Court Opinion

ID: 9630682
Source: CourtListenerOpinion
Date Created: 2023-08-22 10:17:14.276956+00
Date Added: 2024-06-11T18:07:41.414803
License: Public Domain

DUANE BENTON, Judge,
dissenting.
Because benefits here were not denied on the sole basis of the sex of the insured, I dissent.
The facts are stipulated. On June 21, 1994, Buddy Williams — an AFLAC insurance salesman — applied for group health insurance. On the application, he cheeked a box that within the last 10 years, he had “any symptom, diagnosis, or treatment for ... [kjidney disorder, bladder infections, prostatitis, uterine disorders or any other disorder of the genito-urinary system.” The word “prostatitis” was underlined on the application. An “attached sheet,” explaining the answer, is not part of the record.
Between June 21, 1994, and August 1, 1994, the company requested and reviewed Williams’ medical records. They revealed that on March 13, 1992, Williams complained of “pain,” and was first diagnosed with chronic prostatitis. Three months later, Williams was seen for the same complaints, and diagnosed with “erectile dysfunction with a history of chronic prostatitis.”
In 1993, Williams visited his doctor twice regarding his prostate. A January examination notes that the prostate “feels benign.” The other visit, in October 1993— the last examination before issuance of the policy- — -reveals “a questionable small calculus” in the prostate. The “Impression:” paragraph — where a diagnosis was listed before — is blank on the October 1993 entry.
On August 1, 1994, the company issued an insurance policy. It included an “Exception Endorsement”:
No benefits will be paid under this certificate of insurance or under any rider or amendment thereto, for disability, loss or expense resulting from or caused by any disease or disorder of the prostate, seminal vesicles, urinary bladder or urethra, including any treatment or operation for or complications thereof suffered by Bud L. Williams.
The Exception Endorsement is part of the “Schedule of Benefits.” The “PreExisting Condition Limitations” are a separate exception to the policy. The parties stipulated that except for the Exception Endorsement, “there are no other provisions, conditions or exclusions in defendant’s policy that are applicable that would have the effect of precluding coverage to plaintiff for the medical expenses incurred by Buddy Williams in connection with his treatment of prostate cancer.”
The only issue is whether section 375.995 invalidates the Endorsement. The purpose of section 375.995 is to prohibit “denying insurance benefits or coverage on the sole basis of sex or marital status in any terms or conditions of insurance contracts....” Section 375.995.2 (emphasis added). The title of the bill states its subject as “to prohibit unfair sex discrimination.” S.B. 527, 1985 Mo. Laws 81¡,5. The precise prohibition is:
The availability of any insurance contract shall not be denied ... on the sole basis of the sex or marital status of such insured.... Neither the amount of benefits payable under a contract, nor any term, condition,' or type of coverage within a contract, shall be restricted, modified, excluded, or reduced solely on *251the basis of the sex or marital status of the insured....
Section 375.9954 (emphasis added).
Here, the company did not exclude benefits on the sole basis of sex. It excluded coverage after a good-faith review of the medical records of a specific person.
The principal opinion emphasizes that the exclusion was for an organ — rather than a “pre-existing condition.” The policy covers pre-existing conditions, unless specifically excluded. The majority is correct that, in the Exception Endorsement, the policy did not exclude a pre-existing condition. Instead, the policy went further and excludes a particular organ, the prostate.
True, subsection 375.995.4(7) — read alone — prohibits excluding benefits for male organs. However, it is controlled by the stated purpose and plain intent of the section, so that to be illegal, an exclusion must be solely based on the type of organ, with no medical information on the specific person. Here, the policy excluded benefits based upon a review of Williams’ medical history. Prior medical history is a legitimate basis to deny coverage.
The language of section 375.995 is unambiguous. “Sole” or “solely” are used three times in three operative sentences. The definition of these terms is: “alone” and “that is such and no other.” Webster’s Third New International Dictionary 2168 (1993). The exclusion of the prostate, to violate the statute, must be based upon sex, and sex alone. Here, that was not the case — the company made the exclusion based on Williams’ medical history.
“The parties to a purely voluntary insurance contract may agree to such terms and provisions as they see fit to adopt, subject only to the requirements that the contract is lawful and reasonable.” American Family Mutual Insurance Co. v. Ward, 789 S.W.2d 791, 795 (Mo. banc 1990). Courts should not interfere with a party’s right to contract so long as the contract is not otherwise void. Malan Realty Investors v. Harris, 953 S.W.2d 624, 627 (Mo. banc 1997).
Here, Williams had chronic prostatitis, plus other problems. Benefits were not denied on a group basis (sex), but on an individual basis (medical history). In terms of the statute’s scope, what happened here is fair and legal, not unfair and illegal.
Williams’ prostate was not excluded from coverage on the sole basis of his sex. The exclusion did not violate section 375.995.4. Therefore, I dissent.