Title: Thibodeaux v. Pacific Mutual Life Insurance Co.

State: louisiana

Issuer: Louisiana Supreme Court

Document:

112 So. 2d 423 (1959) 237 La. 722 Dalton Joseph THIBODEAUX v. PACIFIC MUTUAL LIFE INSURANCE COMPANY. No. 43657. Supreme Court of Louisiana. June 1, 1959. Dubuisson & Dubuisson, Opelousas, for defendant-appellant. J. Minos Simon, Lafayette, for plaintiff-appellee. HAMLIN, Justice. This is an appeal[1] from a judgment of the trial court awarding plaintiff total disability *424 recovery of $200 per month, commencing May 12, 1952, and extending as long as disability exists, under the coverage of Policy No. 1272142 executed between plaintiff and Pacific Mutual Life Insurance Company, appellant, dated February 6, 1951; ordering a refund to plaintiff of all premiums paid subsequent to May 12, 1951; waiving payments of future premiums and decreeing the policy in force throughout the period of disability; and, providing for the payment of interest on the amounts due at the time of judicial demand and those falling due thereafter. On May 12, 1951, plaintiff, a rice farmer, was endeavoring to unload a barrel of oil from his truck in order to refuel the pump employed for watering his crop, when the bed of the truck broke, precipitating the fall of plaintiff and the barrel to the ground. Plaintiff was rendered unconscious for approximately an hour, and upon regaining consciousness he experienced a burning pain over his entire back. He immediately drove to Kaplan, Louisiana, and consulted Dr. Edward R. Villemez, who administered a light treatment and plastered his back. Plaintiff then reported the accident to Mr. Dennis Simon, defendant's agent, showing him the condition of the truck. Plaintiff was unable to work, and for approximately five weeks he received light treatments from Dr. Villemez. Pain was diminished, but on September 13, 1951, acuteness returned and he consulted Dr. Derwin K. Harmon of Kaplan, Louisiana, who found muscle spasm and severe pain in plaintiff's back. Treatment by this doctor did not diminish pain and disability to work, and he sent plaintiff to Dr. James Gilly, an orthopedic surgeon of Lafayette, Louisiana. This doctor found that back muscle attachments that hold and stabilize the bone structure had been injured, and that the breeching of the traumatized area caused the condition of pain. He found disability and restriction of motion in plaintiff's spine. Study of X-rays revealed that plaintiff had a condition of congenital spondylolisthesis.[2] Treatment was administered, but plaintiff experienced inability to get out of bed in the morning and disability to pursue his former occupation. Under Policy No. 1272142, Pacific Mutual Life Insurance Company paid to plaintiff a total of $1,600, represented by six checksone in the amount of $600 on December 20, 1951, and five in the amount of $200 each on January 18, 1952, March 18, 1952, March 26, 1952, April 22, 1952, and May 19, 1952, respectivelybearing the notations, "on account of sickness" and "disability date, September 13, 1951." On May 30, 1953, plaintiff filed suit on the policy herein for total disability of $200 per month from May 12, 1952, until his death, plus penalties and attorney's fees. Defendant answered, generally denying the allegations of plaintiff's petition which alleged his grounds for recovery. At the termination of evidence the matter was submitted without brief or oral argument, and judgment was rendered as above set forth. In this Court, defendant contends (1) that the loss plaintiff suffered did not result both "directly and independently of all other causes from bodily injuries accidently sustained while the policy was in force"; (2) that a congenital condition (which constituted an infirmity) precluded recovery of total disability by virtue of the reductions clause of the policy which disallows accidental benefits if the disability was contributed to "by bodily infirmity"; (3) that plaintiff was not disabled within *425 the meaning of the accident coverage clause of the policy; and, (4) that no further refund of premiums was due. The pertinent provisions of the instant policy (a combination life, family income, and disability) read: The testimony of record is to the effect that prior to his accident, plaintiff was engaged in rice farming, having performed this type of work from the time he was twelve years of age. He not only had complete supervision of approximately 260 acres, but he performed a great part of the physical work, which embraced the operation of tractors and other implements of farming, the digging of ditches with shovels, the harvesting of rice seeds, the lifting