AETNA LIFE INSURANCE COMPANY, APPELLANT,
v.
MORTON BENJAMIN, APPELLEE

Fla. 1st DCA | 1968-02-06
No. J—112
WIGGINTON, C. J., and CARROLL, DONALD K, J., concur.
206 So. 2d 444 Florida District Court of Appeal, First District (1968) Caution
Cited by 4 cases

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Synopsis

The Florida District Court of Appeal reviewed a case where an insurance company denied coverage for medical expenses incurred by a child at a treatment facility. The court had to determine if the policy's "private accommodations" clause applied to non-hospital institutions and if other medical expenses were covered.


Holding

The court held that the policy's "private accommodations" clause clearly referred to private hospital rooms and did not apply to non-hospital institutions. However, Aetna was liable for 50% of the charges for "services" that fell under the policy's "Other Medical Expenses" definition.


Key Quotes

“Reading the policy as a whole we find no ambiguity as to the words “private accommodations.” This phrase, used in the policy under the classification “Hospital Expenses,” clearly denotes a “private hospital room” just as the words “semi-private accommodations” as used in the policy clearly mean “semi-private hospital room.””

Establishes the court's interpretation of the "private accommodations" clause.

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Facts & Procedural History

David Benjamin, the minor son of Morton Benjamin, was institutionalized for seven months at The Devereux Foundation for treatment of a mental disorder…

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Opinion of the Court
RAWLS, Judge.

RAWLS, Judge.

Defendant, Aetna Life Insurance Company, appealed from a final judgment awarding certain medical expenses to plaintiff, Morton Benjamin.

The only question presented is whether the trial judge correctly found that the insurance policy was ambiguous so that the provisions thereof “ * * * respecting ‘private accommodations’ are readily open to the construction that plaintiff is entitled to 50% of his said expenses under the ‘Covered Medical Expenses’ and ‘Comprehensive Medical Expense Benefits’ of the policy.”

For a period of seven months in 1966, David Benjamin, minor son of plaintiff Morton Benjamin, was institutionalized for treatment of a mental disorder in The Devereux Foundation, Victoria, Texas, at a cost of $600.00 per month. The Benjamin family was insured by a group policy containing medical coverage issued by Aetna. *445When Aetna denied liability, Benjamin brought this suit.

The pertinent facts are not in dispute. The Victoria branch of The Devereux Foundation is not a “hospital” as defined by the terms of the policy. The child, while so confined, did receive certain medical services, nursing care and prescribed drugs, but the charge made for these items was never proven. The only proof of loss was a blanket fee of $600.00 per month for room and board, supervision, recreational and educational therapy, medical services and treatment.

The policy contains a $25.00 deductible clause with general coverage for 80% of the balance of charges covered under the medical expense portion. It does not provide for blanket medical coverage and then list the exclusion. Instead, it lists only the medical expenses covered therein as follows:

“HOSPITAL EXPENSES: These are the charges made by a hospital, in its own behalf, for
“(a) Board and room. However, if private accommodations are wed, any excess of daily board and room charges over the applicable Private Room Limit1 will be disregarded.
“(b) Hospital Services, other than board and room, furnished by the hospital while the covered family member is confined as an inpatient; * * *
“OTHER MEDICAL EXPENSES:
“(1) The fees of a physician or surgeon;
“(2) The charges of a registered graduate nurse— * * *
“(3) Hospital out-patient charges;
“(4) The charges for the following medical services and supplies:
(i) Drugs and medicine obtainable only upon a physician’s prescription;
(ii) Diagnostic x-ray and laboratory examinations;
(iii) X-ray, radium, and radioactive isotopes therapy;
(iv) Anesthesia and oxygen;
(v) Rental of iron lung * * * ;
(vi) Artificial limbs and eyes * * *
(vii) Professional ambulance service
“SPECIAL CONDITIONS:
“As to Covered Medical Expenses resulting from mental or nervous conditions incurred while the covered family member is not confined in a hospital or similar institution on an inpatient basis, any benefit payable with respect to such expenses after the Deductible will be at the rate of 50% rather than 80%.”

Reading the policy as a whole we find no ambiguity as to the words “private accommodations.” This phrase, used in the policy under the classification “Hospital Expenses,” clearly denotes a “private hospital room” just as the words “semi-private accommodations” as used in the policy clearly mean “semi-private hospital room.”

Since the trial judge found, and both parties agree, that the institution is not a hospital within the policy definition, the plaintiffs are not entitled to recover under that portion of the policy designated “Hospital Expenses.” The only coverage in the policy for room and board is that received while an inmate of a hospital. Therefore, the Appellant is not liable for room and board incurred at The Devereux Foundation at Victoria.

*446Both parties concede that the policy was in full force and effect at the time the expenses were incurred. The complaint sought recovery on the basis of the total monthly hospitalization charge without proving the portion attributable to other medical expenses. Although Aetna’s answer denied oil liability for any part of the total monthly charge, it quoted in its answer a provision from the policy by which the applicable medical expenses may be computed. This provision reads:

“In the absence of due proof to the contrary, when a single charge is made for a series of services each service shall be deemed to bear a pro rata share of the charge.”

Aetna is liable for 50% of the amount of charges by Devereux for “services” rendered within the definition of “Other Medical Expenses” and upon remand plaintiffs shall have the right to offer proof of same.

Reversed and remanded for further proceedings in accordance with this opinion.

Reversed.

WIGGINTON, C. J., and CARROLL, DONALD K, J., concur.


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Citator

Cited By

  • Dawson v. Blue Cross Ass'n, 293 So. 2d 90 (Fla. 1st DCA 1974)
    …nville, Fla.App. 1st 1961, 130 So. 2d 105, at page 109) We have not overlooked Travelers Insurance Company v. Esposito, Fla.App. 3rd 1965, 171 So. 2d 177, and the opinion of this court in Aetna Life Insurance Company v. Benjamin, Fla.App. 1st 1968, 206 So. 2d 444, each of which treated cases involving insurance coverage for confinement in or treatment at the Devereux Foundation of Victoria, Texas. It may well be that ultimately the holdings in one of both of those cases will be determinative of the final dis…
  • The AETNA Life Ins. Co. v. Cherise Witters, 402 So. 2d 501 (Fla. 3d DCA 1981)
    …graphs and subparagraphs whereas paragraph (9) merely refers to those categories of medical expenses and defines the manner and mode of payment as well as the division of payment between co-insurors. Compare Aetna Life Insurance Company v. Benjamin, 206 So. 2d 444 (Fla. 1st DCA 1958) and Aetna Life Insurance Company v. Hare, 47 Ala.App. 478, 256 So. 2d 904 (1972). Consequently, the trial court improvidently focused upon the alleged ambiguity between the master policy and the summary of the benefits in order t…

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