Appeal from order of Court of Common Pleas of Luzerne County, No. 4703 of 1974, in case of Harvey H. Miller v. The Prudential Insurance Company of America.
Richard M. Goldberg, with him Joseph J. Heston, and Hourigan, Kluger & Spohrer Associates, for appellant.
S. Keene Mitchell, Jr., with him Darling & Mitchell, for appellee.
Watkins, P. J., Jacobs, Hoffman, Cercone, Price, Van der Voort, and Spaeth, JJ. Opinion by Hoffman, J.
[ 239 Pa. Super. Page 469]
This is an action in assumpsit to recover medical benefits allegedly due under the terms of a medical insurance policy. Appellant contends that the lower court improperly granted the appellee's motion for judgment on the pleadings.
On November 2, 1972, the appellant, Harvey Miller, applied for a "Major Medical Expense Policy" with the appellee, The Prudential Insurance Company of America (Prudential). The application, filed with Prudential's agent, Martin Birnbaum, required the applicant to disclose whether he was covered under other medical expense policies with Prudential or any other company. The application also provided that "[t]he undersigned agrees . . . (2) that no agent has the authority to modify any policy, to waive any of Prudential's rights or requirements or to bind Prudential by making any promise or representation . . . ."
Prudential issued the requested policy on November 18, 1972. The policy provided, in relevant part, as follows: "The Prudential Insurance Company of America will pay the benefits stated in this policy, in the event of sickness or injury as hereinafter defined, subject to all the provisions and exceptions contained herein . . . . B. Deductible Amount. The Deductible Amount applicable to any Benefit Period with respect to one sickness or one injury of a Covered Person shall be the Minimum Deductible Amount specified in the Policy Schedule except that if during such Benefit Period there are, with respect to the same sickness or injury, Other Medical Expense Benefits, as herein defined, for charges which are Eligible Expenses under this Policy, the Deductible
[ 239 Pa. Super. Page 470]
Amount for such Benefit Period shall be the amount of such Other Medical Expense Benefits if such amount is greater than the Minimum Deductible Amount. As used herein, 'Other Medical Expense Benefits' means benefits provided for confinements, services, supplies or equipment by any other insurance or welfare plan or prepayment arrangement . . . ."
While the policy was in effect, the appellant was hospitalized on three occasions. During this time, he received surgical and other medical services at a total cost of $9314.33. The appellant submitted the necessary documentation of the expenses, and requested payment in the amount of $6750.79.*fn1 Because the appellant had received "other medical expense benefits" from Blue Cross and Blue Shield in the amount of $6393.34, Prudential agreed to pay only the total eligible expenses ($9314.33) less the deductible amount ($6393.34) or $2920.99. By the time the action commenced, Prudential had paid all but $578.26 of this amount.*fn2
On June 14, 1974, the appellant filed a complaint in assumpsit claiming that further reimbursement was due under the terms of the policy. Prudential filed an answer and new matter alleging that the benefits received from Blue Cross and Blue Shield must be deducted from the eligible expenses pursuant to the terms of the policy. The appellant then filed a reply to new matter asserting that Prudential's agent, Martin Birnbaum, specifically informed him that other medical expense ...