Court Opinion

ID: 9649454
Source: CourtListenerOpinion
Date Created: 2023-08-23 14:54:06.314695+00
Date Added: 2024-06-11T18:12:11.017188
License: Public Domain

POPOVICH, Judge,
concurring:
I concur with the result reached by Judge Montemuro, but I do so by a different route.
*215As stated most recently by our Supreme Court in Standard Venetian Blind Co. v. American Empire Ins. Co., 503 Pa. 300, 469 A.2d 563 (1983), the interpretation of insurance contracts is governed by general principles of contract law, i.e., the ascertainment of the intent of the parties is to be garnered from the written agreement, with any ambiguities in the policy being construed in favor of the insured.
Application of the aforestated precepts requires the conclusion that the insured has satisfied the terms of the policy so as to entitle her to sue the insurer for its breach.
It is the insurer’s position that the agreement at issue merely requires that the insured be reimbursed for monies expended by her in the securement of health care services covered under the terms of the policy of insurance. Therefore, the insurer would have us endorse the position that, absent the insured’s pre-payment of the health care costs, the insured is foreclosed from suing for the failure to establish “damages”. As stated by the insurer, it has not “agreed to indemnify [the insured] for medical expenses [she] incurred." (Appellee’s Brief at 6; emphasis added).
I would offer that the terms of the health care agreement themselves counsel against such a conclusion. Specifically, Article III. (Conditions), Paragraph J reserved to the insurer “the right to make payments to the [insured] toward expenses incurred for Allowed Services in accordance with the intent of and in accordance with the provision of the Subscription Agreement.” (Emphasis added)
Based on the reasonable inferences to be drawn from the aforementioned paragraph, the insurer obligated itself to make payments to or on behalf of the insured by her mere incurrence of an expense with a health care provider. See Standard Venetian Blind Co., supra. Further, there is no stipulation anywhere in the policy that the insured has to actually pay for the services performed as a sine qua non to holding the insurer liable for payment of the cost related thereto. If this were the case, as noted quite aptly by counsel for the insured in his brief to us, the purpose for *216which the insurance was purchased would be vitiated by having to, initially, come up with the monies to pay for a service for which the insurance was specifically purchased to avoid. Conjure this circumstance: A claimant incurs the cost of medical services well beyond his means to pay. Yet, despite having insurance to cover the cost of said services, under the insurer’s theory he would initially have to satisfy the cost out of his own pocket. The exact reason he secured insurance was to guard against this. If he could afford to defray the cost why should he bother to pay for insurance. The circumstance is reminiscent of a “Catch 22”.
Even under Paragraph G of Article VIII., the insurer restricted the insured’s right to bring a suit at law or in equity for any hospitalization expense for services rendered within two years thereafter. Again, no mention is made to the insured’s (pre)condition of payment for said expenses prior to instituting suit. From my reading of the policy as a whole, the insured need only incur an expense from a health care provider to trigger the implementation of the policy of insurance. The topic of “coverage” is resolved subsequent to the initial incursion of the liability/debt by the insured.
In only one instance does the insurer have the option to pay the insured, as compared to the health care provider, and that is when services have been performed by a “NonParticipating Health Care Institution”. Article I. (Definitions), Section 1, Paragraph D.
The point to be made is that the insurer’s calling for the insured’s pre-payment of the hospital bill would be counter to its own policy provisions which restrict such payment to a non-participating hospital, and the health care provider at bar (Magee Women’s Hospital) is not in this classification.
Lastly, if the insurer is fearful of being exposed to multiple suits and double liability from the health care provider (the two have a separate agreement establishing their relationship for reimbursement for services rendered) if the insured were to recover but did not, in turn, pay the *217hospital, its recourse would be to interplead under the Pennsylvania Rules of Civil Procedure 2301 et seq.