Title: Dirgo v. Associated Hospitals Service, Inc.

State: iowa

Issuer: Iowa Supreme Court

Document:

210 N.W.2d 647 (1973) Fred DIRGO, Appellant, v. ASSOCIATED HOSPITALS SERVICE, INC., d/b/a Blue Cross, Appellee. No. 55781. Supreme Court of Iowa. September 19, 1973. *648 Smith, Peterson, Beckman, Willson & Peterson, Council Bluffs, for appellant. Davis, Jacobs & Gaul, Sioux City, for appellee. Heard before MOORE, C.J., and RAWLINGS, LeGRAND, UHLENHOPP and McCORMICK, JJ. LeGRAND, Justice. The only question for decision here is plaintiff's right to recover under a hospitalization certificate issued to him by Associated Hospitals Service, Inc., commonly known as Blue Cross. The facts are virtually undisputed and the outcome depends upon our interpretation of the following provision in the certificate issued to plaintiff: In January, 1968, plaintiff applied for Blue Cross hospital expense coverage. His application was approved effective March 1, 1968. It is admitted this contract was in force at the time of his hospitalization and that he is entitled to payment of $3,584.73 unless the above exclusion excuses defendant from obligation. Provisions in hospitalization contracts which establish a waiting period before coverage becomes effective for a specific illness or condition, although valid and enforcible, are construed strictly against the insurer. See 45 C.J.S. Insurance § 893, page 972 (1945). The matter to be decided here is whether plaintiff's illness diverticulitis was one which was in existence on March 1, 1968, the effective date of the contract. Defendant argues some significance from the use of the word "condition" in addition to "illness" in the certificate. However, we believe "condition" does not extend the exclusion. We agree with what was said in Broccolo v. Horace Mann Mutual Casualty Company, 37 Ill.App.2d 493, 186 N.E.2d 89, 91 (1962) that "the word 'condition,' as used to describe a state of being, is used synonymously with 'sickness' in discussing and construing an insurance policy." It is necessary to relate in some detail plaintiff's medical history prior to that date. Beginning in 1967, plaintiff had trouble with a chronic prostate infection for which he received medical attention. In August, 1967, surgery was performed to correct his condition. At that time, there was a routine examination of his abdominal tract which revealed no abnormality. He continued complaining of fatigue and vague lower abdominal discomfortsymptoms present prior to his surgeryon the frequent occasions of his post-surgery examinations. He was seen by Dr. A. M. Romano, his attending physician, on September 14, September 22, October 5, November 3, and December 21, all in 1967. At no time did any examination disclose symptoms which could have led to a diagnosis of diverticulitis, although the general *649 complaints about fatigue and abdominal discomfort were consistent with that illness as well as with many others. On March 8, 1968, plaintiff reported for what was to be a routine check-up. It was then determined he should be hospitalized for a "more extensive workup" since his longstanding complaints persisted. This was just one week after the effective date of his hospitalization coverage. He entered the hospital on March 11, 1968, for what Dr. Romano described on the hospital records as either possible pyelitis, an infection of the urinary tract, or diverticulitis, an infection of the colon. On March 13, 1968, plaintiff's condition was definitely diagnosed for the first time as diverticulitis. This diagnosis resulted from an x-ray examination of the bowel. We set out the important parts of Dr. Romano's testimony: On cross-examination, the doctor testified this way: There is more testimony of the same kind, but this is sufficient to show the important facts upon which the trial court's decision rests. They are: (1) plaintiff suffered from symptoms for some time prior to March 1st, 1968, which were later medically related to diverticulitis; (2) the condition itself existed on March 1st, 1968, the effective date of his hospital coverage; and (3) no diagnosis of this condition was made until March 13, 1968, approximately two weeks after the effective date of his hospitalization coverage, although such diagnosis could have been made prior to that date by use of the same procedures resorted to thereafter. This is a law action tried to the court, whose findings, if supported by substantial evidence, are