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Erickson v. Hospital Service Corp.

JULY 3, 1964.




Appeal from the Municipal Court of Chicago; the Hon. L.L. WINN, Judge, presiding. Judgment affirmed in part and reversed in part and cause remanded with directions. MR. JUSTICE BRYANT DELIVERED THE OPINION OF THE COURT.

This is an appeal from a judgment of $277.30 entered against the defendant, Hospital Service Corporation, on February 18, 1963, in the Municipal Court of Chicago; and from a judgment of $61 entered against the defendant, Illinois Medical Service, on February 18, 1963, in the Municipal Court of Chicago. Claims for interest were denied in each case. The defendants are commonly known as Blue Cross and Blue Shield respectively. Both judgments were in favor of plaintiff, Marian Erickson; and since both judgments arise out of claims associated with the same illness, the cases have been consolidated.

We are called upon to determine whether plaintiff received "hospital service" within the meaning of and as defined in her Blue Cross certificate, and, again, whether Miss Erickson received "general medical care" in a hospital as defined by her Blue Shield certificate. The pertinent section of the Blue Cross certificate reads:

"I(o). `Hospital service' means receiving a member who has been referred by a physician into a Plan hospital only as a bed patient in a room containing accommodations for two, but not more than four, bed patients, if available, and providing care for all types of cases, whether acute, chronic or pre-existing conditions, when necessary to and concurrent with service for conditions requiring and receiving hospital bed care. It includes such service during the basic and supplemental periods, provided the member is under the care and treatment of a physician and as long as the physician declares that such service is necessary . . ." (Emphasis supplied.)

The pertinent section of the Blue Shield certificate reads:

"III(C)(1) If the medical treatment of a beneficiary shall require, and such beneficiary shall receive, three or more consecutive days of hospital bed care, the Plan will pay the attending participating physician the amount of his fee for each visit limited to one visit per day, . . ." (Emphasis supplied.)

Plaintiff, Marian Erickson, suffered from acute rhinitis for which she had been unsuccessfully treated by her physician, Dr. Randolph, for fourteen years. Acute rhinitis is a nasal condition marked by acute congestion of mucous membrane of the nose, dryness, increased mucous secretion, impeded respiration and some pain. On July 9, 1959, Dr. Randolph found the rhinitis condition unchanged and discovered that there was almost complete nasal obstruction, plaintiff only occasionally being able partially to breathe through one side of her nose. Under the direction of Dr. Randolph she was admitted to Swedish Covenant Hospital on August 2, 1959, where she remained until August 19, 1959. Treatment during this period consisted of a five-day fast, during which she was allowed only spring water to drink and salt in moderation, but no foods. Following the fast, she was given one food at a time and observed for evidence of reaction. After being tested with fifteen foods in the order of probability associated with rhinitis, she was given a diet of uncommon foods selected from the market because of their known content of insecticide residues and other chemical additives and contaminants. As a result of these tests Miss Erickson was advised to avoid foods that are notoriously chemically contaminated by spray residues or phenolic resin lining of tin cans, fumigated foods, and other chemically contaminated foods. Miss Erickson's condition has improved since her hospitalization.

Dr. Randolph believed that hospitalization was required in order to obtain controllable environmental factors. Treatment on an out-patient basis had in the past been largely unsuccessful. It was also required because acute emergencies sometimes arise in the course of fasting, with nausea and vomiting occurring in about ten per cent of the patients and with one-half of these cases requiring intravenous feedings. Other reactions which Dr. Randolph testified were common in testing of this nature were dehydration, tendencies to become stuporous, passing out, asthma, hives, eczema, headache and depressions.

Defendants offered no evidence oral or documentary before the lower court. On appeal they urge that during Miss Erickson's stay in the hospital she received none of the services commonly understood to be components of "bed care." She was able to walk about as she pleased; care for her own personal hygiene; took and recorded her own pulse; and did not receive any medications.

The key to appellants' argument concerns the definition of "hospital service" under the Blue Cross certificate. This in turn depends upon the meaning of "bed patient" and "bed care" as used in the definition. No case has defined these terms. Appellants suggest that the term "confined to bed" has been defined and that we should adopt that definition by implication.

In Lewis v. Liberty Industrial Life Ins. Co., 166 So. 143 (La, 1936), a case in which the curatrix of an insane woman sought to collect disability insurance for a period during which she was confined in a state hospital, the court had occasion to define the term "necessarily confined to bed." In determining that the present disability was outside of that term, the court said at 145:

"Ruling Case Law, vol 14, p 1318, reads: `A requirement that the insured be confined to his bed also means that the insured must be substantially bed-ridden.'"

"In the instant case the insured has at no time been confined to her bed as a result of her affliction. . . ."

In Interstate Life & Accident Co. v. Spurlock, 16 Tenn. App. 250, 64 S.W.2d 75 (1933), where a blind man attempted to recover under a policy providing "by reason of illness necessarily confined to bed," the court in denying liability stated the following at 78:

"In the policy in the case at bar it is provided that weekly benefits for sickness, where `the insured has been, by reason of illness, necessarily confined to his bed and there visited professionally by a duly licensed and practicing physician,' shall be paid by the company. Under this provision, three things must concur to enable the insured to recover: (1) Illness, (2) confinement to the bed, and (3) there be visited professionally by a physician. By no stretch of the imagination can it be said that plaintiff was confined to his bed. To come within the ...

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