Court Opinion

ID: 9573225
Source: CourtListenerOpinion
Date Created: 2023-08-21 20:50:16.255629+00
Date Added: 2024-06-11T12:38:20.375194
License: Public Domain

Holbrook, Jr., P.J.
('concurring in part and dissenting in part). I concur with part n of the majority opinion. I also concur with part I to the extent that it affirms the trial court’s denial of defendant’s motion for summary disposition and reverses the grant of summary disposition for plaintiff with respect to the breach of contract claim. I write separately, however, because in my view the rule set forth by the majority regarding when a preexisting condition “appears” or “makes itself known” does not reflect the current state of Ohio law. Additionally, I dissent from the majority’s holding that this same rule is now to be applied in Michigan.
The issue of when a preexisting medical condition has manifested itself is dealt with in both Ohio statutory and common law. None of these sources, however, addresses the precise situation that is now before us. Further, the unique division of appellate judicial authority in Ohio means that most of the common law identified both in this opinion and the majority opinion is nonbinding. Given these circumstances, I believe we should be particularly careful when outlining the boundaries of the applicable law.
Mrs. Nesbitt’s short-term insurance policy defined the term “pre-existing condition” to “mean[] an illness, disease, accidental bodily damage or loss that first appears (makes itself known) before the Effective Date.” The first question that must be addressed is whether this definition is ambiguous. If so, then under Ohio law the definition must “ ‘be construed strictly against the insurer and liberally in favor of the insured.’ ” DeMatteis v American Community Mut Ins Co, 84 Ohio App 3d 459, 462; 616 NE2d 1208 *230(1992), quoting Blohm v Cincinnati Ins Co, 39 Ohio App 3d 63, 66; 529 NE2d 433 (1988). Accord Leski v State Farm Mut Automobile Ins Co, 367 Mich 560, 567; 116 NW2d 718 (1962).
As noted by the majority, this same definition has been examined in two prior Ohio cases: Novak v American Community Mut Ins Co, Docket No. 72720, 1998 WL 518166 (Ohio App), and DeMatteis, supra. The DeMatteis court concluded that the language was ambiguous. DeMatteis, supra at 463. Conversely, the Novak court found the language to be unambiguous. Novak, supra at *3. The Novak court’s conclusion, however, was based not on a finding that the language was inherently clear, but on deposition testimony by the plaintiff in which he admitted among other things that “he understood the short term policy would not provide coverage for preexisting conditions.” Id. Given the interpretations of the language adopted in DeMatteis and Novak, and given other case law addressing the more general question of what it means for a condition to manifest itself, I conclude that the definition need not necessarily be construed so as to result in coverage for Mrs. Nesbitt.
The issue then becomes one of identifying what Ohio law has to say about when a medical condition is deemed to have manifested itself. Although I have been unable to find any statutory provision that directly controls this situation, some guidance can be gleaned from the statutes that do exist. For example, the following definition is found at Ohio Rev Code Ann 3923.58(A)(3) (Anderson)(1998 Supp):
“Pre-existing conditions provision” means a policy provision that excludes or limits coverage for charges or *231expenses incurred during a specified period following the insured’s effective date of coverage as to a condition which, during a specified period immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment or for which medical advice, diagnosis, care, or treatment was recommended or received, or a pregnancy existing on the effective date of coverage.
Because the duration of Mrs. Nesbitt’s policy was limited to six months, the above definition is not applicable. Ohio Rev Code Ann 3923.58(L)(Anderson)(1998 Supp). However, I find it instructive that the only reasonable person standard found in the above definition refers not to what a reasonable physician would make out of any manifested symptoms of a condition, but to whether a reasonable policyholder would seek treatment when faced with such symptoms.
Guidance can also be found in Ohio Rev Code Arm 3923.04 (Anderson), which sets forth several standard provisions that are to be included in medical insurance policies. Subsection B(2) states:
No claim for loss incurred or disability (as defined in this policy) commencing after two years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.
No chronic disease or chronic physical condition may be excluded from coverage of a policy of sickness insurance or from the sickness insurance coverage of a policy of sickness and accident insurance except by name or specific description.
*232As interpreted by Ohio courts, see, e.g., Fisher v Golden Rule Ins Co, 60 Ohio St 3d 148, 150; 573 NE2d 650 (1991), a condition, be it acute or chronic, may be excluded by a general exclusionary clause for preexisting conditions within two years of the issuance of the insurance policy. Therefore, because Mrs. Nes-bitt’s claim was filed within this two-year period, the insurance policy did not need to specifically name or describe those conditions that would be excluded from coverage because they were preexisting.
Together, §§ 3923.04 and 3923.58 also inform us that the Ohio legislature has concerned itself with the task of balancing the twin goals of (1) protecting insurance companies doing business in Ohio from fraud perpetrated by policyholders and (2) safeguarding the right of policyholders to receive the benefits for which they contracted.