binding upon us. Rule 344(f)(1), Rules of Civil Procedure. Our question, then, is whether there is substantial evidence to support the trial court's conclusion that plaintiff's illness existed on March 1, 1968, the date upon which his hospitalization certificate became effective. The principles upon which our decision depends are firmly established. First we should point out that although certificates such as Blue Cross issues are not strictly "insurance" policies, nevertheless the rules applicable to interpreting the certificate *650 issued by the defendant are the same as those governing insurance contracts. Wenthe v. Hospital Service, Inc., 251 Iowa 765, 768, 100 N.W.2d 903, 905 (1960). It is generally held a provision postponing protection for certain illnesses until a later date means only those illnesses which have already become manifest or active. The rule is stated in 45 C.J.S. Insurance § 893, page 972, this way: Numerous cases adopting this view under various circumstances and different (but similar) contract provisions are collected in an Annotation in 53 A.L.R.2d 689 (1945). In Richards v. American Security Life Insurance Company, 303 P.2d 1110, 1111, 1112 (Okl.1956), the court adopted the following from one of its previous opinions: The Kansas Supreme Court stated the same rule in Southards v. Central Plains Insurance Company, 201 Kan. 499, 441 P.2d 808, 811 (1968) this way: Other cases supporting this view include Mayer v. Credit Life Insurance Company, 42 Mich.App. 648, 202 N.W.2d 521, 523; Keller v. The Orion Insurance Company (8th Cir. 1970), 422 F.2d 1152, 1153; Hovis v. Industrial Hospital Association (1967) 71 Wash. 2d 169, 426 P.2d 976, 977; Rosenberg v. North Dakota Hospital Service Association, 136 N.W.2d 128, 134 (N.D.1965); Royal Family Insurance Co. v. Grimes (1964), 42 Ala.App. 481, 168 So. 2d 262, 264; Horace Mann Mutual Insurance Company v. Burrow (1963) 213 Tenn. 262, 373 S.W.2d 469, 472; Craig v. Central National Life Insurance Company, 16 Ill.App.2d 344, 148 N.E.2d 31, 36 (1958); Old National Insurance Company v. Johnson (Tex.Civ. App.1958), 312 S.W.2d 715, 717; Jackson v. Pacific Mutual Life Insurance Co. (Mo. App.1957), 308 S.W.2d 291, 293; Davidson v. First American Insurance Company (1935), 129 Neb. 184, 261 N.W. 144, 146; Smith v. Benefit Association of Railway Employees (1932), 187 Minn. 202, 244 N.W. 817, 819; Cohen v. North American Life & Casualty Co. (1921), 150 Minn. 507, 185 N.W. 939. Although this court does not seem to have passed on this matter directly, we skirt close to the issue in Snyder v. National Travelers' Benefit Association, 180 Iowa 1344, 1349, 164 N.W. 176, 177, 178 (1917). *651 However, this does not mean an illness or condition must be diagnosed by name before it may be said to exist. As some courts have pointed out, symptoms may be present and may have progressed sufficiently that an illness is said to exist before it has been medically designated by its proper name. This was the holding in Dowdall v. Commercial Travelers Mutual Acc. Assn. (1962), 344 Mass. 71, 181 N.E.2d 594, 596, where the court said, Similar results were reached in Taormina v. National Hospital Service Assn. (La.App.1949), 43 So. 2d 31, 33 (condition existed prior to effective date of contract but not diagnosed until afterwards), and Tasman v. Associated Hospital Service of New York (1959), 19 Misc.2d 809, 198 N.Y.S.2d 49, 51 (symptoms of long standing but no prior medical diagnosis.) The trial court decided the facts bar recovery by plaintiff here because his illness existed on the date his hospitalization coverage became effective. Under the record before us, we find there was substantial evidence to support this conclusion. Dr. Romano's testimony establishes plaintiff's condition existed long prior to March 1, 1968; that symptoms later determined to be indicative of diverticulitis were present for at least eight months before the certificate was issued; and that a diagnosis of diverticulitis could have been made from facts and symptoms then existing by the use of standard medical procedures. We have not discussed plaintiff's assertion he was entitled to summary judgment because it is obvious from what we have said that we find there was a genuine issue of material fact to be decided. The motion for summary judgment was properly denied. For the reasons stated, the judgment is affirmed. Affirmed. All Justices concur, except RAWLINGS, J., who dissents.