BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., APPELLANT,
v.
RONALD VAN EVERY, APPELLEE

Fla. 4th DCA | 1986-10-15
Nos. 85-1872, 85-2695
HERSEY, C.J., and GUNTHER, J., concur.
495 So. 2d 923 Florida District Court of Appeal, Fourth District (1986) Positive Treatment
Cited by 2 cases

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Synopsis

Blue Cross and Blue Shield appeals a trial court judgment awarding post-termination medical benefits to an employee who terminated his employment without exercising conversion privileges. The court reversed, holding that the plain language of the insurance policy does not extend coverage for medical expenses incurred after employment termination absent specific policy provisions for extension.


Holding

The court held that absent a specific policy provision extending benefits, coverage is not available for post-termination medical expenses resulting from a pre-termination injury. Van Every did not qualify for the extension of benefits provision because the group policy remained in effect at his termination and he was not totally disabled.


Headnotes

[1] An insurance policy provision for extension of benefits upon termination of employment requires the subscriber to be totally disabled on the date the group contract termi…

[2] In the absence of a specific policy provision, insurance coverage is not available for post-termination medical expenses resulting from a pre-termination injury.

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Key Quotes

“If a covered employee ceases to regularly work the required thirty (30) hours per week, coverage respecting such employee and all of his eligible dependents, if any, shall terminate automatically at the end of the payment period during which the employee last worked thirty (30) hours per week.”

Establishes the clear termination provision of the policy that automatically ends coverage upon cessation of required work hours.

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Facts & Procedural History

Van Every was an employee of the Golden Beach Police Department covered under a Blue Cross/Blue Shield major medical insurance policy provided by the …

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Opinion of the Court
DELL, Judge.

DELL, Judge.

Appellant Blue Cross/Blue Shield entered into a major medical insurance contract with the town of Golden Beach. The policy covered appellee, an employee of the Golden Beach Police Department. During the course of his employment appellee filed a claim with Blue Cross/Blue Shield for expenses connected with injuries sustained in an automobile accident. On September 1, 1983, three months after the accident, appellee terminated his employment with the town of Golden Beach. However, he did not exercise the termination conversion privileges provided by the Blue Cross/Blue Shield policy. The insurer denied liability for medical expenses incurred by appellee after his termination date, September 1, 1983. Appellant contends that the trial court erred when it awarded appellee benefits for expenses incurred after his termination date. We agree.

Appellant’s policy provided:

6.1 TERMINATION — If a covered employee ceases to regularly work the required thirty (30) hours per week, coverage respecting such employee and all of his eligible dependents, if any, shall terminate automatically at the end of the payment period during which the employee last worked thirty (30) hours per week.

We find no ambiguity in the language of the foregoing provision. Appellant’s policy provides for extension of benefits beyond the date of termination of his employment:

5.2 EXTENSION OF BENEFITS — If on the date this contract terminates for the entire group, a benefit period has been established by a subscriber and such subscriber is totally disabled by an injury or illness for which benefits are payable under this contract, and, while so totally disabled, the subscriber incurs covered expenses on account of such injury or illness, benefits will be provided, for services rendered within twelve (12) months of the date of contract termination, in accordance with the provisions of this contract, as if it had not been terminated.

However, appellee does not come within this provision because the group policy was in effect when appellee terminated his employment and he makes no allegation of total disability. Since appellee did not exercise his right to convert the policy upon termination of employment, we find no provision within appellant’s policy which would extend benefits for his post-termination medical expenses. In Blue Cross of Florida, Inc. v. Dysart, 340 So. 2d 970 (Pla. 2d DCA 1976), the court concluded that in the absence of a specific policy provision, coverage is not available for post-termination medical expenses resulting from a pre-ter-mination injury. We reach the same conclusion here. Although we recognize the harsh result of this decision, the plain language of the policy precludes us from adopting the reasoning of Judge Board-man’s dissent in Dysart.

Therefore, we reverse and remand this cause to the trial court with instructions to enter judgment in favor of appellant.

REVERSED and REMANDED.

HERSEY, C.J., and GUNTHER, J., concur.


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Citator

Cited By

  • Time Ins. Co. v. Williams, 566 So. 2d 14 (Fla. 1st DCA 1990)
    …te covering, even beyond termination of the policy, an event or illness which arose during the life of the policy. As in Blue Cross of Florida, Inc. v. Dysart, 340 So. 2d 970 (Fla. 2d DCA 1976) and Blue Cross and Blue Shield of Florida v. Van Every, 495 So. 2d 923 (Fla. 4th DCA 1986), the instant policy is a major medical policy which specifically provides that it covers services received and charges incurred while the policy is in force. The policy further contains no post-termination benefits clause thereby…

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