Opinion ID: 1952451
Heading Depth: 1
Heading Rank: 3

Heading: Application of General Principles to the Certified Questions

Text: The insurance policy here begins with a concept that is understandable enough  that is, the coverage is for a sickness which first makes itself known while this policy is in force. So, it would seem at first blush that nothing is covered that was known to the insured before the policy came into force. But this general coverage provision is expressly made subject to all provisions of this policy. Therefore, any other provision of the policy that may be inconsistent with this first manifest provision can sublimate  or trump  the first manifest provision. It is the provision relating to misstatements coupled with the provision relating to the exclusion of pre-existing conditions that appear to be inconsistent with the first manifest provision. First, the pre-existing exclusion provides, in substance, that there is no coverage for a disability if that disability starts or loss is incurred during the first two years and if it results from a pre-existing condition. Here the disability resulted from the pre-existing condition, but the disability was not incurred during the first two years. Second, the misstatement provision states that the insurer will not contest misstatements after the policy has been in effect for two years. Here the two-year period had expired and there was no fraud exclusion. Another provision that is inapplicable to the certified questions should nevertheless be mentioned and put in perspective. Coverage may be denied under the policy after two years if a pre-existing condition had been excluded from coverage by name or specific description. There was a specific exclusion in this policy for a different pre-existing condition of Dr. Oglesby  namely, any impairment due to degenerative arthritis or rheumatism of the hip region. This was a condition he did disclose and it was specifically excluded. The pre-existing condition he did not disclose  cervical degenerative arthritis, which resulted in his claim of disability for herniated disc, weakened arms and shoulder pain  was not specifically excluded. Hence, the provision denying coverage for exclusion from coverage by name or specific description is not applicable here. The insurer argues that we should not reach the exclusion for misstatements because it is not the misstatement that is at issue, and that sickness and pre-existing condition are not synonymous. The insurer contends that the policy never applied at all because the policy does not cover any sickness that was manifest before the policy went into effect. This may have been what the insurer intended, [8] but its argument is refuted by five points: 1. The subject to all provisions language modifies the first makes itself known provision so that these other provisions sublimate or trump the first makes itself known provision. 2. One of these other provisions is the pre-existing condition exclusion that applies only when disability starts or loss is incurred during the first two years. Therefore, this exclusion does not apply here because more than two years have elapsed. 3. The other provision is the misstatement provision, which also provides for repose after two years. 4. The insurer did not take advantage of the fraudulent misstatement provision available under the statute to extend the misstatement period beyond two years. 5. At best, the policy is unclear or ambiguous, with the result that the insurer may not prevail under the doctrine of contra proferentem.