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RICHARD DUTTON v. EDUCATORS MUTUAL LIFE INSURANCE COMPANY (02/14/89)

filed: February 14, 1989.

RICHARD DUTTON, AN INCOMPETENT BY MARY G. DUTTON, PARENT AND NATURAL GUARDIAN, APPELLANT,
v.
EDUCATORS MUTUAL LIFE INSURANCE COMPANY, APPELLEE



Appeal from the Order entered March 12, 1988 in the Court of Common Pleas of Blair County, Civil Division, at No. 2024 C.P. 1983.

COUNSEL

Richard M. Serbin, Altoona, for appellant.

John W. Heslop, Jr., Altoona, for appellee.

Olszewski, Del Sole and Kelly, JJ.

Author: Del Sole

[ 381 Pa. Super. Page 523]

This appeal seeks to resolve whether Section 203 of the No-fault Motor Vehicle Insurance Act*fn1 requires the benefits of a group health insurance policy which contains a coordination of benefits clause to be paid to an employee where that individual has already received payment of medical bills by a no-fault carrier. We conclude that a clearly worded and conspicuously displayed coordination of benefits clause included in a health insurance policy must be enforced preventing duplicate recovery of medical expenses.

[ 381 Pa. Super. Page 524]

The underlying action was initiated after Appellant, Richard Dutton, sustained severe and permanent injuries as a result of a collision between an automobile he was driving and a tractor-trailer. At the time of the accident, Mr. Dutton was an insured under a policy issued by Nationwide Mutual Insurance Company in accordance with the provisions of the No-fault Act. The Nationwide policy did not contain an election making it's benefits excess to any other valid and collectible health insurance benefits, as permitted by the No-fault Act. 40 P.S. 1009.203(b). When the accident occurred, Mr. Dutton was also an employee of Shaw Brothers Packing which maintained a group policy providing health insurance coverage issued by Appellee, Educators Mutual Life Insurance Company. Nationwide, pursuant to the terms of its policy paid various medical bills incurred by Mr. Dutton. However, Appellee denied Mr. Dutton's claims for duplicate benefits relying upon a coordination of benefits provision contained in its policy. It required that any benefits payable "shall be coordinated with the benefits payable . . . under such other Plan or Plans." It further provided that the benefits paid by Educators "and any other Plans will be coordinated so that the aggregate amount paid will not exceed 100% of any necessary, reasonable and customary expenses . . . ." The term "plan" was defined to include "benefits payable . . . under . . . any coverage provided or required by statute." Based upon these facts the trial court was asked to rule on a Motion for Summary Judgment filed by Appellee.

The trial court initially determined that for purposes of summary judgment it would assume Mr. Dutton was an insured under his employer's group health insurance plan, a factual issue contested by the parties. It went on to find that Section 203 of the No-fault Act*fn2 permits double recovery in some instances, but that "the terms of the coordination of benefits clause are clear and unambiguous." It concluded that "there can be no doubt that the clause precludes a double recovery." Accordingly, summary judgment was awarded in Appellee's favor. Mr. Dutton contests

[ 381 Pa. Super. Page 525]

    this ruling and maintains that he should be afforded the benefit of double recovery under the two policies of insurance. He asserts that the trial court failed to follow applicable statutory and case law which would permit him to recover duplicate medical expense benefits.

In support of this position Appellant cites to section 203(a) of the No-fault Act. It states:

If benefits other than no-fault benefits are provided to an individual through a program, group, contract or other arrangement for which some other person pays in whole or in part that would inure to the benefit of a victim or the survivor of a deceased victim injured as a result of an accident in the absence of no-fault benefits, then any reduction or savings in the direct or indirect cost to such person of such benefits ...


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