Winfield v. CIGNA COMPANIES

532 N.W.2d 284, 248 Neb. 24, 1995 Neb. LEXIS 127
CourtNebraska Supreme Court
DecidedMay 19, 1995
DocketS-93-870
StatusPublished
Cited by43 cases

This text of 532 N.W.2d 284 (Winfield v. CIGNA COMPANIES) is published on Counsel Stack Legal Research, covering Nebraska Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Winfield v. CIGNA COMPANIES, 532 N.W.2d 284, 248 Neb. 24, 1995 Neb. LEXIS 127 (Neb. 1995).

Opinion

Lanphier, J.

Plaintiff-appellee, David John Winfield, initiated this action in the county court for Buffalo County to obtain medical expense benefits under an insurance contract issued by defendant-appellant, Life Insurance Company of North America (LINA). Pursuant to a motion for summary judgment filed by LINA, the county court held that the terms of the insurance contract were unambiguous. The insurance contract states that “treatment” must begin within 60 days of an injury. Winfield received only massages within 60 days. At issue is the policy definition of “treatment.” The county court held that *26 Winfield was not entitled to benefits under the policy. Winfield appealed to the district court claiming that a condition of the insurance contract requiring that he obtain treatment not more than 60 days after an accident was ambiguous as to whether it included massages and should be construed against the insurer. On appeal, the district court held that the contract was ambiguous, reversed the county court’s judgment, and remanded the case for further proceedings. From this judgment, LINA appealed to the Court of Appeals. We removed the case to this court in order to regulate the caseloads of the appellate courts. Although we find the contract unambiguous, we affirm the judgment of the district court because the county court erroneously concluded that LINA was entitled to judgment as a matter of law.

BACKGROUND

The parties do not dispute that on February 8, 1991, Winfield injured his back at work. Neither do the parties dispute that the insurance policy which is the subject of this dispute was in force and effect at that time. At issue is the coverage of the policy, particularly what is referred to as “Coverage D: Medical Expense Benefit.”

Coverage D provides the following:
If a person is injured by one of the types of accidents described in Schedule IV, which happens while he is covered for this benefit, then we will pay this benefit for the services listed below, which he needs as a direct result of the injury, and from no other cause, within a year of the accident.
a) Stays in a hospital.
b) Medical or surgical treatment by a doctor.
c) The services of licensed or graduate nurses.
d) X-Ray examinations.
e) Professional ambulance service from the scene of the accident to the nearest hospital.
The treatment must begin not more than 60 days after the accident.
The amount of this benefit will be the actual cost of these services, minus the deductible amount (if any) shown *27 on page 3. The deductible must be satisfied once for each accident.
This benefit will be reduced to the extent that benefits are payable for the medical services under: (i) any employer sponsored health care plan; or (ii) any government program or any law, including any Worker’s Compensation law.
We will not pay more than the maximum amount shown on page 3, for all medical treatment needed as a result of any one accident.

(Emphasis supplied.)

On February 13, 1991, Winfield sought care for his injury from a licensed masseuse. On March 21, Winfield again sought the services of a masseuse. Then, on July 29, Winfield had surgery on his back. Winfield later made a claim for benefits, but LINA refused to pay any amount for Winfield’s medical care because it claimed he did not begin treatment in 60 days as the policy required. Winfield then sued CIGNA. In an amended petition, LINA was substituted for the defendant CIGNA. The county court held that the policy was clear that medical or surgical treatment was required within 60 days, and since this was not done, no coverage was provided. On appeal, the district court held that the term “treatment” was ambiguous and sent the case back for a new trial.

ASSIGNMENTS OF ERROR

On appeal, LINA asserts the district court erred (1) in failing to find that the insurance contract was not ambiguous and (2) in failing to find that the insurance contract was clear on its face and presented no genuine issue of material fact, and thereby in not affirming the judgment of the county court.

STANDARD OF REVIEW

In reviewing a summary judgment, an appellate court views the evidence in a light most favorable to the party against whom the judgment is granted and gives such party the benefit of all reasonable inferences deducible from the evidence. Cimino v. FirsTier Bank, 247 Neb. 797, 530 N.W.2d 606 (1995). Summary judgment is to be granted only when the pleadings, depositions, admissions, stipulations, and affidavits in the *28 record disclose that there is no genuine issue as to any material fact or as to the ultimate inferences that may be drawn from those facts and that the moving party is entitled to judgment as a matter of law. Id. Regarding questions of law, an appellate court has an obligation to reach a conclusion independent of that of the trial court. Curtis O. Griess & Sons v. Farm Bureau Ins. Co., 247 Neb. 526, 528 N.W.2d 329 (1995).

ANALYSIS

The first issue in this appeal is whether the insurance contract is ambiguous. Whether an insurance contract is ambiguous and therefore in need of construction is a question of law. Union Ins. Co. v. Land and Sky, Inc., 247 Neb. 696, 529 N.W.2d 773 (1995). A contract is ambiguous when a word, phrase, or provision in the contract has, or is susceptible of, at least two reasonable but conflicting interpretations or meanings. Id. While an ambiguous insurance policy' will be construed in favor of the insured, ambiguity will not be read into policy language which is plain and unambiguous in order to constme it against the preparer of the contract. Id.

Coverage D begins by explaining that if an insured is injured by an accident described in the policy, then benefits will be paid for certain “services.” A list of covered “services” follows. One of the items in that list of “services” is “Medical or surgical treatment by a doctor.” (Emphasis supplied.) The contract then provides the following: “The treatment must begin not more than 60 days after the accident.” (Emphasis supplied.) The word “treatment” is not defined in the policy. The term is sometimes qualified or limited as in “medical and surgical treatment” and “medical treatment.” The “treatment” to begin in 60 days is not so qualified.

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Bluebook (online)
532 N.W.2d 284, 248 Neb. 24, 1995 Neb. LEXIS 127, Counsel Stack Legal Research, https://law.counselstack.com/opinion/winfield-v-cigna-companies-neb-1995.