Opinion
No. 25461
September 19, 2003
Appeal from the Circuit Court of Greene County, The Honorable Dan Conklin, Associate Circuit Judge.
Joseph P. Winget and William C. Robinson, Turner, Reid, Duncan, Loomer Patton, P.C., Springfield, Missouri, for Appellant.
Dale L. Davis, Crouch, Davis, Lewis Rykowski, Springfield, Missouri, for Respondent.
Jacqueline A. Williams is personal representative of the Estate of Buddy L. Williams, her deceased husband. This action was instituted prior to Buddy Williams' death, after which Mrs. Williams ("Appellant") was substituted for plaintiff. At issue here is Appellant's claim that National Casualty Company's ("Respondent") "Exception Endorsement" contained within the policy of insurance purchased by Mr. Williams "is void and unenforceable pursuant to § 375.995, RSMo."
On June 21, 1994, Buddy L. and Jacqueline A. Williams applied for group health insurance coverage with National Casualty Company. On his application, where Mr. Williams was asked whether during the last ten years he had "any symptom, diagnosis or treatment for . . . [k]idney disorder, bladder infections, prostatitis, uterine disorders or any other disorder of the genito-urinary system[,]" the word "prostatitis" was underlined. In addition, a notation was entered under the section provided for an explanation which stated "see attached sheet." No such attachment was found in the record.
Prior to the issuance of a policy, Respondent requested and obtained medical information regarding Mr. Williams. An insurance policy was issued with an effective date of September 1, 1994, for Bud L. Williams. The policy's "Schedule of Benefits" included an "Exception Endorsement" pertaining to Mr. Williams that read as follows:
NO BENEFITS WILL BE PAID UNDER THIS CERTIFICATE OF INSURANCE, OR UNDER ANY RIDER OR AMENDMENT THERETO, FOR DISABILITY, LOSS OR EXPENSE RESULTING FROM OR CAUSED BY ANY DISEASE OR CONDITION OF THE PENIS SUFFERED BY BUD L[.] WILLIAMS.
NO BENEFITS WILL BE PAID UNDER THIS CERTIFICATE OF INSURANCE, OR UNDER ANY RIDER OR AMENDMENT THERETO, FOR DISABILITY, LOSS OR EXPENSE RESULTING FROM OR CAUSED BY ANY DISEASE OR DISORDER OF THE PROSTATE, SEMINAL VESICLES, URINARY BLADDER OR URETHRA, INCLUDING ANY TREATMENT OR OPERATION FOR OR COMPLICATIONS THEREOF SUFFERED BY BUD L[.] WILLIAMS.
Mr. Williams' policy of insurance defined pre-existing conditions as
[A] condition to which either "1" or "2" below applies:
1. A condition for which a covered person received medical advice or treatment within 24 months immediately preceding the date he or she became insured under the policy.
2. A condition which, in the opinion of a qualified doctor: (a) began prior to the date of the covered person's coverage under the policy; and (b) produced symptoms that would cause an ordinarily prudent person to seek diagnosis or treatment within the 12 months immediately preceding the date he or she became insured under the policy.
Also contained in the policy was Section XV, providing for "Pre-Existing Limitations." In pertinent part, Section XV states:
We will pay the benefits of the policy for Allowed Charges that are due to a pre-existing condition, subject to the rules set forth below:
. . . .
2. Coverage of the pre-existing condition must not be excluded or limited by name or specific description.
. . . .
No claim for Allowed Charges incurred more than 24 months after a person became a covered person will be reduced or denied solely on the grounds that the expense is due to a pre-existing condition, unless the condition was excluded or limited by name or specific description prior to the date the charge is incurred.
In November or December of 1998, Mr. Williams was diagnosed with prostate cancer and subsequently received medical care and treatment for the disease. Claims for medical bills and expenses related to his treatment were submitted to Respondent for payment and/or reimbursement. However, Respondent denied coverage for such claims related to the prostate cancer for the reason that such bills and expenses were specifically excepted from coverage under the terms of Mr. Williams' policy.
A lawsuit was filed by Mr. Williams on May 9, 2001, alleging breach of contract and violation of the provisions contained in § 375.995, RSMo. In its defense, Respondent contended that coverage was denied pursuant to the above-quoted exception endorsement contained in Mr. Williams' policy which was inserted "because of evidence of unsatisfactory individual insurability of [Mr. Williams] at the time of application for policy issuance[.]"
