Walter v. Travelers Insurance

33 Pa. D. & C.3d 83, 1984 Pa. Dist. & Cnty. Dec. LEXIS 243
CourtPennsylvania Court of Common Pleas, York County
DecidedOctober 2, 1984
Docketno. 3675-5 of 1981
StatusPublished

This text of 33 Pa. D. & C.3d 83 (Walter v. Travelers Insurance) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, York County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Walter v. Travelers Insurance, 33 Pa. D. & C.3d 83, 1984 Pa. Dist. & Cnty. Dec. LEXIS 243 (Pa. Super. Ct. 1984).

Opinion

RAUHAUSER, J.,

On June 21, 1983, this court entered an order granting summary judgment to plaintiff for damages in excess of $15,000 plus interest and costs of suit. Defendant now files exceptions to that order, listing four assignments of error.

The summary judgment order was based upon the court’s analysis of an issue theretofore not briefed by counsel. Upon consideration of the arguments of counsel offered in regard to defendant’s exceptions, and after careful reflection upon our pri- or reasoning, the court is of the opinion that defendant’s exceptions must be granted.

I. DEFENDANT’S EXCEPTIONS

Plaintiff Paul J. Walter was, at all times relevant to this case, employed by Johnston Construction Company, of York, Pa., having begun his employment there on December 17, 1979. As a fulltime employee at Johnston Construction Company, Paul J. Walter was entitled to participate in a group [85]*85health insurance plan underwritten by defendant, The Travelers Insurance Company. The insurance policy provided that coverage would commence after the completion of two months of service to the employer, at which time all eligible dependents of the employee would also receive coverage. (“Group Insurance Benefits” Booklet, p. iii.)

A daughter, Cynthia L. Walter, was born to plaintiffs on January 30, 1980 at Hanover General Hospital, York County, Pa. Doctors detected a serious problem with the child’s heart, and on February 12, 1980, Cynthia L. Walter was admitted to Johns Hopkins Hospital in Baltimore for cardiac surgery. The operation was performed on February 15, and Cynthia was discharged from the hospital on February 27, 1980. In connection with Cynthia L. Walter’s hospitalization and surgery, plaintiffs incurred a hospital bill of $10,550.93 and physicians’ fees of $4,705. Defendant has refused to make payment for any of these expenses, claiming that they were not covered under the terms of the insurance policy.

The coverage provisions of the group insurance policy are contained in a booklet entitled “Group Insurance Benefits.” The relevant provisions are reproduced below. (Paragraph numbers are supplied by the court in order to facilitate future reference to these provisions.)

(1) A pre-existing condition is any sickness or injury for which medical care and treatment is received by you or your Dependent during the 3 month period ending on the date of coverage. In the event of a pre-existing condition, coverage for that condition will be postponed until 3 consecutive months have elapsed during which no care or treatment has been received. (Booklet, p. 32).

(2) If a dependent, other than a newborn child, is confined in a hospital ... on the date he becomes [86]*86covered, he will not be covered under the Major Medical Expense Benefits part of the insurance until 30 days have elapsed during which he has not been so confined . . . (Booklet, p. 6) (Emphasis added.)

(3) No payment shall be made under any health benefit of the policy in any event for:

4. Charges on account of a Dependent for any medical expense incurred during or in connection with a hospital confinement which commenced pri- or to the date the Dependent became covered under the policy. (Booklet, p. 40).

The fact that Cynthia L. Walter is an eligible dependent of Paul J. Walter is not in dispute. It also appears that the parties are willing to agree that plaintiffs and their daughter became covered under the policy on February 15, 1980, the 60th day of Paul J. Walter’s employment at Johnston Construction Company. Thus, it is clear that Cynthia L. Walter was admitted to Johns Hopkins Hospital three days prior to the date her insurance coverage commenced. The only disputed issue in the present posture of this case is the manner in which the above-quoted insurance policy provisions should be interpreted and applied to the given circumstances.