and sewing of bags of rice weighing over 160 pounds, and the driving of trucks. Seven lay witnesses and plaintiff's father affirmed this fact. Only spasmodicallyespecially during harvesting timedid plaintiff employ farm workers to assist him. A number of lay witnesses testified that plaintiff performed no physical work after the accident, hiring them to do the work he had previously performed himself. Plaintiff completed a high school education; he was twenty-seven years of age at the time of the accident being a vigorous, robust male of medium stature and weight. The record conclusively discloses that up to the time of his accident, plaintiff had neither suffered nor experienced any impairment of activity. Only after the fall was his condition rendered such that he became disabled. The medical testimony of record, based on X-rays taken after the accident, is that, in addition to the injury suffered, plaintiff had either developmental or congenital condition of spondylolisthesis, bilateral isthmus, and spina bifida occulta. Dr. Blaise Salatich, who examined plaintiff after he had filed the instant suit, explained this condition as follows: From the testimony of record, we deduce that the injury sustained by plaintiff was a torsion-type low back injury, involving ligamentous and musculofascial structures. There was force exerted on plaintiff's lower trunk by the sudden falling and turning over of a heavy drum of oil. The injury was accompanied by complete disability to pursue his former occupation, dysfunction, and pain, and the pre-existing condition became symptomatic. In the case of Frerichs v. London & Lancashire Indemnity Co. of America, 169 La. 182, 124 So. 821, 822, this Court determined that death was not caused by accidental means, but it made the following pertinent statement. In Carnelious v. Louisiana Industrial Life Ins. Co., 138 So. 533, the Court held: We conclude that the injury which plaintiff suffered was the cause of his loss. It was effected by accidental meansthe giving way of the bed of the truck and the resulting fall. The injury was independent of plaintiff's pre-existing condition, which was awakened by the occurrence. A review of authorities convinces us that where an insured has a dormant condition and such condition is awakened by accident, the condition is not deemed the cause of the disability or loss which the insured suffers. LaBarge v. United Insurance Company, 209 Or. 282, 303 P.2d 498, 306 P.2d 380; Scanlan v. Metropoliton Life Ins. Co., 7 Cir., 93 F.2d 942; Kilgore v. Reserve Life Insurance Company, 231 S.C. Ill, 97 S.E.2d 392; Underwriters At Lloyd's, London, England v. Lyons, 9 Cir., 248 F.2d 149; Schonberg v. New York Life Ins. Co., 235 La. 461, 104 So. 2d 171. The "Reductions" clause of the policy, supra, provides that accident indemnity is not payable for any loss which results from or is contributed to by sickness or bodily or mental infirmity. Defendant argues that plaintiff's pre-existing condition, principally spondylolisthesis, was an infirmity which contributed to the loss. Webster's New World Dictionary of the American Language, College Edition, defines "Infirmity" as follows: In determining whether plaintiff's preexisting developmental or congenital condition might be classed as an infirmity, the following testimony[3] of Dr. Gilly on redirect examination is pertinent: Dr. Salatich stated that the word "infirmity" was not contained in the medical dictionary. He considered spondylolisthesis a mechanical abnormality. He stated that plaintiff was not chronically or mentally afflicted, as he knew the term "infirmity." "* * * so he could not be considered, according to my standards of comparison, afflicted or presenting any infirmity." He further testified: Dr. Derwin K. Harmon testified that spondylolisthesis [4] is not a disease, and that if the personprevious to the injuryhad no pain, it was not an impairing condition. His definition of the condition was that it was a peculiarity of the bone structure. He stated that where one has an anatomical or peculiarity of the bone structure, the body more or less adjusts to it. Dr. E. R. Villemez, who examined plaintiff shortly after the accident and found that he had a low back injury, testified that he would classify the pre-existing condition of plaintiff, revealed by X-ray, as a malfor mation or congenital abnormality. He stated that one may have such a condition without any impairment of physical agility. He testified: We have not been able to find in our Louisiana jurisprudence a thorough discussion of a "Reductions Clause", as is herein involved; the jurisprudence of other jurisdictions, however, is