charges" would have been placed together in one definition. The purpose of separate treatment for the two terms can be discerned, and careful examination of the policy exclusions for occupational diseases and injuries unquestionably reveals the intent of the drafters, who in the first subparagraph desired to exclude occupational injury, which can usually be determined as job-related with little difficulty. Hence, the definition is broadly defined. Whether the etiology of a claimant's disease involves employment conditions usually poses a more perplexing problem. See, for example, Roesberg v. Johns-Manville Corp., 85 F.R.D. 292 (E.D.Pa.1980) (asbestosis). Identification of the nexus between the employment and the disease may be elusive. To avoid disputes with claimants as to whether a person's employment caused a disease, the drafters of this contract used more narrowly tailored language to define the term "occupational disease". Unmistakably, the syntax of this exclusionary clause requires no judicial alteration to comprehend its meaning. Interpolation of the workmen's compensation language into the "occupational injury" portion of the clause would create an ambiguity where none presently exists. Plaintiff's injury occurred during the course of his employment; the exclusionary clause expressly disallows any compensation therefor. See also Buntz v. General American Life Insurance Co., 136 Pa.Super. 284, 289, 7 A.2d 93 (1939) ("all phrases and sentences are to be construed according to the rules of grammar; and these require as a general thing, a limiting clause or phrase, following several expressions to which it might be applicable, to be restrained to the last antecedent").
Plaintiff also contends that, if an insurer seeks to deny benefits through the operation of an exclusionary clause, reliance thereon acts as an affirmative defense, which places the burden of proof on the insurer. See Weissman v. Prashker, 405 Pa. 226, 175 A.2d 63 (1961) and Armon v. Aetna Casualty & Surety Co., 369 Pa. 465, 87 A.2d 302 (1952). Specifically, plaintiff argues that defendant must show that he, plaintiff, knew and understood the effect of the exclusionary clause. Hionis v. Northern Mutual Insurance Co., 230 Pa.Super. 511, 327 A.2d 363 (1974). Essentially plaintiff asserts that defendant's failure to explain the limitations of the policy estops it from invoking the clause to defeat plaintiff's claim.
In Hionis, supra, plaintiff purchased insurance to protect himself against loss to improvements made to his restaurant. The policy excluded reimbursement for improvements which he did not repair or replace following destruction thereof. The court construed the insurance policy to cover the total loss despite plaintiff's failure to replace destroyed improvements. The court, considering the legally untutored status of the plaintiff and the technical, unclear terms of the policy, concluded that the defendant should not be able to avoid coverage unless it could establish that plaintiff knew of the exclusion. Id. at 513, 327 A.2d 363. See also Daburlos v. Commercial Insurance Co. of Newark, 521 F.2d 18 (3d Cir. 1975).
However, in Miller v. Prudential Insurance Co. of America, 239 Pa.Super. 467, 362 A.2d 1017 (1976), the court acknowledged that this rule admitted of exceptions, including the circumstances where "the language of the policy is clear and unambiguous in declaring that other medical benefits will be deducted from eligible benefits under (the) policy". Id. at 469, 362 A.2d 1017. In Brokers Title Insurance Co. v. St. Paul Fire & Marine Insurance Co., supra, the Court of Appeals recognized another exception.
When two parties with relatively equal bargaining positions negotiate for insurance, the insurer need not explain to the insured the exclusionary provisions thereof. In this situation the purpose of the Hionis rule, protecting consumers from the trammels of "adhesive" contracts, has been satisfied by the business knowledge and sophistication of the party purchasing the insurance. In Brokers Title Insurance Co. the insured was a professional title insurance broker who sought to avoid the effect of an unambiguous contract clause. Similarly, in the case at bar the party which purchased the insurance, Bamburger's Department Store, the employer of plaintiff's wife, cannot be classified as a layman unschooled in legal argot. Moreover, the group insurance policy issued to the employer does not appear to be an adhesion contract. Typically, insurance companies and organizations, not individuals, enter into group insurance contracts. The organizations who purchase such policies have more bargaining power than individual consumers. Usually people with acumen in business dealings and some expertise in insurance represent these organizations. Consequently, the parties negotiate the coverage, price and terms thereof at arm's length. The rationale supporting the Hionis rule finds no opportunity for enhancement under these circumstances; hence the rule does not here apply. One court confronted with this question has so held. In Weiss v. CNA, 468 F. Supp. 1291 (W.D.Pa.1979), the insured sought recovery of major medical benefits under a group insurance policy. The insurance company denied liability on the basis of an exclusionary clause; the insured argued that the limitation did not apply because the insurer could not establish that the insured knew of the exclusion. Acknowledging the general applicability of the Hionis rule, the court distinguished the situation involving group insurance:
Plaintiff obtained insurance through group policies issued to organizations (which) ... generally have more bargaining power than an individual has in negotiating for insurance coverage. The individual intends to rely on the organization to obtain the best coverage. Therefore, the need to protect the individual purchaser from overreaching by an insurance company is minimized.
Id. at 1293.
Moreover, an insurer has no duty to inform an employee covered by group insurance directly; rather the insurer must provide a copy of the master policy to the employer, who shoulders the responsibility for transmitting group insurance policy information to employees. See Aetna Life Insurance Co. v. Messier, 173 F. Supp. 90 (M.D.Pa.1959), Layman v. Continental Assurance Co., 416 Pa. 155, 205 A.2d 93 (1965), Peyton v. Equitable Life Assurance Society, 159 Pa.Super. 318, 48 A.2d 145 (1946) (insurer and employer are primary parties to contract of group insurance) and Hanaieff v. Equitable Life Assurance Society, 371 Pa. 560, 92 A.2d 202 (1952) (employer acts as agent of employees in contracting for group insurance). Defendant had no legal duty to guarantee that the policy information reached members of the group and that they understood the terms and conditions thereof. As one court stated,
(having) furnished to the party acting for and in behalf of the employees full and accurate information as to the terms of the contract it would make, the insurer would not be required to go further or be held responsible for the way in which the employer imparted the information to the employee for whom the employer was acting. If the employer failed in this duty, the employee might have a cause for complaint against his unfaithful representative, although he would have none against the third party with whom the representative dealt.