Opinion ID: 1226544
Heading Depth: 1
Heading Rank: 3

Heading: the accident of august 30, 1974, and proceedings in district court

Text: As misfortune would have it, the Linn vehicle was hit by another motorist, and all of the Linns were hospitalized for their injuries, of which the most serious were to Mrs. Linn and the daughter, as reflected in their doctor and hospital bills submitted to MSB of $4,875.25 and $3,557.77, respectively. Linn himself submitted total bills of only $450.85, and the son's bills were $917.60. The total of bills submitted to MSB, $9,801.47, was not all of the bills, but only those which Linn contended were chargeable to MSB under his NELSON TRUST policy. His total bills were considerably above those submitted, but as pointed out above, the pamphlet explaining his NELSON TRUST contract did contain certain limitations, especially on hospital and cosmetic surgery expenses. Pursuant to his medical payments policy with Farmers Insurance, Linn received $14,898.52 from that company. After MSB refused to pay the bill submitted, Linn brought suit, alleging his entitlement to $9,801.47 that he had demanded but which remained unpaid, and asking for judgment in that amount and for attorney fees under I.C. § 41-1839. MSB in answering the complaint by way of affirmative defense brought in the additional facts that the Linns had been injured in a two-car collision occasioned by the negligence of one John Giovanelli, an uninsured motorist, and that Linn and his dependents received full payment of all medical expenses in addition to the sum of Twenty Thousand Dollars ($20,000) paid by way of uninsured motorist protection benefits from Farmers Insurance Group, plaintiff's insurance carrier, under the terms of his policy with said company which constituted the maximum benefits payable for medical and uninsured motorist protection; that all bills sought to be recovered in plaintiff's Complaint were and have been included in the settlement of plaintiff's claim under his policy with Farmers Insurance Group and were paid to plaintiff by said company. Thereafter the complaint was amended to correct an error in the caption and to correct the amount sued for from $9,801.47 to $9,738.67. The case was submitted to the trial court on a stipulation of facts which included a copy of the master NELSON TRUST policy and the pamphlet above referred to. It was a stipulated fact that individual employees covered by the master policy, including the plaintiff, were not furnished a copy of the master policy, but also that the pamphlets were furnished to the unions involved for distribution to the employees, which booklets summarized the provisions of the master policy. Further stipulated were the facts of the accident, of the injuries to Linn and his dependents, and of the bills for medical, surgical and hospital services. It was agreed that the bills were, to the extent of $9,738.67, an obligation of MSB, if MSB were liable at all. Relative to MSB's defense it was a stipulated fact that: 7. Subsequent to the accident plaintiff made claim upon his insurance carrier, Farmers Insurance Company, under plaintiff's policy with said carrier, a copy of which is hereunto attached, marked `Exhibit B', and by reference made a part hereof as though specifically set forth herein, for medical expenses and for benefits of the uninsured motorist provisions of such policy; that plaintiff has received from Farmers Insurance Company, under the provisions of Exhibit B, the maximum uninsured motorist benefit of Twenty Thousand Dollars ($20,000) and, in addition, has received payment of $14,898.52 for medical expenses incurred by plaintiff and plaintiff's family, which are included in plaintiff's claim against MSB. Reaching the basis of MSB's denial of coverage and its defense of the lawsuit, the stipulation further recited: 8. MSB has denied plaintiff's claim of Nine Thousand Seven Hundred Thirty Eight and 67/100 Dollars ($9,738.67), as hereinbefore set forth, basing its denial on the exclusions appearing in the master policy (Exhibit A), particularly the exclusion which provides: `The benefits of this contract for sickness or injury resulting from the negligent or wrongful act or omission of another party shall be reduced by the amount of funds reasonably recoverable by or on behalf of the subscriber or dependent from or on account of such other party. Funds reasonably recoverable include but are not limited to all money obtained from or on account of such other party as a result of claim or litigation for the recovery of special damages, general damages or punitive damages or in consideration of any release, receipt, covenant not to sue, acquittance or agreement of any kind, written or oral...'. Regarding the pamphlets, a final recitation of the stipulation was that Linn acknowledged receipt of those dated February 1, 1969, and November 1, 1973. Others were dated March 1, 1979, and February 1, 1972. Copies of all four of the pamphlets were stipulated into evidence, but it was stipulated that the one dated November 1, 1973 (from which excerpts above were taken), was referenced to the master policy effective on the date the Linns were injured. It was agreed that a paragraph found on the frontpiece of the pamphlet contained a statement that it was furnished for the purpose of giving a brief and clear summary of the benefits available to you under the plan, but which also went on to provide that if any question arose concerning benefits payable, the group insurance contracts issued by the insurance carrier and the medical-surgical-hospital service organization underwriting the benefits of the plan shall control. As counsel for Linn and for MSB saw the issues, and stated them in their stipulation, the court was asked to decide (1) whether the pamphlets superseded, modified, or otherwise abrogated the terms of the master policy, and (2) whether the exclusion of the master policy precluded Linn from recovering from MSB in view of payments received by him from Farmers.