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Olivero v. Horace Mann Mut. Ins. Co.

FEBRUARY 17, 1964.

CARLO F. OLIVERO, PLAINTIFF-APPELLEE,

v.

HORACE MANN MUTUAL INSURANCE COMPANY, A CORPORATION, DEFENDANT-APPELLANT.



Appeal from the Circuit Court of Bureau County; the Hon. WALTER DIXON, Judge, presiding. Affirmed in part reversed in part and remanded.

SCHEINEMAN, J.

This is an appeal by defendant from a judgment in the amount of $1,052.15 in favor of plaintiff in an action to recover hospital expenses and surgical costs under the provisions of a health and accident insurance policy.

The policy contains a table entitled HOSPITAL BENEFITS setting forth the maximum amounts payable for specific number of days confined to the hospital up to a total of 20 days and a further payment of $9 per day from the 21st day through the 365th day. There was also a surgical expense endorsement entitled SCHEDULE OF OPERATIONS, which lists the following items:

Maximum Tissue Repair $112.50 Varicose Veins (bilateral) 112.50 Maternity Care, Obstetric Delivery 90.00

There was also a rider attached entitled FAMILY HOSPITAL EXPENSE RIDER WITH MATERNITY BENEFITS, and provided:

"Under this rider, obstetrical cases shall be covered after 10 months from the effective date of this rider. Indemnity payable for hospitalization as the result of pregnancy or childbirth shall be limited to 10 days."

It is not disputed that the plaintiff was hospitalized for 4 days, November 1 to November 5, 1959, for pregnancy at term and that she delivered a baby and was discharged. She returned to the hospital November 7, 1959, because of thrombophlebitis. Because of this ailment she was in the hospital continuously for 48 days and was then discharged. The defendant refuses to pay any of the hospital or medical bills for this 48-day period, on the ground the policy did not apply. The plaintiff then filed this suit.

The defendant takes the position that the illness of the plaintiff at her second hospitalization was the result of pregnancy and that the maternity benefit rider excluded coverage for that condition. The first contention is based upon the testimony of a doctor called by defendant who gave an opinion that there was a direct relationship between her existing infirmity and her delivery on November 1, 1959. On cross-examination he was asked whether he would say her infirmity could not have come from many other sources. He answered, "No, I will say that she could have gotten it from another source." The deposition of her treating physician introduced by agreement of counsel shows it is very doubtful that the thrombophlebitis was connected with the pregnancy and delivery.

The treating physician who had delivered of her, three babies, over a period of time, said she never had any indications of thrombophlebitis, and moreover, while that disease may result from pregnancy, it would usually be below the knee. In her case it was above the knee, and it is apparent from this testimony that it is rather unlikely to be caused simply by the delivery of a child.

The main argument for the defendant is that the thrombophlebitis was the result of the pregnancy and apparently regards that as settling the case.

This overlooks the wording of the maternity benefit rider. The limitation as stated is "Indemnity payable for hospitalization as the result of pregnancy or childbirth shall be limited to 10 days." The ordinary meaning of these words would be that coverage was provided if she went to the hospital for childbirth or for a stillbirth. There is no statement that any and all after effects that may arise as a result of pregnancy will also be excluded, and we do not regard that interpretation as a reasonable inference. If that is what the policy intended, it could have said so.

In the interpretation of words in an insurance policy, it is the usual rule that the terms will be taken and understood according to the plain and generally accepted meaning. Moscov v. Mutual Life Ins. Co. of New York, 387 Ill. 378, 56 N.E.2d 399; Pioneer Life Ins. Co. v. Alliance Life Ins. Co., 374 Ill. 576, 30 N.E.2d 66.

On the other hand: "Ambiguous provisions or equivocal expressions whereby an insurer seeks to limit its liability will be construed most strongly against the insurer and liberally in favor of the insured." Lenkutis v. New York Life Ins. Co., 374 Ill. 136, 28 N.E.2d 86.

This citation was quoted in Mosby v. Mutual Life Ins. Co. of New York, 405 Ill. 599, 92 N.E.2d 103. The court added: "This is a sound rule. It recognizes the realities of the transaction, that is, that the provisions of an insurance policy are not the product of negotiations between the insurer and insured but are written by the insurance company and out of necessity, perhaps, submitted for acceptance without change. ...


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