Heilman v. American Cas. Co. of Reading, Pa.
Heilman v. American Cas. Co. of Reading, Pa.
Opinion of the Court
Plaintiff, Louis Heilman, sued to recover certain benefits which he claimed were due him upon an accident and health insurance policy issued by defendant, the American Casualty Company. The case was tried by the court without a jury, which gave judgment for defendant. Plaintiff appeals. The amount of recovery, if any, was stipulated as $838.33, with interest from September 1, 1949, and costs of suit.
The policy provided indemnity for hospital and surgical expense and for loss of time due to accident or illness and also indemnity for loss of life through accident. In June 1949 plaintiff became ill with a kidney ailment and was operated on two- weeks later. He was. totally disabled from June through August of that year. He claims compensation in the amount of $838.33 for loss of time, hospital and surgical expense and other miscellaneous expenses. Due proof of claim was furnished the company. This action to recover that amount was commenced in June 1950.
As a bar to recovery defendant contends that the kidney condition existed prior'to the issuance of the policy and that it had no knowledge of this because of misrepresentations made by the plaintiff. Over objections of counsel, defendant was allowed to introduce evidence that during the five-year period preceding the original application for the policy, plaintiff had suffered from a kidney ailment; that he had undergone X-ray and medical examinations during this period; and that in March 1946, after the policy had been in effect about one year, he had consulted a physician and entered John Hopkins Hospital for a medical examination.
Plaintiff made original application for the policy in February 1945. In his application he stated that he had not been disabled either by accident or illness or received medical or surgical treatment for the previous five years. He agreed that the falsity of any answer in the application would act as a bar to recovery if made with intent to deceive or if it materially affected the acceptance of the risk assumed by defendant. The policy was issued March 1, 1945. It provided coverage only for illness or accident sustained during the term of the policy. It expressly provided that the application was to be a part of the agreement between the parties.
Plaintiff allowed the policy to lapse in November 1946, and it was not reinstated by payment of the premium until December 1, 1947. In his application for reinstatement plaintiff stated that he had received no medical or surgical attention for the previous three years other than what was known by the company.
Plaintiff relies, however, on a provision found in a rider to the policy to support his contention that the defendant could not challenge recovery on the basis of plaintiff's prior medical history. The rider, after providing that the policy should not cover certain types of illness and accident, reads:
Incontestability clauses generally are found in: life insurance policies. In many jurisdictions they are required 'by statute. Such a clause ordinarily provides that, after the expiration of a certain period of time, the policy shall be incontestable, i. e., that the insurer will no longer be able to set up matters which would formerly have been a defense to a suit on the policy.
Often life insurance policies contain provisions for indemnity in cases of disability. It has been held that whether an incontestability clause in a life insurance policy is applicable to the disability provisions depends on whether the disability provisions have been specifically excluded from the clause.
The provision, relating to the time of, commencement of sickness which is found in the rider to the policy involved here is not the incontestability clause usually found in insurance policies. It does not preclude generally all defenses on the policy but is applicable only to the issue of the time of commencement of the sickness.
The coverage afforded by the policy is specifically limited in its terms to illness arising after its inception, yet the rider provides that the defendant will not dispute the time of commencement of sickness after the policy has been in effect 24 months. It is apparent that the defendant has qualified its right to question the coverage afforded by the policy by this provision. It is clear
It seems to us that the rider, while not the usual incontestability clause, is meaningless unless it means exactly what it says, namely, that after the policy had been in effect for 24 consecutive months defendant could not question the time of commencement of illness. To say that in reality plaintiff’s illness began when he first had kidney trouble would be to directly contradict this provision. This, we think, defendant may not do. The - situation would be different,' we think, had the illness from which plaintiff suffered and for which he had been treated during’ the period preceding the taking out of the policy been other than kidney trouble — for example, heart trouble or any of the other sicknesses listed in the questions on the application blank. The offering of proof of such other illness and medical attention would have had a bearing on the issue of fraud and at the same time would not have violated the stipulation about not questioning the time of beginning of illness. It is in this sense, we think, that this was not the sort of incontestability clause found in life insurance policies.