Plaintiffs invoke paragraph 2 to support their contention that, as a “new-born child,” Cynthia L. Walter was expressly exempted from the condition postponing coverage of a dependent who is hospitalized on the date when coverage would otherwise begin. Since the precondition of nonhospitalization is waived in the case of newborn children, Plaintiffs reason, Cynthia L. Walter became covered on February 15, 1980 and is entitled to benefits in the amount of all medical expenses incurred on or after that date.

[87]*87Defendant argues strenuously that Cynthia L. Walter was not a “newborn child” within the meaning of paragraph 2, because she had been discharged from the hospital where she was born. We find no merit in this argument. Webster’s Third New International Dictionary (1968) defines “newborn” as “recently born.” Cynthia L. Walter, who was little more than two weeks old on February 15, 1980, would seem to fall under that definition. If, when drafting its Benefits Booklet, defendant intended to postpone coverage to hospitalized two-week-old infants who had been discharged from the hospital of their birth, then defendant had a duty to define its terms with greater precision. A vague or ambiguous provision in an insurance policy will be interpreted against the insurer and in favor of coverage. Miller v. Prudential Ins. Co. of America, 239 Pa.Super. 467, 362 A.2d 1017 (1976); Celley v. Mutual Benefit Health and Accident Association, 229 Pa. Super. 475, 324 A.2d 430 (1974).

Having determined that Cynthia L. Walter was a “newborn child” within the meaning of paragraph 2, we now arrive at the decisive issue of the present dispute. In our prior opinion, this court held that a patent inconsistency existed between the provisions of paragraph 2 and paragraph 3 of the policy and that the conflicting terms and conditions should be construed against defendant insurance company as drafter of the policy.

Paragraph 2 extends immediate coverage to a “newborn child” on the same day that her parent becomes covered under the policy, despite the fact that the infant happens to be hospitalized at the time. The newborn child’s major medical benefits begin immediately and are not postponed until 30 days after discharge from the hospital, as would be the case with other dependents of the policyholder.

[88]*88Paragraph 3, on the other hand, clearly provides that no benefit of any kind will be paid to cover medical expenses incurred by a dependent during a hospital confinement which began prior to the date of coverage.

In reconsidering the correlative effect of these two clauses, we are mindful of the standards governing the construction of insurance contracts. Any ambiguity in the language of an insurance document is to be read in a light most strongly supporting the insured. Mohn v. American Casualty Company of Reading, 458 Pa. 576, 326 A.2d 346 (1974). Yet, the language of an insurance policy should be read to avoid ambiguities, if possible. Monti v. Rockwood Insurance Co., 303 Pa. Super. 473, 450 A.2d 24 (1982). Applying these standards to the policy in question, we conclude that no ambiguity exists and that paragraphs 2 and 3 are plainly susceptible of an interpretation rendering them consistent with each other.

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Related

Pfeiffer v. Grocers Mutual Insurance
379 A.2d 118 (Superior Court of Pennsylvania, 1977)
Miller v. Prudential Insurance Co. of America
362 A.2d 1017 (Superior Court of Pennsylvania, 1976)
Mohn v. American Casualty Co.
326 A.2d 346 (Supreme Court of Pennsylvania, 1974)
Wasilko v. Home Mutual Casualty Co.
232 A.2d 60 (Superior Court of Pennsylvania, 1967)
Rempel v. Nationwide Life Insurance
370 A.2d 366 (Supreme Court of Pennsylvania, 1977)
Monti v. Rockwood Insurance
450 A.2d 24 (Supreme Court of Pennsylvania, 1982)
Celley v. Mutual Benefit Health & Accident Ass'n
324 A.2d 430 (Superior Court of Pennsylvania, 1974)

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Bluebook (online)
33 Pa. D. & C.3d 83, 1984 Pa. Dist. & Cnty. Dec. LEXIS 243, Counsel Stack Legal Research, https://law.counselstack.com/opinion/walter-v-travelers-insurance-pactcomplyork-1984.