Court Opinion

ID: 9668548
Source: CourtListenerOpinion
Date Created: 2023-08-24 02:17:51.396133+00
Date Added: 2024-06-11T18:15:46.066366
License: Public Domain

SPURLOCK, Justice,
dissenting.
The group health insurance contract in question defines “sickness” as “physical sickness, mental illness, functional nervous disorder and Covered Pregnancy.” I will limit my dissent to the discussion of the term “physical sickness” in an attempt to demonstrate why Mae Janell Shelton’s condition falls within this category.
A small percentage of the women in our population are born with an Rh negative factor in their blood. That by itself presents no problem. However, as the bulk of the population is Rh positive a woman with a Rh negative factor runs the risk of marrying and conceiving children with a man whose blood type is Rh positive and thus incompatible with hers. Again, the husband’s blood, should it be Rh positive is incompatible in the situational sense only, that situation being the conceiving and the giving of birth to children. Even at this point the first child is usually “a freebie”. During the first pregnancy, assuming it to be normal, the newborn’s blood does not mix with the mother’s until birth. If the child’s blood is Rh positive, as mathematics dictate it usually will be, at the point of mixing the child’s incompatible blood with the mother’s, the mother’s body responds as if it were being invaded by an “antigen”, a substance perceived by her body as deleterious to it. This triggers the mother’s body to produce antibodies specifically tailored to destroy the invading antigen; in this case, the baby’s blood. As her body is not so alerted until the birth of the first child the complications that arise affect only subsequent pregnancies. During the course of any future pregnancies the mother’s system, now alerted to the antigens (the Rh positive blood of the fetus) “attacks” the fetus’ blood supply with antibodies. Normally her system does what is intended; the fetus dies and the mother miscarries.
To avoid the continuous and recurring possibility of this gruesome scene our plaintiff, a woman born (and borne) with an Rh negative factor “chose” to become sterilized. It is this capacity to choose that has singled her out to be denied coverage. People normally don’t choose to become physically ill. In line with the majority opinion it is this inability to choose that allows for insurable risks. There exists that element of chance, a chance that the group as a pool seeks to insure against.
Mrs. Shelton is perceived as having denied chance by having chosen to receive elective surgery. What the insurance company and the majority fail to realize is that the ailment for which Mrs. Shelton seeks *933redress is not the undoing of the tubal ligation but the condition that made it necessary in the first place. For Mrs. Shelton, despite the limits of the English language, did not “choose” to become physically sick. The term choice as it is normally applied to elective surgery has no significance here. It would be far more accurate to depict Mrs. Shelton’s situation, when she “chose” to have a tubal ligation sixteen years ago as one in which she was forced to trade one illness for another. She may have had some input as to what effect her condition would impose on her body (inability to conceive as opposed to the inability to bear children.) But Mae Shelton did not choose to be sick; she merely chose from limited possibilities what form that sickness would take. It was chance that made her sick, chance that created her Rh negative and chance that exposed her to the perilous environment of conceiving children with a male that was Rh positive. In this regard Mae Shelton was no better and no worse than anybody else born with a susceptibility to a particular disease.
To argue that surgery to avoid the complications arising from her Rh negative factor was elective is preposterous. To argue further that the inability to produce healthy, live born children does not somehow demonstrate a serious impairment in a female body borders on the far reaches of common sense. A primary ability of a healthy, normally functioning female is the ability to successfully bear children. The fact that Mae Shelton, as previously married and without a tubal ligation, would have birthed still-born children or miscarried indicates a deficiency in an otherwise normal female.
The majority would have us believe that such a deficiency manifests itself only on the fetus; that the mother’s health is in no way affected. Are we to presume that the ability to give birth to healthy, alive children is not the function of a healthy female? Somehow, because there temporarily and frailly exists a child to accept, unwillingly, the onus of this failure, we are expected to conclude that such a condition affects only the health of the child. As these frail souls depart into the next world we are expected to sit here content in the knowledge that the mother is a healthy and unimpaired woman. In fact it is her body that is possessed by the disease. The miscarried child exists as sad testament to this disease. Only by curing the mother can the tragedy to the child be avoided. Mae Shelton did not choose to become sterile, not in the true sense of the word. It was a decision forced upon her as she sought the lesser of two evils. Such a Hobson’s choice is a choice in name only. And now she seeks to have removed a deficiency the yoke of which she had no choice but to struggle under.
Connecticut General, in its brief, cited and relied upon the following definition from Couch on Insurance 2d § 41:803:
“ ‘Disease’ has been defined as an alteration in the state of the human body or some of its organs or parts interrupting or disturbing the performance of the vital functions or as a deviation from the healthy or normal condition of any of the body, and as a morbid condition of any of the functions or tissues of the body. “The words ‘sickness’ and ‘disease’ are technically synonymous, but given their popular meaning as required in construing a contract of insurance, ‘sickness’ is a condition interfering with one’s usual activities, whereas disease may exist without such result; in other words, one is not ordinarily considered sick who performs his usual occupation, though some organ of the body may be affected, but is regarded as sick when that diseased condition has advanced far enough to incapacitate him.”
The definition speaks for itself. The Rh negative factor incapacitated Mae Shelton’s ability to have a normal pregnancy and childbirth. The tubal ligation in no way altered that symptom; it only allowed her a little greater freedom in her sex life. Her present operation stems from a desire to cure the illness and restore Mae Shelton to a normal state. I would affirm the lower court.
I respectfully dissent.