Following our grant of a discretionary appeal under OCGA § 5-6-35 (a) (1), Robert J. Michna appeals the grant of summary judgment to Blue Cross and Blue Shield of Gеorgia, Inc. (“Blue Cross”). The appeal arises from a suit Michna brought against Blue Cross, his insurer, which had refused to pay a hospital bill he submitted. 1
Michna went to the emergency room, sought treatment, and was placed in a bed
The insurance in question is a limited policy designed to offer catastrophic cоverage. The policy specifically excludes payment for outpatient services in Section 9.1 (1) of the policy. The policy provides benefits for inpatient services and outpatient surgical care. If Michna was an “outpatient,” his stay would not be covered under the policy, but he would be covered if he was an “inpatient.” The terms “outpatient” and “inpatient,” however, are not well defined in the insurance policy.
The hospital’s director of clinical care coordination testified that the services provided to Michna did not include any “inpatient charges.” She also testified that the hospital determined that the services provided were “outpatient mеdical care.” The claim submitted by the hospital to Blue Cross was coded as “outpatient services.” Further, any inpatient admission was requirеd to be “pre-certified” by Blue Cross, and, because the hospital did not consider Michna’s care as inpatient care, it did not ask Blue Cross to pre-certify his admission to the hospital.
In granting summary judgment to Blue Cross, the trial court noted that Michna was not charged for a room and thаt his stay was for less than 24 hours, and that while the terms were not specifically defined in the policy, “inpatient” and “outpatient” were of cоmmon usage among laypeople. Thus, to a layperson, an inpatient “would imply, at the least, that one would be charged by the hosрital for a hospital room.”
“Insurance in Georgia is a matter of contract and the parties to the contract of insurance are bound by its plain and unambiguous terms. [Cit.]”
Hurst v. Grange Mut. Cas. Co.,
construction of contraсts involves three steps. At least initially, construction is a matter of law for the court. First, the trial court must decide whether the language is clear and unambiguous. If it is, the court simply enforces the contract according to its clear terms; the contract alone is looked to fоr its meaning. Next, if the contract is ambiguous in some respect, the court must apply the rules of contract construction to resolve the ambiguity. Finally, if the ambiguity remains after applying the rules of construction, the issue of what the ambiguous language means and what the parties intended must be resolved by a jury. (Cit.)
Schwartz v. Harris Waste Mgmt. Group,
Under our law, when a provision in a policy is susceptible to more than one mеaning, even if each meaning is logical and reasonable, that provision is ambiguous.
Hurst v. Grange Mut. Cas. Co.,
supra
Further, when construing contracts, “[wjords generally bear their usual and common signification; but technical words, words of art, or wоrds used in a particular trade or
Article 3.3 (1) of the policy provides:
3.3 Covered Hospital Inpatient Services This individual direct pay policy is designed to offer you catastrophic coverage. It pays for covered Hospital inpatient care and surgеry and selected outpatient services related to inpatient Admissions. Strict limitations apply to Covered Services. For examplе, this Contract does not cover outpatient medical care including Physician office visits, prescription drugs, nervous and mental carе, maternity care, Physical Therapy, durable medical equipment and many other services. Exclusions are explained more fully in Article 9.
In Artiсle 11.1 (Hospital Inpatient Benefits) defining the “Conditions Under Which Benefits Shall Be Rendered,” the policy states:
[Hospital inpatient] benefits arе available only if you are admitted as a bed patient to a Hospital on the order of a licensed Physician. You must be under the cаre of this Physician. The Physician must be a member of the staff of, or acceptable to, the Hospital where you are a patient. Thе service which you get at a Hospital is subject to all the rules and regulations of the Hospital which you or your Physician selects. Such rules аlso control Admission policies.
Although this reference to “bed patient” is probably obsolete, the phrase is not entirely relevant tо disposition of the case. The key question is whether Michna was admitted to the hospital as a patient. The trial court considered evidence as to the customs and practices of the hospital and insurance businesses, both of which viewed a hospital stay of less than 24 hours to be an “outpatient” visit, and granted summary judgment to the insurance company, concluding that Michna was an “outpatient” and not an “inpatient.” Under the contract language, the correct path to determining whether Michna was an “inpatient” is to determine whether he wаs admitted to the hospital, and he was not.
“Competent parties are free to choose, insert, and agree to whatever provisions they desire in a contract... unless prohibited by statute or public policy. [Cit.]”
Simmons v. Select Ins. Co.,
Therefore, even though Michna remained at the hospital for an extended period he was not admitted to the hospital, and the trial court did not err by granting summary judgment to Blue Cross.
Judgment affirmed.
Notes
An application was required because the case originated in magistrate court and was appealed to the superior court.