Published on:

Court Decides if Insurance Co. Liable in Hospital Mishap


The wife of the complainant went to a Hospital where she had a normal delivery of a child and she remained for five days at which time she and the infant were discharged.

The facts further indicate that the child was born with a right congenital hernia. In the best interest of the infant’s health, the operation was postponed for three months. A New York Injury Lawyer said that at that time, herniotomy was performed at another Hospital and the child was discharged after three days.

The services of the hospital and doctors during the confinement of the woman and her child amounted to $474.90 and the expenses incurred for correcting the hernia amounted to $288.00.

The insurance forwarded to the complainant two checks, one in the amount of $179.92 and the other for $30.40. These sums were arrived at in the following manner: $474.90 less $250.00, the deductible amount, leaving a balance of $224.90 of which $179.92 or 80% was paid for the confinement; $288.00 less $250.00 the deductible amount, leaving a balance of $38.00 of which $30.40 or 80% was paid for herniotomy.

The husband of the woman rejected both of the checks claiming that under the provisions of the policy there should be but one deductible amount applied to all the charges. A Suffolk County Personal Injury Lawyer said the husband contends, however, that the bills involved two separate charges and it was, therefore, proper to apply the deductible amounts to each one separately.

The provisions of the policy of insurance provide that when deductible amount shall apply separately to each insured family member, and to each accident or sickness, except that only one deductible amount shall apply as well as to all charges incurred as a result of childbirth, including charges incurred for the infant, until and including the fourteenth day after the date of such birth.

The law is established that when an insurance policy contains ambiguities, they must resolve against the insurer as the party who drafted the instrument. A Westchester County Personal Injury Lawyer said the meaning to be given to a contract of insurance must be the meaning that the ordinary business man must give it.

A contract of insurance is to be construed according to the sense and meaning of the terms used, which if clear and unambiguous, are to be understood in their plain, ordinary, and popular sense. However, if there is any ambiguity the provision will be construed most strongly against the insurer, and in favor of the insured.

When uncertainty and doubt arise from policy language susceptible of more than one meaning, we may adopt the oft-quoted but seldom decisive formula of resolving all ambiguity against the insurer.

The law is well established, and the cases too numerous to cite sustaining the principle, that if there is any doubt as to the meaning of its terms, the language in the policy of insurance should be given the meaning most favorable to the insured.

When reasonable men on reading the terms of an ambiguous insurance contract would honestly differ as to its meaning, the doubt should be resolved against the company and if the company desires to exclude from its general coverage or limit its liability, it has the responsibility of wording it in clear and unmistakable language so that no average person can be misled.

Contracts are to be interpreted in the light of the language which we commonly use and understand; in other words, our common speech. Such at least should be the rule applied to the interpretation of the policies, and which sometimes referred to as a liberal construction.

In seeking to ascertain the scope and meaning of the provision of the policy, a charge shall be deemed to be incurred as of the date of the service or purchase giving rise to the charge, we ascribe to it the ordinary and popular meaning, importing the construction that would be given it by the average assured when he purchased the policy.

In rejecting the claim of the insurance company that the use of the phrase expenses incurred, as used in the policy, meant expenses of services that had already been rendered or performed within one year from the date of the accident, the court held that the insurer was liable for all reasonable expenses for repairs of the child’s injuries, whether the services correcting them were or were not performed within one year from the date of the accident.

The case held that Incurred means to become liable for, or subject to, to render liable or subject to; incur means something beyond contract, something not embraced in the word debt. In actions for injuries, recovery may be had for amounts shown to have been expended or incurred for hospital bills and medical treatment, provided such damages are properly pleaded; incurred means to become liable for.

In support of its conclusion, the court said that a debt has been incurred when liability attaches, and that a contingent promise to pay has been incurred when the contingency upon which the payment depends occurs, so that the insurance company became liable for all reasonable expenses caused by the accident on the day it occurred.

Viewed in their context and applied to the instant facts, we think the words ‘giving rise to the charge’ were intended to refer to the occurrence of the event giving rise to the claim of liability and not to the accrual of liability. This conclusion gives the contract a fair and reasonable interpretation and will not lead to harsh and unreasonable results.

It is not uncommon that an accident insurance policy which was in force at the time the insured suffered an accidental injury terminates while medical treatment or hospitalization are still being furnished to the insured. In such cases it is submitted that the view which is supported by the closely reasoned cases is that the liability of the insurer for medical expenses continues even after the termination of the policy. The viewpoint is based upon the theory that all claims under an accident policy originate at the time the compensable accident occurs.

It is stated when an accident policy is in full force and effect when insured sustains an accidental injury, the cause of action arises immediately, regardless of whether the policy is kept alive by subsequent payment of premiums, and he is entitled to recover the full amount of indemnity provided.

The apparent purpose of the clauses in question was to compensate the policyholder for charges incurred as a result of childbirth, including charges incurred for the infant, until and including the fourteenth day after the date of such birth. The sense and meaning of the words used indicate that the charges were incurred at the time when the claim of liability arose. The claim originated when the congenital hernia was discovered in the infant and it was well within the fourteen day period referred to in the policy. The fact that the medical expenses for the correction of this condition continued and extended beyond that time limitation did not acquit the accused from its responsibility of treating the expense as part of the charge of childbirth. The view seems to be supported by the authorities and there was unquestionably a continued service of required medical treatment which was uninterrupted and unbroken, except for the postponement of the operation required for the best interest of the infant’s health.

It follows therefore, that the complainant is justified in his claim. Accordingly, the court finds that the confinement of the wife and the confinement of the infant are to be considered as one charge. From the amount will be subtracted the deductible amount leaving a balance of which the accused is to pay 80%. Judgment is granted to the husband of the wife against the insurance provider.

Insurance policies promise us assistance and help when we need them but most of the time, they do otherwise. If you have been declined of insurance coverage during hospitalization, or have suffered from medical malpractice, feel free to consult a NY Injury Lawyer or New York Medical Malpractice Attorney from Stephen Bilkis and Associates.

Contact Information