EULA DANIEL, APPELLANT,
v.
ORANGE STATE LIFE INSURANCE COMPANY, APPELLEE
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The court held that there is a genuine issue of fact as to whether the insured's condition manifested before the policy's effective date, precluding summary judgment.
[1] A genuine issue of material fact exists as to whether a medical condition manifested itself prior to the effective date of an insurance policy when the insured experience…
[2] The determination of when a sickness first manifested itself, for purposes of insurance coverage, is a question of fact for the jury, not a matter of law for the court, w…
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Join FLexlaw to unlock all legal intelligenceThe appellant sought insurance benefits for a tumor discovered after her policy's effective date. She had experienced heavy menstrual bleeding prior t…
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DANAHY, Judge.
Appellant challenges a summary final judgment against her in her effort to obtain insurance benefits under policies of medical insurance issued by appellee. She argues that there is a genuine issue of fact as to whether the condition for which she incurred medical and hospital expenses had manifested itself prior to the effective date of the policies. We agree, and reverse.
Both policies of insurance issued by appellee define “sickness” as a condition first manifested after the effective date of the policy and while the policy is in force. The effective date of coverage was March 28, 1979. It is undisputed that on that date and for almost a year previously, appellant had been experiencing increased menstrual flow which had become quite frequent and heavy; however, appellant, who was forty years of age, thought her menstrual periods to be regular and the change possibly caused by the fact that she had changed jobs and was doing different work.
About twelve days after the effective date of the policies, appellant made an appointment with Dr. Richard O’Leary, a specialist in obstetrics and gynecology. She said she went for a check-up and a Pap test, but Dr. O’Leary thought she consulted him specifically about her heavy menstrual bleeding. Dr. O’Leary conceded that this condition, known medically as menorrhagia, could have been hormonal bleeding in a woman of appellant’s age group.
On the basis of his examination and tests, Dr. O’Leary prescribed diagnostic procedures, which were performed and led to the discovery of a tumor later removed by surgery. Appellee denied coverage for the expenses thus incurred by appellant on the ground that the tumor had manifested itself prior to the effective date of coverage by the heavy and frequent menstrual flow. The trial judge agreed with appellee as a matter of law. We think that the question is one which should be determined by a jury in the light of all the circumstances of this particular case.
REVERSED AND REMANDED for further proceedings not inconsistent with this opinion.
GRIMES, A. C. J., and OTT, J., concur.
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Preferred Risk Life Ins. Co. v. Sande, 421 So. 2d 566 (Fla. 5th DCA 1982)…an’s force and applicability, however, is lessened by the facts of the case since the disease was clearly diagnosed before the policy provision took effect, whereas in the instant case no diagnosis occurred. In Daniel v. Orange State Life Ins. Co., 403 So. 2d 438 (Fla. 2d DCA 1981), the court reversed a summary judgment granted for the insurance company, holding that the issue of when the illness manifested itself was one for the jury, not for the judge, in light of all the circumstances of the case.3 Daniel…
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Life Gen. Sec. Ins. Co. v. Cook, 648 So. 2d 237 (Fla. 4th DCA 1994)…to the effective date of the policy. There is nothing in the policy which would require an accurate diagnosis. Nor has the insured cited any authority to support her argument. The two cases on which she relies, Daniel v. Orange State Life Ins. Co., 403 So. 2d 438 (Fla. 2d DCA 1981) and American Sun Life Ins. Co., v. Remig, 482 So. 2d 435 (Fla. 5th DCA 1986), are distinguishable. In Daniel, the insured had not seen a physician prior to the policy becoming effective, and there was an issue of fact as to whethe…