replete. The landmark case of Silverstein v. Metropolitan Life Ins. Co., 254 N.Y. 81, *430 171 N.E. 914, where Justice Cardozo was the organ of the court, involved a policy similar to the instant one. The insured, while lifting a milk can into an ice box, slipped and fell, the can striking him on the abdomen and causing such pain that he was unable to get up. Operation revealed a duodenal ulcer, about the size of a pea, which had been unknown to the insured. He later died from peritonitis. The court stated: In Mutual Life Ins. Co. of New York v. Dodge, 4 Cir., 11 F.2d 486, 489, 59 A.L.R. 1290, the court stated: Considering the medical and lay evidence as to the physical condition of plaintiff before the injury and the fact that he had performed farm work of a laborious nature for approximately fifteen years without any difficulty or pain, we cannot hold that at the time of the occurrenceaccident herein involvedhis physical condition was such that he had any infirmity which in the absence of trauma contributed to his present physical condition. Plaintiff's life, traced supra, is conclusive evidence of the fact that if he did have any congenital or developmental condition or abnormality, if was of such a slight or dormant nature as to have virtually no significance. Scanlan v. Metropolitan Life Ins. Co., 7 Cir., 93 F.2d 942, 946. The medical examination required before defendant issued the instant policy was passed by plaintiff with no rating nor requirement of additional premiums. No false representations were made. Plaintiff paid the premiums due to and charged by the defendant in consideration of its issuance of the policy. He went about his business and affairs in the even tenor of his ways until he suffered his injury. The above are all circumstances which the court is bound to consider in a case of this kind as being favorable to plaintiff. We conclude that plaintiff was disabled within the meaning of the accident coverage clause of the policy and is entitled to total disability as set forth in the provisions of the policy. Plaintiff has answered the appeal, asking that the judgment of the trial court be reversed, insofar as it did not allow penalties and attorney's fees. LSA-R.S. 22:657. A study of the highly scientific questions herein involved and the surrounding facts and circumstances of this case convinces us that the defendant was not arbitrary and capricious in its refusal to pay plaintiff total disability benefits. The trial judge correctly stated: The judgment of the trial court ordered a refund to plaintiff of all premiums paid subsequent to May 12, 1951, the date of the accident. Article VIII of defendant's answer avers that it refunded to plaintiff premiums paid by him on the life policy during the period from October 6, 1951 to June 6, 1952, in the sum of $245.70. The evidence of record shows that such a check was issued to plaintiff on August 4, 1952. For the reasons assigned, the judgment of the trial court is amended so as to allow defendant a credit of $245.70, the amount of the refund of premiums. In all other respects, the judgment of the trial court is affirmed. All costs are to be paid by defendant. [1] Previously defendant's appeal of this Court was dismissed. 231 La. 617, 92 So. 2d 385. Defendant's subsequent appeal to the Court of Appeal, First Circuit, was transferred to this Court. 95 So. 2d 183. Plaintiff's motion to dismiss the appeal was denied by this Court. 233 La. 804, 98 So. 2d 195. [2] Dr. Gilly defined congenital spondylolisthesis as: "* * * a defect in the function or joining of the back part of the vertebra to the front part. This is not necessarily hereditary, but it is usually present at birth and represents the failure of the separate, or ossification, or separate bone forming of the vertebra to form a joined vertebra in that the vertebra exists in separate front segments or anterior and posterior segments." [3] There is other testimony of Dr. Gilly, which apparently does not substantiate this testimony, but we believe that the quoted testimony sets forth what he really believed and the meaning he intended to convey. [4] "It is not necessarily slipping forward. It is a forward misplacement that is formed that way. You can interpret the vertebra as just boxes one on top of the other and they are held to both by ligaments. In spondylolisthesis one of these boxes is pushed forward on the other and the reason it is is because the thing that holds it to the litigaments in the back is longer in that vertebra than the other. It is not actually it is pulled forward and stays there, it is not a thing that pulls forward and backward."