Merritt Personal Lines Manual: How the Policy Defines Sickness
sickness: Disease or illness which manifests itself while this policy is in force. Sickness includes complications of pregnancy, as defined.
Policies only provide benefits for sickness which begins or becomes evident while the coverage is in force (a sickness that began earlier would be a preexisting condition). Normal pregnancy is not a sickness, but complications of pregnancy are treated as a sickness or disease.
Sometimes disputes over what constitutes an illness or disease can turn a little obscure. In the 1993 decision Anna Bartolina v. Investors Life Insurance Co., a Florida appeals court had to sort through some considerable obscurity.
Bartolina received periodic treatment for asthma beginning in April 1985 and continuing through December 1988. She controlled her asthmatic condition with treatments prescribed by her physician. In April 1989, however, she required hospitalization for treatment of her asthma.
The hospitalization occurred within the preexisting condition exclusionary period of a Life Investors group health plan she'd recently joined. But the two sides didn't agree over whether the reason for the hospital stay counted as a preexisting condition.
Bartolina's doctor said that the need for treatment resulted from heavy environmental pollution from smoke caused by wildfires over the Everglades.
Life Investors refused to cover the hospitalization because it treated a preexisting condition. Bartolina claimed this event had triggered a new condition -- not a preexisting one. She sued the insurance company.
Life Investors pointed to two parts of its policy to defend it refusal of coverage.
First, the policy defined sickness as:
disease or illness, or more than one disease or illness, resulting from the same or related causes or conditions, including all complications thereof and all related conditions and recurrences resulting in medical expense insured under the Policy or otherwise resulting in a claim for benefits while the Policy is in force with respect to the Insured Person for whom claim for benefits is made.
Second, the policy excluded coverage for sickness resulting in medical expenses incurred before the inception of the policy. It included in this exclusion:
expenses incurred in connection with any distinct bodily injury or sickness for which an Insured Person received medical treatment... within the previous twelve months....
This language was unambiguous. The appeals court held that the preexisting condition exclusion of the policy barred coverage for hospitalization caused by her exposure to environmental pollution.
For support, the appeals court cited a 1986 Florida decision, American Pioneer Life Ins. Co. v. Parks. In that case, the court also supported an insurance company's exclusion.
The policyholder had a diseased condition before the inception of policy coverage. She claimed entitlement to coverage, however, "on the basis that [she] suffered no 'sickness' within the contemplation of the policy until she was first made 'sick' by the hemorrhaging of her varices in January 1982."
That court had written:
[T]he record reveals that Mrs. Parks' sickness in January 1982 resulted from her esophageal varices condition which manifested itself within 90 days before the effective date of the policy. The continuing nature of her illness was confirmed by the fact that she was kept on [a therapeutic drug] from June 1, 1981, until she was again hospitalized on January 13, 1982.
As in that case, Bartolina had received medication prescribed by a physician during the preexisting condition period defined by the policy.
"We find Bartolina's external cause argument persuasive, but to find coverage for Bartolina would require us to ignore the express terms of the policy," the appeals court concluded.
termination date: The date on which coverage ends. This date is shown on [the declarations] page.
Coverage ends on the termination date stated in the policy. Usually this is shown at the beginning of the policy in a schedule that also shows the policy number, effective date, names of insureds, benefit amounts and premium.
usual and customary charge: The prevailing charge which is made for the same type of or comparable care by most providers in the area in which the care is furnished.
"Usual and customary charge" is simply a variation of the term "regular or customary charge." Some policies use this alternative language when limiting benefits to the usual or customary charges in the local area, in order to discourage excessive charges for services.
we, our, us: The insurance company providing this policy. In the general provisions we are referred to as the company.
You, your: The owner of this policy. The owner may be someone other than an insured person. In the general provisions the owner is referred to as the policyholder.
Policies often use the personal pronouns "we," "our" and "us" to refer to the insurance company and "you" or "your" to refer to the policyholder. The owner or holder of a policy (the person who initiates the contract and pays the premiums) does not have to be an insured person.
