was erroneous. We affirm.

Brown and his wife are beneficiaries of a medical insurance policy by which Travelers contracted to pay “reasonable charges” for certain medical services incurred by them. The critical issue in this case is whether they proved that their medical expenses were reasonable.

Brown’s wife, Nancy, had a cancerous mole removed from her back. After it was removed, the surgical area was repaired with a skin graft. Travelers paid all it was required to pay for that medical problem. Several months later, however, Nancy began to suffer excruciating pain around the skin graft. She consulted doctors in various cities but they could not help her. Finally, a doctor recommended, and she consulted, Dr. Julia Terzis of Norfolk, Virginia, a plastic surgeon specializing in reconstructive microsurgery. Dr. Terzis concluded that Nancy’s pain was caused by nerves severed during the first surgery. She then performed corrective surgery that alleviated the problem.

For her services, Dr. Terzis charged the Browns $10,016.00. When her charge was submitted to Travelers, the company concluded it was excessive and paid only $3000. After Travelers rejected Brown’s demand for full reimbursement, he sued, successfully, for the unpaid balance of $7016.00 on Dr. Terzis’ bill, plus attorney’s fees, penalty, interest, and costs.

By its first three points, Travelers questions the legal and factual sufficiency of the evidence to support the award of $7016, the balance due on Dr. Terzis’ bill. In resolving those challenges we will first examine the entire record for any probative evidence to support the court’s finding, ignoring all contrary evidence. Garza v. Alviar, 395 S.W.2d 821 (Tex.1965). If we find probative evidence, we will then examine all of the evidence in the record to determine whether the finding is manifestly unjust. In re King’s Estate, 150 Tex. 662, 244 S.W.2d 660 (1951).

Travelers’ attack focuses on the definition of “reasonable charge” as contained in the policy. In the “Plan Highlights” of the policy, Travelers explains that “Payments will be based on the Reasonable Charges for the services and supplies covered by the Plan.” The policy then defines reasonable charge as follows:

Reasonable Charge
An amount measured and determined by comparing the actual charge with the charges customarily made for similar services and supplies to individuals of similar medical condition in the locality concerned.

To prove that Dr. Terzis’ charge was reasonable, Brown introduced the following testimony, by her:

Q. Is this specific kind of surgery generally performed by all plastic surgeons?
A. No.
Q. If not, what percentage of plastic surgeons, in your opinion, have experience with this specific type of surgery?
A. Very few.
Q. Was all the care and treatment upon which your charges are based necessary treatment, in your opinion?
A. Yes.
*918 Q. Were your charges reasonable charges at the time and place where such was given, in your opinion?
A. Yes.

To counter that testimony, Travelers presented evidence from another doctor, and a company employee, who said the charge was excessive.

Brown did not carry his burden of proving a reasonable charge, Travelers says, because his evidence on the issue did not include the comparison contemplated by the definition. Specifically, Travelers argues, Brown must present specific evidence that the expert witness actually compared the submitted claim with “charges customarily made for similar services to individuals of similar medical condition in the locality concerned.”

The general rule is well established. The insured must prove, among other things, that the charge for which he or she seeks reimbursement is reasonable. Sherman v. Provident American Insurance Company, 421 S.W.2d 652, 654 (Tex.1967); International Security Life Insurance Co. v. Armel, 461 S.W.2d 639, 640 (Tex.Civ.App.—Fort Worth 1970, no writ). In Texas jurisprudence, the accepted method of proving that fact is by an expert witness who utters, in ultimate conclusory fashion, his or her opinion that the charge is reasonable. International Security Life Insurance Co. v. Ramage, 446 S.W.2d 944, 947 (Tex.Civ.App.—Amarillo 1969, writ ref’d n.r.e.); American Bankers Insurance Company v. Fish, 412 S.W.2d 723, 727 (Tex.Civ.App.—Amarillo 1970, no writ); International Security Life Insurance Co. v. Bryant, 453 S.W.2d 869, 871 (Tex.Civ. App.—Amarillo 1970, writ ref'd n.r.e.). For example, in American Bankers Insurance Company v. Fish, supra, the policy obligated the insurance company to pay “the usual, customary and regular” hospital charges. A doctor testified that the charges were “reasonable.” The court held that testimony to be sufficient evidence of the usual, customary and regular nature of the charges. 412 S.W.2d at 727.

In reviewing the pertinent authorities, we find no requirement that the expert go beyond the conclusion of reasonableness and explain the mental process by which the conclusion was reached. That would certainly be an appropriate area for cross-examination, but we are not willing to hold that the expert must, in his or her testimony, track the policy definition before the opinion can be received as credible evidence. The conclusion is sufficient; its basis can be tested by cross-examination.

We hold, therefore, that the evidence quoted above is sufficient to prove that the charge was reasonable as defined in the policy, and that the contrary evidence is not so overwhelming that the result is unjust. Points of error one, two, and three are overruled.

By points four and five, Travelers contends the trial court’s award of penalty and attorney’s fees is erroneous because it does not owe Brown anything under the policy. The points have merit only if we sustain Travelers’ first three points.

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Bluebook (online)
750 S.W.2d 916, 1988 Tex. App. LEXIS 1202, 1988 WL 51621, Counsel Stack Legal Research, https://law.counselstack.com/opinion/travelers-insurance-co-v-brown-texapp-1988.