Since 24 months had elapsed before the defendant in'its answer to this suit questioned the commencement of the sickness, evidence of prior medical history of the plaintiff should have been excluded.
Reversed with instructions to enter judgment for plaintiff in the amount stipulated.
.The defendant company refused to allow reinstatement of the policy in 1947 until plaintiff had signed a waiver for vari-cosity. Plaintiff had an operation for varicose veins some time after the policy was issued and had collected benefits therefor.
. Turner v. National Hospitalization, Inc., D.C.Mun.App., 52 A.2d 274.
. This provision was followed by another which read: “Nothing herein contained shall be held to vary, alter, waive or. extend any of the Declarations, Agreements, Exclusions or Conditions of this Policy other than as above stated.”
. 1 Appleman, Insurance Law and Practice, § 311 (1941)
. Densby v. Acacia Mut. Life Ass’n, 64 App.D.C. 319, 78 F.2d 203, 101 A.L.R. 863.
. Densby v. Acacia Mut. Life Ass’n, supra, and cases cited therein.
. Connecticut General Life Ins. Co. v. McClellan, 6 Cir., 94 F.2d 445; Pyramid Life Ins. Co. v. Selkirk, 5 Cir., 80 F.2d 553.
. John Hancock Mut. Life Ins. Co. v. Markowitz, 62 Cal.App.2d 388, 144 P.2d 899; Pekras v. Prudential Ins. Co. of America, 291 Ill.App. 597, 10 N.E.2d 704; Mills v. Metropolitan Life Ins. Co., 210 N.C. 439, 187 S.E. 581; Apter v. Home Life Ins. Co. of New York, 266 N.Y. 333, 194 N.E. 846, 98 A.L.R. 1281; Palumbo v. Metropolitan Life Ins. Co., 293 Mass. 35, 199 N.E. 335; John Hancock Mut. Life Ins. Co. v. Hicks, 43 Ohio App. 242, 183 N.E. 93.
. Apter v. Home Life Ins. Co. of New York, supra; John Hancock Life Ins. Co. v. Hicks, supra.
. Stinson v. New York Life Ins. Co., 83 U.S.App.D.C. 115, 167 F.2d 233; Pennsylvania Indemnity Fire Corp. v. Aldridge, 73 App.D.C. 161, 117 F.2d 774, 133 A.L.R. 914.
Dissenting Opinion
(dissenting).
In his original application for insurance appellant stated he had received no medical or surgical treatment during the five preceding years, and in his application for reinstatement of the insurance he stated he had received no medical or surgical attention in the past three years except such as was known to the company. Both statements were false and unquestionably the trial court was justified in finding they were made with intent to deceive and that they materially affected the risk assumed by the company. I cannot agree that the provision of the rider, quoted in this court’s opinion, prevented the company from proving this defense.
I agree with the statement in the opinion that the rider means “that after the policy had been in effect for 24 consecutive months defendant could not question the time of commencement of illness.” As a matter of fact the insurance company also agrees for it says in its brief that the provision “would seem to us to mean that the insurer cannot question the beginning of the illness after the policy has been in effect for twenty-four consecutive months.” The insured also agrees, with some modification, because in his brief he says that by the rider “the insurer has agreed that after the policy has been in consecutive force for a period of 24 months it will not question the date of commencement of sickness.” But the insured adds that the agreement also was that the insurer would not. “attempt to prove that sickness ■ had- its inception at some time prior' to the issuance of the policy, or existed at the time of the application for the policy.” From this last he argues that proof of time of commencement of the sickness is prohibited even for the purpose of proving fraud in ’ securing the policy, and this brings us to the heart of the question.
I agree with the opinion that the provision in question is not the usual incontestable clause. I think its only incontestable effect is to prevent questioning the commencement of the sickness in determining whether the sickness is within the coverage of the policy. I do not think it means that the validity or existence of the policy itself
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