Opinion ID: 1312074
Heading Depth: 2
Heading Rank: 2

Heading: The Medical Payment Provisions Issue

Text: The second certified question, as set forth above, is: Whether the provisions of the State Farm policies providing medical payment coverage which provide that the bodily injury through being struck as a pedestrian by a motor vehicle prior to being applicable are satisfied when Stacey Hamric was injured as a pedestrian while avoiding being struck by a vehicle driven by an unknown driver. State Farm also denied coverage under the medical payment coverage (med-pay) provisions of the insurance policies because Stacey Hamric was not physically struck by the unknown vehicle. The med-pay provisions of the State Farm policies at issue provide: Persons for Whom Medical Expenses Are Payable We will pay medical expenses for bodily injury sustained by: 1. a. the first person named in the declarations; b. his or her spouse; and c. their relatives. These persons have to sustain the bodily injury: a. while they operate or occupy a vehicle covered under the liability section; or b. through being struck as a pedestrian by a motor vehicle or trailer. A pedestrian means a person not an occupant of a motor vehicle or trailer. No statutory requirements govern medical payments coverage; therefore, we must look to the language of the policy to determine if coverage is available. This Court has previously said: `Where provisions in an insurance policy are plain and unambiguous and where such provisions are not contrary to a statute, regulation, or public policy, the provisions will be applied and not construed.' Syl. Pt. 2, Shamblin v. Nationwide Mut. Ins. Co., [175] W.Va. [337], 332 S.E.2d 639, 640 (1985). Syllabus Point 2, Deel v. Sweeney, 181 W.Va. 460, 383 S.E.2d 92 (1989). Syllabus Point 1, Keiper v. State Farm Mut. Auto. Ins. Co., 189 W.Va. 179, 429 S.E.2d 66 (1993). An ambiguous insurance policy is defined as one that is reasonably susceptible of two different meanings or is of such doubtful meaning that reasonable minds might be uncertain or disagree as to its meaning[.] Syllabus Point 1, Prete v. Merchants Property Ins. Co. of Indiana, 159 W.Va. 508, 223 S.E.2d 441 (1976). State Farm argues the med-pay provisions of the policies are clear and unambiguous and must be applied as written. Even though Stacey Hamric is an insured and was a pedestrian on September 9, 1994, State Farm argues she was not actually struck by a motor vehicle on that day. Therefore, under the policy language, no med-pay is available. Vernon Hamric and Debra Hamric argue that, under Norman, an insured does not have to be physically struck for coverage to be afforded. Rather, a close and substantial physical nexus must exist between an unknown hit-and-run vehicle and the insured. We turn to 43 Am.Jur.2d Insurance § 632 (1982) for guidance. This provision states: It has been held that the proper construction of the policy provision struck by an automobile does not necessitate physical contact of the body of the insured with the automobile as a prerequisite to recovery. Thus, such a policy provision was held to cover an injury to one who suffered an accident while attempting to avoid being struck by an oncoming automobile, and when in imminent danger of being struck, even though the moving car did not come in contact with his body. (Footnotes omitted). Liberally construing the med-pay provisions of the State Farm policies, as our law requires us to do, and viewing the phrase must be struck or through being struck in light of the method and logic we just used to define physical contact under the uninsured motorist statute, we now concur with the construction outlined in Am.Jur.2d, supra. Since this phrase is reasonably susceptible of two different meanings, we believe it is ambiguous. Ambiguous ... provisions of an insurance policy should be construed strictly against the insurer and liberally in favor of the insured[.] Syllabus Point 2, in part, Marson Coal Co. v. Ins. Co. of State of Pennsylvania, 158 W.Va. 146, 210 S.E.2d 747 (1974). Even though Stacey Hamric was not actually physically struck by the unknown vehicle, a liberal construction of the med-pay provisions of the insurance policies allows this claim to go forward. In the instant case, there simply is no doubt the actions of a negligent automobile driver proximately caused Stacey Hamric's injury. The parties stipulated that but for the evasive actions of Stacey Hamric, she would have been struck. No less than four disinterested adults witnessed the accident. These witnesses can provide the necessary independent third-party testimony to meet the corroborative evidence requirement. We therefore hold that medical coverage benefits should be available to an insured under the medical payments coverage provisions of his or her automobile insurance policy or policies when an insured is struck as a pedestrian in the same way coverage is available under the uninsured motorist statute. In order for the claim to go forward, the insured must satisfy the same tests that must be satisfied in order for a claim to proceed under the uninsured motorist statute. These tests include the but for test and the corroborative evidence test. Accordingly, we answer the second certified question affirmatively. We pause here to note that this Court has unequivocally declared that although we have allowed the stacking of uninsured motorist coverage based on the public policy mandate of W.Va.Code 33-6-31 [1988], there exists no statutory or other public policy requirement that would provide a basis for invalidating or modifying the anti-stacking language for medical benefits contained in an insurance policy. Keiper v. State Farm Mut. Auto. Ins. Co., 189 W.Va. 179, 183, 429 S.E.2d 66, 70 (1993). We now reiterate that the stacking of medical coverages and benefits is not permissible when the language of an insurance policy prohibits such stacking. Thus, the trial court must determine whether or not any of these six insurance policies contain anti-stacking language and determine coverage accordingly. For the foregoing reasons, we find the Hamrics' claims for uninsured motorist benefits and medical benefits should be allowed to proceed if they satisfy the but for test and the corroborative evidence test, both of which are articulated in this opinion. Certified questions answered. DAVIS, J., deeming herself disqualified, did not participate in the decision of this case.