*1
WARDLOW,
KALI
BETTY L.
Appellant,
v.
OF
SPELL GENERAL HOSPITAL
BLUE CROSS
Respondents.
MONTANA, Defendants
No. 12555.
Submitted Nov.
1973.
Decided
Feb.
MR. JUSTICE Gumming, Salansky, argued,. A. Cumming & James Measure, appelltnt. Palls, plaintiff and for Columbia Kalispell, Christiansen, & Korn, Warden, Walterskirchen argued, Williams, LaBar, & A. Harris, Donald Church, Johnson respondents. Palls, for Great defendants Opinion of the Court. DALY delivered MR. JUSTICE plaintiff Betty L. Wardlow stated wherein This is an action Kalispell Hospital and General a claim defendants failure claimed medical Blue of Montana for Cross appeals Plaintiff a result of an illness. due her as summary judgment by the district court of entered from a County dismissing Blue Cross as a defend- defendant Flathead party Kalispell Hospital is not a General ant. Defendant appeal. Kalispell Hospital as employed by was General 6, 1964. on December On December practical nurse licensed accepted 31, for 1964, and was she hospital’s group, By Blue of Montana. health insurance Cross paid premiums agreement, Mrs. her for the Wardlow first subsequently premiums paid were three months and hospital by the without deduction Mrs. Cross Wardlow’s wages. May 1965,
In last Mrs. in week Wardlow’s doctor requiring she had cervical cancer formed her immediate treat May 1965, employer or about she informed ment. On her inquired emergency and about leave and her health coverage. by deposition that at the time She testified ;she emotionally frightened an distressed and state inquired mind. She she Eleanor Disbrow, stated employee administering plan, health eon the Blue Cross eerning premium payment during her leave of absence due sickness, granted which she understood had been to her. worry testified Mrs. Disbrow told her “Don’t about a thing, everything completely right, your just all insurance is fine.” “Hospital Policy” Personnel which was furnished to employees provided
new only that sick leave was available employment six months of full time and accumulated at per day up "the rate of one days month to a total 24of employees that on leave absence their own Blue must membership. continue physician, Under the care of a Billings Mrs. Wardlow com- menced treatment for her cancer condition on June *3 hospitalized She was Hospital Billings at St. Vincent’s from 13 17, 1965, again June to July 25, June and from 24 to June 1965, at which time she was released as cured. Kalispell
The Hospital General notified Blue Cross on or July 2, about 1965, employment that Mrs. Wardlow’s had been appear terminated. It does not that the notified Mrs. Wardlow. She contends she first learned her termination August 1965, attempted when she to resume work. July 2, 1965,
On Blue Cross mailed a form notification letter to address, Mrs. Wardlow at her advising home her of non- stating that she must for $37.05 period September 15, 1965, lapse June to avoid a in coverage. Mrs. Wardlow contends she did not receive the notice. expenses
Mrs. Wardlow incurred medical totaling approxi- mately $1,800. paid hospital expenses Blue Cross totaling $170.95. Blue Cross counterclaimed for contending $46, that pay- 1965,
Mrs. Wardlow’s ended on June pe- hospitalization covered the by ment made for Blue Cross 13 through riod from 1965. June June presents appeal: Plaintiff on six issues plaintiff notice from Blue- 1. Was to termination entitled ? so, If notice? 2. did Wardlow receive termination Mrs. commenced', 3. Was the treatment for the cancer condition coverage? prior to of her termination If to termination of' the treatment was commenced ill- coverage, for the same was the course of treatment entire covered? ness representations by hospital, alleged
5. Were the made imputable Mrs. Wardlow Cross? proper? summary judgment 6.. Was and fact and are- The issues contain mixed elements of law finding would that of merit in one of them constitute- such record, summary grounds judgment. of the reversal legal not disclose the district does rationale summary judgment. granting court plaintiff' third, appeal, on In her fourth and sixth issues at that in foree the time- contends her Blue Cross the- physician condition and at informed her cancer treatment for it. contends that oc- time she commenced peril and commencement of the insured while currence obligates directly was in insurer the contract force expenses. related and dealing have asserts no cases been found area, cases hospitalization therefore she cites involv- disability policies which extend insurer’s- ing accident subsequent expenses. In- ensuing medical liability to furnish *4 Andersen, Mutual Insurance Co. v. Life Nev. tercoast 75 A.L.R.2d 345 P.2d many respects, favorable in but
Intercoast Mutual is Life language. There, substantially in the contract con differs weight given “ambiguity, any” con siderable to the * * policy tained in the such termination clause of the —“* claim,originating prejudice termination shall be without to (Emphasis ours). thereto.” principle Blue to Cross contends that if this were longer health to would no have insured premiums sick, plaintiff’s once she became and construes argument membership to mean to in she is entitled resulting but benefits, required not to she became sick.