Turning to Ohio common law, the majority concludes that the relevant case law can be summed up in the following rule:
[W]e hold that an illness is a preexisting condition, in the sense that it “appears” or “makes itself known,” if the symptoms and the medical investigation attendant to them are sufficient to provide a physician possessing the skill and knowledge of an ordinary specialist in the area with the means to ascertain the probable nature of the illness. [Ante, p 223-224.]
In support of its formulation of the above rule, the majority cites Novak, supra1 In Novak, the court made the following observations:
*233The second issue to be addressed is whether a preexisting condition “first appears (makes itself known)” by symptoms which are indicative of the condition or a specific diagnosis of the condition by a doctor. We find the latter argument more persuasive than the former. [Novak, supra at *4, quoting the policy at issue (emphasis added).]
I read this passage to mean precisely what it says: the phrase “first appears (makes itself known)” means that the alleged preexisting condition must be specifically diagnosed for the condition to have manifested itself. The Novak court further explains that the term “specific diagnosis” does not mean that the attending physician must have arrived at a final diagnosis. Rather, the Novak court considered it sufficient that the plaintiff in that case was told by his doctor at the time of the plaintiffs examination that his “symptoms were consistent with coronary artery disease.” Id.
The Novak court also observed that the facts in the case distinguished it from Sheeler v Administrator, Ohio Bureau of Workers’ Compensation, 99 Ohio App 3d 443; 651 NE2d 7 (1994). Novak, supra at *5. In Sheeler, the court observed that “ ‘[i]n order for a condition to pre-exist, it must manifest itself. That means the individual knew of the condition due to prior diagnosis, or was aware of the problem.’ ” *234Sheeler, supra at 450, quoting Thomsett, Insurance Dictionary (1989) 159 (emphasis added). The Novak court distinguished Sheeler in the following way:
Plaintiff also cites Sheeler . . . for the proposition that a pre-existing condition is made known when it is diagnosed or identified. Plaintiff claims that this means more than unidentified non-specific symptoms are required to establish a pre-existing condition. Plaintiff is correct. In the instant case, there was more than unidentifiable nonspecific symptoms. There was specific identification of symptoms by the plaintiff, there was an examination by a doctor, and the doctor indicated to plaintiff his symptoms were clearly indicative of coronary artery disease. Therefore, plaintiff’s reasoning is correct but simply misplaced. [Novak, supra at *5.]
Nowhere in Novak or Sheeler do the courts speak of a “reasonable physician” standard.
Such a standard is also not found in Goshom v Hospital Care Corp, 46 Ohio App 3d 47; 545 NE2d 930 (1989). In Goshom, the plaintiff “was diagnosed and treated for a prolapse of the posterior leaflet of the mitral valve” approximately two weeks after her insurance contract had gone into effect. Id. at 47.2 The plaintiff also “had been examined and treated for chest pains by a heart specialist shortly before the effective date of the policy.” Id. at 47, n 2. The Gosh-om court upheld the trial court’s finding that this earner treatment was for a condition that was unrelated to the plaintiff’s mitral valve problem. Id. The Gosh-om court concluded that because the plaintiff neither *235knew of her congenital condition nor had manifested any specific symptoms of the problem before her hospitalization, the preexisting condition exclusion at issue was not applicable. Id. at 47-48.3
From these sources, I distill the following general principles: (1) if the policyholder has no actual knowledge, and has manifested no specific symptoms of a condition before the issuance of the policy, then the condition cannot be considered to be a preexisting condition within the meaning of the coverage exclusion of the policy; (2) the fact that a policyholder has not sought treatment for the condition is not dispositive, if the evidence establishes that the policyholder was aware of the problem before the issuance of the policy by the presence of specific symptoms; (3) if the policyholder sought treatment and was given either a tentative or final diagnosis before the execution of the policy, then the condition is a preexisting condition within the meaning of the coverage exclusion of the policy; and (4) if the policyholder sought treatment and was not given a specific diagnosis, and there is nothing about the symptoms themselves that would alert a reasonable person to the existence of the condition, then the condition is not a preexisting condition within the meaning of the coverage exclusion of the policy.
Under the facts of the case before us, I conclude that reasonable jurors could disagree concerning whether Mrs. Nesbitt’s lung cancer was a preexisting condition for the purpose of the coverage exclusion of her policy. Ramamurthy N. Alam, M.D., the doctor *236who first treated plaintiff on October 16, 1993, averred that (1) Mrs. Nesbitt did not “display any symptoms to suggest a diagnosis of carcinoma” before October 25, 1993, and (2) “Mrs. Nesbitt was not diagnosed with having lung carcinoma until November, 1993.” The lower court record also includes a letter signed by Dr. Alam in which he states that the symptoms Mrs. Nesbitt displayed on October 16, 1993, “were suggestive of Bronchitis and she was given appropriate treatment.” The fact that Dr. Alam tentatively diagnosed bronchitis is supported by contemporaneous office records made after Mrs. Nesbitt’s October 16, 1993, examination.
