Court Opinion

ID: 9487210
Source: CourtListenerOpinion
Date Created: 2023-08-05 12:11:08.486196+00
Date Added: 2024-06-11T17:52:09.253377
License: Public Domain

K.K. HALL, Circuit Judge,
dissenting:
According to Dr. Phillips-Seitz, “we were lucky to have found this elongated ropey mass ... because otherwise we wouldn’t have noticed the cancer.” Today the majority turns Mrs. Hardester’s luck into the insurance companies’. There are times when the law compels such an unjust result, but not this time. I dissent.
I.
Plaintiff Barbara Hardester was diagnosed with fibrocystic breast disease in 1982. This “disease” is wholly benign, and is common in women in their thirties and forties. A woman suffering from fibrocystic disease will develop cysts, masses, and other accumulations of fibrous tissue in her breasts. Fibrocystic disease is not cancer, and does not develop into cancer; indeed, it does no damage to the woman’s physical health at all.
On April 6, 1992, Mrs. Hardester had her annual gynecological examination. Her gynecologist, Dr. Phillips-Seitz, noted fibrocystic changes from the previous year in both breasts and an “elongated ropey mass” in the left breast. As she always did when she noted any new manifestation of the fibrocystic disease — indeed, as she had the previous year — Dr. Phillips-Seitz referred Mrs. Har-dester to a surgeon, Dr. Boyle, for follow-up.1
Dr. Boyle saw Mrs. Hardester on May 1, the day she first became insured under the policy. Dr. Boyle diagnosed fibrocystic disease as well. In addition, because of the fibrocystic changes and because it had been more than a year since Mrs. Hardester’s last mammogram, Dr. Boyle ordered a mammogram. The mammogram, performed May 7, was negative.
Mrs. Hardester returned to Dr. Boyle on May 15 as a follow-up to the mammogram. Because mammograms are less accurate for women with dense fibrous breast tissue, Dr. Boyle recommended a biopsy of the mass in the left breast. The “elongated ropey mass” was removed on May 26, and the results of a biopsy were returned on June 3. Most of the mass was fibrocystic tissue; however, it contained a small (9 mm across) malignant carcinoma. That the fibrocystic “ropey mass” happened to encase the unrelated cancer had saved Mrs. Hardester’s life. Dr. Phillips-Seitz explained, “we were lucky to have found this elongated ropey mass ... because otherwise we wouldn’t have noticed the cancer. If she had simply had this tiny cancer in her breast, we wouldn’t have felt it.” Dr. Boyle likewise described the cancer as merely “coincident” with the fibrocystic disease, ■with no causal connection.
Though the carcinoma itself was removed before it was even discovered, Mrs. Hardes-ter had to undergo chemotherapy to prevent recurrence of breast cancer. Lincoln National and Employers Health have refused to pay for this vital treatment because they assert that the cancer was a “preexisting condition” under the policy. After she exhausted the companies’ internal remedies, Mrs. Hardester, along with her husband (the *338named insured), filed this suit in district court. The district court conducted a de novo review of the record, found that Mrs. Hardester’s breast cancer was not a “preexisting condition,” and ordered the insurance companies to pay. Hardester v. Lincoln National Life Insurance Co., 841 F.Supp. 714 (D.Md.1994).
The insurance companies appeal.
II.
Review here, as in the district court, is de novo. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 956-57, 103 L.Ed.2d 80 (1989). In interpreting the policy, we apply ordinary principles of contract law. Glocker v. W. R. Grace & Co., 974 F.2d 540, 544 (4th Cir.1992). These principles require us to enforce the policy’s plain language in its ordinary sense and to construe ambiguous terms against the drafter if they are not clarified by extrinsic evidence of the parties’ intent. Id.
For the first year following the effective date of coverage, the insurance policy at issue does not cover a “preexisting condition”:
a Sickness or Bodily injury for which You have received medical attention (care, treatment, services, medication, diagnosis or consultation) prior to [the effective date].
A “Sickness” is
a disturbance in the function or structure of Your body which causes physical signs and/or symptoms and which, if left untreated, will result in a deterioration of the health state of the structure or system(s) of Your body.
I agree with the district court that Mrs. Hardester’s breast cancer was not a “preexisting condition” under these clauses. The medical record shows that Mrs. Hardester went for a routine annual gynecological exam and received a routine referral to a surgeon for followup on the new manifestations of her fibrocystic disease. She received absolutely no “care, treatment, services, medication, diagnosis or consultation” for the tiny carcinoma in her breast before the effective date of the policy.
Lacking evidence, the insurance companies resort to distortion of the record and of the district court’s opinion. Their most pervasive gimmick is to absolutely ignore a fact undisputed in this record — the large ropey fibrocystic mass and the small carcinoma were merely, and luckily, coincident. From the very beginning of their briefs “Statement of the Case,” the insurance companies refer to “the mass” as if a single condition were involved.2 Through this distortion, the companies are then able to make arguments that “the mass” had “caused physical signs or symptoms” and had received “medical attention” before the effective date of the policy. The companies have convinced the majority to look at the ease this way,3 but they have not convinced me.
Most of “the mass” was just what Dr. Phillips-Seitz thought it was — benign fibrous tissue. The tumor, on the other hand, would not have been palpable to Dr. Phillips-Seitz 4 but for the “lucky” happenstance that it was encased in unrelated benign tissue. The tumor had not caused any noticeable physical change or symptom in Mrs. Hardester before the effective date of the policy, and it had not received any medical attention.
The best way to illustrate is to hypothesize a woman precisely like Mrs. Hardester except that she did not suffer from fibrocystic disease. On April 6, she would have had a routine, normal breast exam; because the *339tumor was too small to be felt, she would not have been referred to Dr. Boyle for followup, and may not have had a mammogram or biopsy for several months or years. When she was finally diagnosed with cancer, could the insurance companies assert that she had received “medical attention” for her cancer on April 6? Of course not. Why, then, should the result be any different just because Mrs. Hardester had a benign, unrelated condition that was treated on April 6 and that, through sheer luck, led to the timely discovery of her cancer? The answer is simple: it should not make any difference.
I reiterate: according to the undisputed medical record, there was no causal or associative relationship between the fibrocystic tissue and the carcinoma. What if Dr. Boyle’s follow-up had uncovered cancer in Mrs. Hardester’s other breast, and nothing but fibrocystic tissue in the “elongated ropey mass?” Could the insurance companies assert that she had received “medical attention” for cancer on April 6? I would hope that all persons of good will would answer, “Of course not.”5 Why, then, should the result be any different just because Mrs. Hardester had a benign, unrelated condition that was treated on April 6 and that, through sheer luck, led to the timely discovery of her cancer? The answer is simple: it should not make any difference.
The companies’ best case is Bullwinkel v. New England Mutual Life Insurance Co., 18 F.3d 429 (7th Cir.1994). Bullwinkel involved, as the companies wish this case did, a single, suspicious “lump,” discovered just before the effective date of the policy. The doctor felt at the time that “the lump” was more likely than not benign, but he was concerned about “the possibility” of cancer, The lump was later removed and was found to be malignant. The Seventh Circuit held that the cancer was preexisting, and that the lack of a definite diagnosis was irrelevant.
I am not sure that I agree with Bullwink-el, but I can say that it is easily distinguishable from this case. Here, the cancer was discovered in the course of treating an unrelated manifest condition, while in Bullwinkel the only issue was whether the manifest condition was or was not malignant. In other words, the cancerous lump was discovered before the effective date in Bullwinkel; here, the cancerous lump was discovered after the effective date.6
Finally, the companies assert that Judge Motz “held” that applying a preexisting condition clause to an undiagnosed condition would violate public policy. He did no such thing. He held that Mrs. Hardester’s cancer was not preexisting under the clause at issue, and, because “the case can be decided on its own narrow facts[,] I need not decide the broader question which it poses.” Judge Motz then went on to question whether public policy would permit the enforcement of a preexisting condition clause, like the one here, that wholly dispenses with a requirement that the patient know (or have reason to know) of his condition on the effective date of the policy. He quoted an Illinois case: “ ‘to consider a disease to exist at a time when the victim is blissfully unaware of the medical “seeds” visited upon his body, is to set a trap for the unwary purchaser of health insurance policies.’” 841 F.Supp. at 716 *340(quoting Mutual Hospital Ins., Inc. v. Klapper, 153 Ind.App. 555, 288 N.E.2d 279, 282 (1972)). I share the concerns of Judge Motz, but, just as he resolved the case in Mrs. Hardester’s favor on the terms of the clause, so also would I.
I respectfully dissent.