Mr. Williams died in January, 2002. Jacqueline A. Williams was substituted for plaintiff on July 18, 2002. Medical bills and expenses for Mr. Williams' treatment and care totaled $78,784.71, of which Appellant claimed Respondent was obligated to pay $59,807.17.
By agreement between the parties, a joint stipulation of facts was filed along with documents pertaining thereto, and the cause was submitted to the trial court on briefs. Oral argument was heard December 17, 2002. The parties stipulated "[t]hat the only legal issue before the court is whether Section 375.995[, RSMo] renders the terms and conditions of defendant's policy and defendant's Exception Endorsement invalid, unenforceable and void[.]" The trial court found in favor of Respondent, concluding that such "Exception Endorsement" was not in violation of § 375.995, RSMo. This appeal followed.
Appellant's sole point relied on assigns error to the trial court's "judgment in favor of Respondent because the `Exception Endorsements' in Respondent's insurance policy is void and unenforceable pursuant to § 375.995 [RSMo.] in that Respondent's denial of medical benefits for Buddy Williams' prostate cancer and related conditions was discriminatory as it restricted, reduced, modified and excluded benefits due to the genital organs of only one sex."
On review, the trial court's judgment will be sustained unless there is no substantial evidence to support it, it is against the weight of the evidence, or it erroneously declares or applies the law. Grey v. American States Ins. Co. , 708 S.W.2d 821, 822 (Mo.App. 1986). Because this case was submitted on stipulated facts, review is confined to a determination of whether the trial court drew the correct legal conclusions from the facts so stipulated. Hadel v. Board of Educ. of School District of Springfield, R-12 , 990 S.W.2d 107, 114 (Mo.App. 1999). The trial court's judgment must be affirmed if the judgment is correct on any tenable basis. Id.
"Where an insurer seeks to escape coverage because of a policy exclusion, the burden is on the insurer to prove facts which would make the exclusion applicable." Drury v. Blue Cross/Blue Shield of Missouri , 943 S.W.2d 834, 836 (Mo.App. 1997).
The trial court had before it the policy of insurance issued to Mr. Williams containing the above-quoted exception endorsement and language limiting benefit payments for pre-existing conditions. Medical records concerning the diagnosis, treatment and medical care provided to Mr. Williams were included and made a part of the parties' joint stipulation filed with the trial court. Such medical records reflect a possible diagnosis of chronic prostatitis as of March 13, 1992.
We find no prior cases interpreting § 375.995, RSMo. Guided by the tenants of statutory construction, our primary focus is to ascertain the intent of the legislature from the language used, giving such language its plain and ordinary meaning. Missouri Nat'l Educ. Ass'n v. Missouri State Bd. of Educ. , 34 S.W.3d 266, 279 (Mo.App. 2000).
In pertinent part, § 375.995.4 sets forth the following:
4. The availability of any insurance contract shall not be denied to any insured or prospective insured on the sole basis of the sex or marital status of such insured or prospective insured. Neither the amount of benefits payable under a contract, nor any term, condition, or type of coverage within a contract, shall be restricted, modified, excluded, or reduced solely on the basis of the sex or marital status of the insured or prospective insured except to the extent such restriction, modification, exclusion, or reduction is a result of the application of rate differentials permitted under the insurance laws of this state. Nothing in this section shall prohibit an insurer from taking the marital status of an insured or prospective insured into account for the purpose of defining persons eligible for dependents' benefits. Specific examples of practices prohibited by this section include, but are not limited to, the following:
. . . .
(7) Restricting, reducing, modifying, or excluding benefits relating to coverage involving the genital organs of only one sex;
Section 375.995.4(7), RSMo.
The intent of § 375.995, RSMo is plainly stated: "to eliminate the act of denying insurance benefits or coverage on the sole basis of sex or marital status in any terms or conditions of insurance contracts and in the underwriting criteria of insurance carriers." Under the facts of this case, we cannot hold that Respondent's "exception endorsement" as stated in the policy purchased by Mr. Williams "is void and unenforceable pursuant to § 375.995." When, as here, a policy exclusion is based on an undisputed pre-existing condition, it cannot be said that insurance benefits were denied "on the sole basis of sex." Thus, rather than the endorsement serving to restrict, reduce, modify, or exclude "benefits relating to coverage involving the genital organs of only one sex," it sought to restrict benefits related to Mr. Williams' pre-existing condition, which was no more in violation of § 375.995, RSMo, than the endorsement on Appellant's own policy excluding benefits relating to her pre-existing asthmatic condition. Appellant's point is denied.
The judgment is affirmed.
Barney, P.J., and Garrison, J., concur.