An examination of the facts in the instant case reveals an ambiguity that compels this court to construe the policy in favor of Mr. Totedo. The phrase, "eligible or qualified for benefits under Medicare," when considered in isolation leads the average reader to the conclusion that one must actually be entitled to receive benefits, not merely to enroll. When the reader proceeds to the conversion privilege provision allowing the insured to take out a policy supplementing the Medicare benefits, his conclusions are confirmed and reinforced. It would be patently unreasonable to expect someone not intimate with the provisions of the Social Security Act to anticipate that his Catastrophic Health policy could be terminated when he was "eligible or qualified for benefits" but not actually eligible or qualified to receive those benefits.
The concepts embodied in the renewal clause are not so complicated that a clear expression of them is impossible given the space constraints of an insurance policy. Many ways exist of expressing the same concepts more clearly, some more efficiently than others. For example, with eleven extra words, the clause could have read, "eligible to enroll in Medicare, even if disqualified from receiving benefits by another provision of the Medicare Statute." Bankers Life could then make the conversion clause consistent with the renewal clause by adding language stating that the conversion to supplemental coverage is available to those participants whose policies have been terminated pursuant to the renewal clause and who actually receive Medicare benefits.
This court realizes that insurance policies would become unwieldy if insurance companies were required to explain in detail the effects of each provision under every possible scenario. Nonetheless, if an insurance company wants a particular clause to enable them to terminate the insured's coverage, the insurance company must use non-technical, unambiguous, understandable language.
For the above stated reasons, this court will grant the plaintiff's motion for summary judgment and deny the defendant's motion for summary judgment.
An appropriate order will be entered.
AND NOW, this 23rd day of September, 1987, for the reasons set forth in the accompanying Memorandum Opinion,
IT IS HEREBY ORDERED that:
(1) Defendant's Motion for Summary Judgment is DENIED;
(2) Plaintiffs' Motion for Summary Judgment is GRANTED;
(3) Judgment is entered in favor of the plaintiffs, Dennis J. Totedo, an incompetent, by the Union National Bank of Pittsburgh, and Gloria A. Totedo, co-guardians, and against the defendant, Bankers Life and Casualty Company; and
(4) Interest at the rate of six percent (6%) per annum shall attach to all amounts due the plaintiffs under the Catastrophic Health Expense Policy No. 817,024,881, with such interest commencing sixty (60) days after the rendering or supplying of the particular medical service for which the defendant has been, is now, or may in the future become, responsible.
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