Opinion ID: 600836
Heading Depth: 2
Heading Rank: 2

Heading: Determination of Ambiguity

Text: 15 Ordinary rules of construction require us, first, to assess the natural or plain meaning of the policy language. E.g., Landress Auto Wrecking Co., Inc. v. United States Fidelity & Guaranty Co., 696 F.2d 1290, 1292 (11th Cir.1983). We must strive to give meaning to every provision, so we must look at the phrase considered experimental to determine its meaning within the policy. The policy does not define the term experimental. The plain language of subparagraph (b), the provision relied upon by the district court to exclude coverage, does not indicate who will determine whether a proposed treatment is considered experimental. 3 Further, it also omits standards for how that determination will be made. Thus, the contract phrase considered experimental, without more, gives rise to a genuine uncertainty about who will determine whether a particular treatment is experimental and how that determination will be made. Indeed, even Mutual of Omaha concedes that there could be more than one source of such a determination. Ambiguity in the contract terms arises from the contract's silence on definitions. 16 The absence of a definition does not create ambiguity per se, as noted above. Nonetheless, the insurance company cannot then claim the narrow and favorable interpretation that its determination, alone, is controlling. In this case, Mutual of Omaha took upon itself the determination of whether the proposed treatment is considered experimental. While that is a reasonable interpretation of the policy language, it is not the only reasonable interpretation. It would also be reasonable to allow the determination of what is considered experimental to be made, for example, by the relevant medical specialists, according to generally accepted standards of community practice, or by a national association. 17 Mutual of Omaha's interpretation excludes coverage, but other reasonable interpretations may result in coverage. For example, although in its order in this case the district court did not assess whether HDC-ABMT is considered an experimental treatment by the relevant medical specialists, other courts have found that the relevant medical specialists do not consider HDC-ABMT experimental. E.g., Adams v. Blue Cross/Blue Shield, Inc., 757 F.Supp. 661, 663 (D.Md.1991) (at the time Blue Cross denied coverage, Maryland oncologists generally acknowledged HDC-ABMT as accepted medical practice). 18 The existence of differing interpretations of the term experimental provides further evidence of a genuine ambiguity. Some courts 4 have found that ambiguity is cured when the term experimental is qualified by specifying who will determine the experimental nature of the treatment or by specifying the standards by which the determination of experimental will be made. For example, in Fuja v. Benefit Trust Life Insurance Company, 809 F.Supp. 1333 (N.D.Ill.1992), the insurance contract provided coverage for medically necessary treatment, which was defined as treatment that is, among other criteria, not deemed to be experimental ... by any appropriate technological assessment body established by any state or federal government. Id. at 1336. The court noted that a predecessor version of this criterion had been considered ambiguous, but that the qualifier deemed ... by [a] technological [assessment] body largely removed any ambiguity. Id. at 1340 n. 4. The court also noted that the National Cancer Institute, an appropriate technological assessment body under the contract, stated in its literature that the term[ ] ... 'experimental' cannot be simply or unambiguously used to define new cancer therapies. Id. at 1340. 19 Similarly, in Boland v. King County Medical Blue Shield, 798 F.Supp. 638, 640 (W.D.Wash.1992), a collective bargaining contract excluded experimental or investigational procedures, which were defined as: 20 any services so classified by the National Blue Cross and Blue Shield Association and any service whose use is still under clinical investigation by health professionals or is not generally recognized by the medical profession as tested and accepted medical practice. This exclusion also applies to items requiring Federal Drug Administration or other governmental agency approval if such approval was not granted at the time the service or supply was ordered. 21 The court determined that the contract unambiguously relied on a third-party classification of what was experimental or investigational, and, because the National Blue Cross and Blue Shield Association had classified the proposed treatment as investigational, granted summary judgment for the insurance company. Id. at 646. 22 Other courts have found that the term experimental is ambiguous when it is undefined in medical insurance contracts. For example, in holding that Blue Cross-Blue Shield's policy excluding experimental procedures was ambiguous, the United States District Court for the Eastern District of Virginia noted that the policy did not define experimental and did not explain what evidence would be used to demonstrate whether a particular treatment was experimental. Pirozzi v. Blue Cross-Blue Shield, 741 F.Supp. 586, 589-90 (E.D.Va.1990). See also Nesseim v. Mail Handlers Benefit Plan, 792 F.Supp. 674 (D.S.D.1992) (granting a preliminary injunction and requiring coverage for HDC-ABMT because the terms of the contract were ambiguous). Indeed, in Johnson v. District 2 Marine Engineers Beneficial Association, 857 F.2d 514, 516 (9th Cir.1988), the court stated that [i]n the context of modern medicine, the term 'experimental' seems clearly ambiguous on its face. We agree that, in the context of a major medical insurance policy, the term experimental, and in this case the phrase considered experimental, is ambiguous when it is undefined.