Opinion ID: 2224859
Heading Depth: 1
Heading Rank: 4

Heading: The Exclusions Issue.

Text: Contrary to Central States' contention, the result we reach is not inconsistent with several exclusionary provisions of the policy here. Turning to the exclusions issue, we note that expenses incurred refers to those charges for which the insured is legally obligated to pay in the absence of insurance. The language in the absence of insurance implies no coverage when other insurance is available. Another policy provision excludes from coverage [e]xpenses for services, supplies or treatment provided by or paid for by an agency of the federal or state government, or any government plan or law where you are not charged or legally liable for services provided (unless such program by law specifies that the insurance hereunder is primary coverage). This exclusion includes, but is not limited to, Medicare payments. As to the first provision, suffice it to say that Medicaid is not insurance as that term is used in the exclusion. Insurance is a contract whereby, for a stipulated consideration, one party undertakes to compensate the other for loss on a specified subject by specified perils. Black's Law Dictionary 721 (5th ed. 1979). In contrast, Medicaid provides government medical assistance to a limited category of persons who are unable to meet the full cost of their care. No contractual arrangement for a stipulated consideration is involved. As to the second provision, the regulations make it clear that the insurance coverage provided by Central States is primary coverage. See 441 Iowa Admin.Code 75.2 (health insurance must be used when reasonably available); 441 Iowa Admin. Code 80.5(2) (When a third-party liability for medical expenses exists, this resource shall be utilized before payment is made through the medical assistance program except when authorized by the department.). Additionally, as we said earlier the health care providers charged Timothy the medical expenses. He was legally obligated to pay them the moment he received care and treatment. Finally, even if it were clear that the exclusion covered Medicaid, we would not allow an insurer to take advantage of an exclusion brought into play by its own breach.