However, when her symptoms persisted, Dr. Alam sent Mrs. Nesbitt to get a chest x-ray on October 20, 1993. The x-ray revealed a large right pleural effusion. A pleural effusion is defined as: “An accumulation of fluid in the space between the membrane (pleura) which covers the lung and the membrane (pleura) which lines the inner surface of the chest wall.” Attorneys’ Dictionary of Medicine and Word Finder (1999), volume 4 at P-295. The major causes of pleural effusions include:
(1) Congestive heart or circulatory failure .... (2) Tumors (benign or malignant). (3) Infections (tuberculous and nontuberculous). (4) Fungus infections .... (5) Rupture of esophagus (gullet). (6) Chylothorax .... (7) Pulmonary embolism .... (8) Trauma (injury). (9) Rheumatoid arthritis. (10) Collagen disease .... (11) Subphrenic abscess (abscess under diaphragm). (12) Hepatic (liver) abscess. (13) Cirrhosis of liver .... (14) Pneumonia. (15) Nephritis .... (16) Pacreatitus (inflammation of the pancreas). (17) Ovarian fibroma (tumor of ovary). [Id. at P-295 to P-296.]
*237The x-ray results indicate that an “[underlying infiltrate[4] or mass cannot be excluded.”
Whether given the treatment she received Mrs. Nes-bitt’s condition can be considered to have manifested itself before the issuance of her policy is a question that should be left to the trier of fact. Also unanswered by the facts before us is whether the observation that an “[u]nderlying infiltrate or mass cannot be excluded” constitutes a tentative diagnosis that put Mrs. Nesbitt on notice that she might have lung cancer. Therefore, viewing the documentary evidence in a light most favorable to defendant as the nonmoving party, I conclude that a genuine question of material fact exists with regard to whether Mrs. Nesbitt’s lung cancer had appeared before the issuance of the policy.
I do not criticize the soundness of the rule announced by the majority. As they note, several other courts from different states have also applied a reasonable physician standard in cases involving exclusions for preexisting conditions. However, our concern is not to determine in general what would be the best rule for resolving when a preexisting condition “appears” or “makes itself known.” Our concern is to determine what Ohio law has to say about the issue and then to apply that law accordingly. The “reasonable physician” standard may be a logical next step in the evolution of Ohio law, but that is a step for the Ohio courts—not this Court—to take.
I also believe that it is inappropriate for us to use this case as a vehicle to hold that the “reasonable *238physician” rule will now be followed in Michigan. Ante, p 224, n 5. Both the majority and this opinion are based on an examination of the relevant law from Ohio. No search has been made for Michigan authority that addresses the issue, and, given the circumstances of this case, I do not believe such a search is warranted. While the rules of contract interpretation and construction are similar in Michigan and Ohio, that does not mean that in light of our unique jurisprudential and legislative history we would necessarily arrive at the same conclusion with regard to the matter as the Ohio courts.
For example, there is the case of Karagon v Aetna Life Ins Co, 58 Mich App 677; 228 NW2d 515 (1975). The plaintiff in Karagon was insured under a group policy that excluded coverage for
“disability commencing during the first twelve months of the employee’s current period of insurance ... if the disability is caused or contributed to by or as a consequence of, a disease . . . for which the employee received treatment or services, or took drugs or medicines which were prescribed or recommended by a physician.” [Id. at 678, quoting policy at issue.]
The plaintiff was initially “treated for a right carotid kink.” Id. Approximately thirteen months after the onset of symptoms, it was established that the plaintiff was suffering from multiple sclerosis. Id. The trial court determined that the plaintiff was foreclosed by the policy’s exclusion provision. Id. at 679. The Karagon Court reversed the holding of the trial court, reasoning as follows:
. So, in this case, if the disease or injury for which the employee previously received treatment or services is to be *239covered by the exclusion, it must have been correctly diagnosed and appropriately treated during the period covered by the exclusion. When, as here, the disease does not manifest itself with sufficient clarity to allow such an accurate diagnosis and treatment before the exclusion time has run, the exclusion cannot be made to apply because some of the symptoms were treated before the disease was recognized. [Id. at 679 (emphasis added).]
Whether Karagon supports, contradicts, or limits the “reasonable physician” rule announced by the majority remains unanswered. See also Mayer v Credit Life Ins Co, 42 Mich App 648, 650-651; 202 NW2d 521 (1972).5 I believe the Court would be wise to wait until we are presented with a similar issue that directly implicates substantive Michigan law before announcing a general rule that will bind future courts of this state.
Accordingly, I would affirm the trial court’s denial of summary disposition for defendant with respect to the breach of contract claim, reverse the trial court’s grant of summary disposition for plaintiff with respect to the breach of contract claim, and reverse the trial court’s grant of summary disposition for defendant with respect to the claim brought under the Michigan Consumer Protection Act. I also would not adopt as binding standards derived from Ohio law.

