Bodziony v. Blue Cross & Blue Shield of Kansas City
2011 Mo. App. LEXIS 155
Mo. Ct. App.2011Background
- Bodziony, a long-time firefighter, had a work-related left shoulder injury requiring surgery in 2004 while insured by Blue Cross.
- Blue Cross initially paid medical bills, then revoked payments after learning the injury was work-related and tied to a workers' compensation claim.
- Bodziony filed a workers' compensation claim; the City and insurer stipulated a 16% permanent partial disability with an award, but past medical expenses dispute remained.
- An ALJ ruled the medical expenses were not covered by Chapter 287 R.S.Mo due to lack of timely notice to the employer.
- Blue Cross denied coverage on grounds the injuries were job-related and excluded from coverage regardless of workers' compensation reimbursement or claim status.
- Bodziony sued for breach of contract, vexatious refusal to pay, and specific performance; the trial court granted summary judgment in Blue Cross's favor.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the policy exclusion is ambiguous and favors Bodziony. | Bodziony argues the exclusion language is ambiguous and should be construed in his favor. | Blue Cross contends the exclusion unambiguously bars coverage when injuries are covered or required to be covered by workers' compensation. | Exclusion is ambiguous; policy must be construed in Bodziony's favor. |
Key Cases Cited
- Burns v. Smith, 303 S.W.3d 505 (Mo. banc 2010) (defines ambiguity and contra proferentem in insurance contracts)
- Hunt v. Hospital Service Plan of New Jersey, 162 A.2d 563 (N.J. 1960) (two reasonable readings of 'compensable' for coverage; favors insured when ambiguous)
- Walters v. State Farm Mutual Automobile Insurance Co., 793 S.W.2d 217 (Mo. App. S.D.1990) (interpretation of 'payable' in workers' compensation context)
- Gen. Motors Corp. v. Buckner, 49 S.W.3d 753 (Mo. App. E.D. 2001) (definition of 'payable' in context of compensation)
- Hines v. Blue Cross Blue Shield of Virginia, 788 F.2d 1016 (4th Cir. 1986) (illustrative exclusion framework in BCBS context)