Wallace v. Globe Life & Accident Insurance Co.

478 So. 2d 656, 1985 La. App. LEXIS 10064
CourtLouisiana Court of Appeal
DecidedOctober 30, 1985
DocketNo. 17325-CA
StatusPublished
Cited by1 cases

This text of 478 So. 2d 656 (Wallace v. Globe Life & Accident Insurance Co.) 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
Wallace v. Globe Life & Accident Insurance Co., 478 So. 2d 656, 1985 La. App. LEXIS 10064 (La. Ct. App. 1985).

Opinion

HALL, Chief Judge.

This is an action for medical benefits, in particular the total amount of surgical fees incurred by plaintiff, Robert E. Wallace, allegedly due under the terms of a hospital and surgical expense insurance policy issued by defendant, Globe Life and Accident Insurance Company, together with statutory penalties and attorney’s fees. From the judgment of the district court awarding limited surgical fee benefits in the amount of $600.00 plus a penalty of $600.00 and attorney’s fees in the amount of $1,000.00, plaintiff appeals. The defendant neither appealed nor answered the appeal. For the reasons expressed in this opinion, we affirm the judgment of the district court.

Plaintiff contends that under the terms of the policy, he is entitled to recover the full amount of the surgical fees for his coronary bypass operation, which plaintiff contends totalled $6,490.00. Defendant argues that under the Schedule of Operations contained in the policy, the maximum amount due by it for the surgical fees incurred by plaintiff is $600.00, the amount awarded by the trial court.

FACTS

On February 1, 1982, defendant issued a hospital and surgical expense insurance policy to plaintiff. Plaintiff was hospitalized in Community Hospital in Springhill, Louisiana on October 24, 1982. The final diagnosis was angina pectoris and plaintiff was discharged from the hospital on October 25, 1982. Pursuant to the terms of the policy, defendant paid medical benefits for this hospitalization in the amount of $441.00. Shortly thereafter, plaintiff was hospitalized at Schumpert Medical Center in Shreveport, Louisiana from October 28, 1982 to November 10,1982 where he underwent coronary bypass surgery. The total medical bills for this hospitalization were in excess of $22,000.00. The fee charged by the surgeon was $4,750.00. Defendant paid benefits for this hospital stay in the amount of $2,715.75. Additional benefits for this hospitalization in the amount of $110.75 were later paid by defendant. Suit was filed in July, 1983. Defendant deposited $600.00 for surgical benefits into the registry of the court in May, 1984.

THE INSURANCE POLICY

Benefits for surgical operations are set forth in Part 3 of the insurance policy, which provides in pertinent part:

Part 3 BENEFITS FOR SURGICAL OPERATIONS
If the Insured or any member of the Family Group, as a result of such injury or such sickness, shall have a surgical operation performed by a licensed physician or surgeon the Company will pay the Insured (or will pay the physician or surgeon if authorized by the Insured to do so) for the fee charged by such physician or surgeon for such operation, not to exceed the amount set opposite the name of the operation in the Schedule of Operations below. Not more than one indemnity, the largest, will be paid for operations performed on account of any one injury or sickness or for two or more surgical procedures performed during one operation....

The Schedule of Operations contained in Part 3 of the policy enumerates numerous operations, including the following chest surgeries and the amounts recoverable therefor:

CHEST
Thoracoplasty (complete), pneumonectomy, lobectomy.600.00
Empyema-lung abscess requiring rib resection, phrenic nerve crushing or excision.200.00
Breast, radical operation, double.200.00
Breast, radical operation, single.150.00
Removal of tumor or tumors from breast.50.00
Bronchoscopy.70.00
Aspiration-artificial pneumothorax.. .40.00
Other operation on chest wall.30.00
Fractures
Clavical.60.00
Scapula.80.00
Ribs, one or more.40.00

The maximum compensable amount for any surgical operation in the Schedule of Operations is $700.00 for brain surgery. [658]*658The schedule does not list any operations relating to the heart.

The Schedule of Operations further provides:

“For operations or fractures not otherwise specified in this Part 3, the Company will determine the amount to be paid for such operation on a basis commensurate to similar operations or fractures under this Part 3. No amount will be allowed for the extraction of teeth or dental surgery.”

TRIAL COURT DECISION

Although plaintiff contended that since bypass surgery was not specifically enumerated in the Schedule of Operations, he was entitled to recover the total amount of the surgical fees, the trial court found that under the language of the policy, plaintiff was only entitled to recover surgical expenses in an amount commensurate to surgical fees for similar operations listed in the Schedule of Operations. The court awarded plaintiff the sum of $600.00, which was the amount determined by defendant to be reasonable under the provisions of the policy and which the court found to be fair. The court found that plaintiff did not show that this amount was not commensurate with similar operations as provided by the provisions of the policy. The court further awarded penalties in the amount of $600.00 plus reasonable attorney’s fees in the amount of $1,000.00. Noting that the record was void of any evidence relating to the alleged late $110.75 payment of medical benefits, the court did not award statutory penalties on that amount.

APPLICABLE LEGAL PRINCIPLES

It is well-settled that the rules which govern the interpretation of written agreements also apply to contracts of insurance. The terms and provisions of insurance contracts, as with other written agreements, are to be construed in their general and popular meaning. Martin v. Phillips, 356 So.2d 1016 (La.App. 1st Cir.1977) and citations therein. See also Carney v. American Fire & Indem. Co., 371 So.2d 815 (La.1979). The insurance contract must be interpreted as a whole and all the terms and provisions of the policy must be construed together to ascertain the true intent of the parties. See Martin v. Phillips, supra and Carney v. American Fire & Indem. Co., supra. In interpreting insurance policies, the principal consideration is to ascertain the intention of the parties from the language of the contracts. Courts must give legal effect to the insurance policy provisions according to the true intent of the parties, which intent is determined by the words of the policy when these are clear and explicit and lead to no absurd consequences. Agreements which have been legally entered into have the effect of laws between the parties who formed them. Therefore, when the words of the insurance policy are clear and explicit and lead to no absurd consequence, the courts may not alter them. LSA-C.C. Art. 1945, Graves v. Traders & General Insurance Company, 252 La. 709, 214 So.2d 116 (1968); Hampton v. Lincoln Nat. Life Ins. Co., 445 So.2d 110 (La.App. 2d Cir.1984); Rogers v. Metrailer, 432 So.2d 390 (La. App. 1st Cir.1983); McClelland v. Security Indus. Ins. Co., 426 So.2d 665 (La.App. 1st Cir.1982), writ denied, 430 So.2d 94 (La.1983); Saucier v. John-Clai Co., 408 So.2d 27 (La.App. 3d Cir.1981); Hall v. National Life & Acc. Ins. Co., 383 So.2d 74 (La.App.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Marsh v. Reserve Life Ins. Co.
516 So. 2d 1311 (Louisiana Court of Appeal, 1987)

Cite This Page — Counsel Stack

Bluebook (online)
478 So. 2d 656, 1985 La. App. LEXIS 10064, Counsel Stack Legal Research, https://law.counselstack.com/opinion/wallace-v-globe-life-accident-insurance-co-lactapp-1985.