 In Nutter v Concord Twp Bd of Zoning, Docket No. 92-L-118, 1993 WL 256808 (Ohio App), the Eleventh District Court of the Ohio Court of Appeals observed that under Ohio Supreme Court Rules, any court is free *233to cite an unpublished opinion from any judicial district within the state. Id. at *2. “While unpublished opinions from another judicial district may not constitute binding authority,” the court continued, “they are commonly cited as persuasive authority and the analysis therein may be adopted by any court where there is no binding authority to the contrary.” Id. The record indicates that plaintiff and his wife lived in the eleventh judicial district when the insurance contract was executed. I have been unable to locate any binding authority from that district addressing the issue under examination. Therefore, like the majority, I will cite as persuasive unpublished opinions from districts other than the eleventh judicial district.

 The plaintiff’s insurance contract defined a preexisting condition as “ ‘an illness, injury, or condition (including maternity) which exists on the effective date of the coverage.’ ” Id. at 48, quoting the insurance contract at issue.

 The onset of the plaintiff’s symptoms and the final diagnosis of the condition were relatively contemporaneous, and both occurred after the insurance policy was executed. Goshom, supra at 47.

 An infiltrate is defined as: “1. To pass into, or invade, a tissue or structure; said of a fluid. 2. The material that has passed into a tissue.” Attorneys’ Dictionary of Medicine and Word Finder, supra, volume 3 at 1-89.

 Like the plaintiff in Karagon, the plaintiff in Mayer had initially been misdiagnosed. Mayer, supra at 649. The Mayer Court concluded that “[s]ince defendant required no physical examination, it took the chance that the plaintiff, not being learned in medicine, would misinterpret his own symptoms or would rely on past erroneous diagnoses made of his condition.” Id. at 650-651.