Court Opinion

ID: 9705195
Source: CourtListenerOpinion
Date Created: 2023-08-26 00:59:38.480936+00
Date Added: 2024-06-11T18:22:08.836994
License: Public Domain

PEDERSON, Justice,
dissenting.
The only questions in this case are (1) whether the language in Article II(I)(l)(d) is ambiguous and (2) whether a person who has a full-coverage Blue Cross policy is entitled to the reasonable expectation that should he fall and be injured his ambulance and hospital expenses will be paid by Blue Cross.
Article II(I)(l)(d) states: “The Member shall not be entitled to any item of Hospital Service . . . for . . . any . . . injury arising out of and in the course of employment for which Benefits are available in whole or in part under the laws of the United States or any State or political subdivision thereof.”
A statement is ambiguous when: it admits of two or more meanings, it is capable of being understood in more than one way, there is uncertainty of meaning or significance or of position in relation to something or somebody else, or it is possible to maintain two or more logically incompatible beliefs or attitudes at the same time or alternately. See, Webster’s Third New International Dictionary, Unabridged, 1971.
*898“An ambiguity exists when good arguments can be made for either of several contrary positions as to the meaning of a term, . . .” Kruger v. Soreide, 246 N.W.2d 764, 768 (N.D.1976).
See also, In re Estate of Johnson, 214 N.W.2d 112 (N.D.1973), and In re Tonneson’s Estate, 136 N.W.2d 823 (N.D.1965).
One could make a good and logical argument that the quoted Blue Cross policy provision excludes everyone who is self-employed, whether or not they have elected to carry self-employed workmen’s compensation coverage — because benefits are available under the Workmen’s Compensation Laws of North Dakota for all self-employed persons who have not been refused under § 65-07-02, NDCC. It is likewise possible to reach the completely opposite conclusion that, because Ranes was a voluntary participant in workmen’s compensation coverage, the benefits available to him are not under the laws, but pursuant to a private contract. The ambiguity is obvious.
The majority relies upon a statement found in Tennefos v. Guarantee Mutual Life Co., 136 N.W.2d 155, 157 (N.D.1965), that “the language should not be strained in order to impose liability [upon] the insurer.” To place that quotation in its proper context, the “language” referred to was the word “or.” The word “or” was present in an exclusionary clause, and the appellant in that case sought to read the exclusionary clause without that crucial conjunction. The quotation from Tennefos is good law, but is simply not a proper comment in the instant case.
The ambiguity ought to have a significant relationship to the circumstances of the case before us before we arbitrarily declare that the exclusion is ineffective. Thus an ambiguity that couldn’t possibly mislead anyone, or couldn’t possibly be the basis for a misguided, reasonable expectation, should be ignored. In this case the ambiguity is significant and relates directly to the problem at hand. Under the theory of the majority or minority in Mills v. Agrichemical Aviation, Inc., 250 N.W.2d 663 (N.D.1977), Blue Cross should pay for the hospital costs incurred when Ranes was injured.
The fact that payment by Blue Cross would lead to a double recovery can be no bar to this decision. Certainly Blue Cross may, by contract, prevent such a result with a properly drawn clause of exclusion or subrogation. Here, in an attempt to exclude too much, Blue Cross succeeds in excluding nothing.
Although the argument of the majority is based on Article II(I)(l)(d), two other portions of the policy are described as “relevant,” and as expressing “a clear intent to prevent an insured member from receiving double coverage.” Those two portions are quoted in the majority opinion. They are more properly read as reflecting an intent to prevent an insured member from receiving double coverage in certain circumstances. Those circumstances are not present in this case.
The first provision, Article 11(H)(1), says that the limitation applies only “if a member is eligible for Benefits under any other group, blanket or franchise plan, . . . ” and, if so, benefits under the Blue Cross and Blue Shield contracts “will be coordinated according to regulations established by the North Dakota Insurance Commissioner.” The evidence in this case was by stipulation, and contains nothing as to any coordination under regulations of the Insurance Commissioner. More importantly, the policy under which Ranes claims benefits is not a “group, blanket or franchise plan” — it is an individual contract of a self-employed person with the Workmen’s Compensation Bureau. Therefore, by its own terms, the “Coordination of Benefits” provisions of the policy cannot be applied to the facts before us. See § 26-26-15, NDCC.
The second extraneous policy provision cited by the majority opinion as relevant is that which excludes payment “to the extent a Member is entitled to such Benefits from . any state agency.”
The benefits claimed by Ranes are claimed under a private contract between-him and a state agency, the Workmen’s *899Compensation Bureau. He made an individual contract with the Bureau, as a self-employed person, a contract which he could not demand as a right and which the Bureau could have declined to enter into. Chapter 65-07, NDCC. The parties entered into a contract which adopted the schedule of benefits of the Workmen’s Compensation Bureau as the amounts to be paid in case of injury. The benefits payable in case of injury were therefore due because of contract, not state law. If such payments are payable because of state law, so are the payments from any private life or accident insurance company, since they are licensed by the state and are required, under state law, to comply with their voluntary contracts. The judgment should be reversed.
Vogel, J., joins this dissent.