Here, be, problem we do not view the to as Blue Cross supporting but authority, contends offers no not whether or plaintiff pay- was entitled without litigation ment premiums. presents problem The instant of under contract after termination. It does not concern membership. continued provides is a hospital
Involved health service contract which and medical benefits for its members. The contract does not distinguish coverage. between health accident pertinent conditions, same limitations and so far as to this case, apply coverage. to and medical here,
To resolve issues we look to the terms employ generally applicable the contrct the rules to the interpretation of insurance contracts. We must also resolve ambiguities in an contract light most favorable to insured. provision governs eligibil-
The contract involved here which ity and benefits states: that, certify
“This the payment consideration of required membership dues, appears the Subscriber whose name membership card, eligible on the and such members of his or family (if any) accepted membership, who have been subject are entitled the benefits hereinafter described terms, conditions, and limitations set forth this Certifi- cate.” *5 terms, conditions
Following provision benefits, the through I IX. As stated limitations are forth in Articles set hospitalization heretofore, the of contract is silent as cause it merely also as The contract is silent deals services. pertains There right will vest. when the to receive benefits specific concerning bene- are termination of no conditions the fits, once under the The matter of dues vested contract. of in Article VII: termination covered is IN OR PROVI- “VII. CHANGES MEMBERSHIP DUES AND SIONS OF TERMINATION THIS CERTIFICATE may Membership “a. of this or dues Provisions Certificate by Plan changed be at Board Trustees of the time the of by thirty (30) days prior to- mailing uotices or more written change employer of the of to the Subscriber or the date the in a participates organization in which the Subscriber group. Payment payment effective of the first due proof change of be as conclusive of date shall deemed agreement change. with Subscriber’s immediately upon non- “b. This Certificate is terminated event, of of In such reinstatement this Certifi- dues. of, be sole and under such condi- cate shall at the discretion by plan. may specified tions as be may by by giv- “c. This Certificate be terminated Plan prior thirty (30) days written ing at the Subscriber least receiving hospital on the notice, however, service Member if termination, provided be this Cer- shall under date benefits discharge or the Member until the tificate used— days until care available under this are Certificate shall occur. whichever first by the may This be terminated Subscriber
“d. Certificate by thirty (30) days written giving the Plan at least beyond Dues, paid by any, the date notice. the Subscriber ours). by (Emphasis the Plan.” will be refunded termination only is the reference contained reference benefits “e”, which continues when cancellation is subsection exclusionary Cross, at the hand of no however there is language voluntary with termination section concerned (subsection non-payment (sub- “d”), or termination for of dues “b”). contrary section To the “b” sub- subsection seems be ject Testing to reinstatement at the discretion of Blue Cross. by any rule, this contract mat- we have to conclude that the urged by ters and distinctions Blue Cross are either not covered ambiguous. the contract or at best are *6 problem points The here is treated from two in a view majority opinion concurring opinion "Washing- and a in a 1970 case, Myers Kitsap Physicians Service, ton v. 78 Wash.2d majority opinion P.2d 109. There the holds contract open to interpretation more than one reasonable and because ambiguity insured, it in was resolved favor of the fol- lowing contingent a right theory. majority event vested The opinion cites 75 (1961) appli- A.L.R.2d 876 as a reasonable cation objected to a health service contract. This a citation to in the instant pertaining only case Blue Cross as “acci- applicable. dent” and not concurring opinion Myers recognizes position
The but ambiguous language because construes the contract employee favor of the for whose benefit the contract is drawn. purpose
For the of our consideration of the contract involved both here are views reasonable under the circumstances and we so hold. expenses
The factual were incurred issues—whether of an illness contracted course treatment during period in force and effect—is a Accordingly, disputed material find the district court we fact. granting summary judgment dismissing erred Blue Cross as a defendant. remaining by plaintiff, not
We need discuss the issues raised except express state that under the terms the contract without
existing litigants, find them to be between the we merit. summary judgment is and the granting reversed order proceedings. for further
cause remanded the district court MB. T. and MR. JAMES HARRISON CHIEF JUSTICE concur. HASWELL and JOHN C. HABBISON JUSTICES (dissenting). MB. CASTLES JUSTICE I dissent. personnel hospital’s
The facts reveal that Wardlow read the employee policy clearly that an was not entitled which stated employee. full time until six months of service as a to sick leave personnel qualify. Neither, policy, under the did did not attempt leave at no time did she establish a of absence and she period Appellant premium involved. Ward- which, against hospital, allegations low make various hospital, against proven, may have merit but these alle- support respondent a claim gations Cross. cannot view, summary judgment in favor of Blue Cross was my In I proper, would affirm.