. At her deposition. Dr. Phillips-Seitz testified that she refers “anybody with a fibrocystic condition" to a surgeon, but that those referrals uncovered latent breast cancer less than five percent, "maybe one percent” of the time. Where Dr. Phillips-Seitz actually suspects cancer, she refers her patient to a surgeon within a day, rather than the several weeks for an ordinary referral.

. E.g., under "Nature of the Case,” the companies assert:
The gynecologist erroneously believed the mass was benign. One month after the effective date, the breast mass was conclusively diagnosed as cancerous.

. See supra at 334-35, where the majority applies the policy's preexisting condition test to "the mass” rather than to the cancer.

. The majority cites Dr. Boyle's deposition testimony (supra at 356) in an attempt to show that, perhaps, the carcinoma itself was palpable. I see no relevance in what Dr. Boyle felt or did not feel after the effective date of the policy. Dr. Phillips-Seitz stated that she could not have felt the tiny cancer on April 6, which is the only possible date the cancer could have received "medical attention” before the policy went into effect.

. Nonetheless, the logical extension of the insurance companies’ argument here would call for a contrary answer. According to their brief, any referral for testing motivated by a desire to rule out breast cancer is "medical attention” for cancer under the Plan. This argument badly distorts the manner in which preventive care is administered to women in this country. Every woman must be concerned about and take precautions against breast cancer. Physicians like Drs. Phillips-Seitz and Boyle order mammograms and other diagnostic tests routinely, not because the risk to any single woman is very great, but because the risk is there in every woman, and the consequence of not taking routine precautions is so dire. A doctor who ignores a one percent risk of death present in all of her patients can be assured that several will die eveiy year. On the other hand, the dead patients' insurance companies would not have any “precautions” to point to as evidence of a “preexisting” condition. Excuse me for using the law’s most hackneyed literary allusion, but a medical insurance system that covers only well persons and those sick persons who have not vigilantly monitored their health makes sense only if viewed through the looking glass.

. My comment on Kirk v. Provident Life and Accident Insurance Co., 942 F.2d 504 (8th Cir.1991), is simply that I agree with Senior Judge Bright's dissent in that case. Id. at 506-508.