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MANZELLA v. INDIANAPOLIS LIFE INS. CO.

UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA


February 2, 1993

JOHN R. MANZELLA, M.D., Plaintiff
v.
INDIANAPOLIS LIFE INSURANCE COMPANY, Defendant

The opinion of the court was delivered by: WILLIAM H. YOHN

MEMORANDUM AND ORDER

 Yohn, J.

 Defendant, Indianapolis Life Insurance Company, has filed a motion for reconsideration of the court's order, dated January 26, 1993, granting partial summary judgment for plaintiff. Because trial is imminent, the court has acted upon the motion prior to the filing of a response by plaintiff. For reasons discussed below, the court will deny the motion.

 Defendant claims that the court was in error in granting partial summary judgment for the plaintiff under one of the policies in the case, the income protection policy, because there is an issue of fact as to whether the incontestability clause, subsection (b), in that the policy precludes denial of the claim under the facts of this case. The subsection states:

 

(b) no claim for loss incurred or disability beginning after two years from the date of issue will be reduced or denied because of a pre-existing condition unless it is excluded by name or specific description.

 No pre-existing conditions were excluded from the policy by name or specific description. Defendant contends that, while this clause prevents denial of claims for loss incurred or disability beginning after two years from the date of issue, it does not prevent denial of such claims when the loss or disability begins during the two year period. Defendant contends that plaintiff's loss or disability began during the two year period.

 It is well established that the interpretation of contractual provisions is a question for the court. McDowell-Wellman Engineering Co. v. Hartford Accident & Indemnity Co., 711 F.2d 521, 525 (3d Cir. 1983); Johnson v. Bensalem, 609 F. Supp. 1340 (E.D.Pa. 1985). The court interprets the subsection in question to mean that, if a claim can be contested because the disability began before the end of two years, then the claim can be contested only if the specific loss or disability for which the claim is made began during the two year period. It does not interpret the subsection to mean that any disability or loss during the two year period will allow the defendant to deny a later claim for loss or disability that is due to a different cause.

 At the very least, the subsection is ambiguous as to whether it applies to a loss during the two year period from a disability different from the one resulting in plaintiff's claim after the two year period. When the language of an insurance policy is ambiguous or susceptible to more than one interpretation, it is well established under Pennsylvania law that it must be strictly construed against the insurer and in favor of coverage for the insured. Celley v. Mut. Ben. Health & Accident Assn., 229 Pa.Super. 475, 324 A.2d 430 (1974); Standard Venetian Blind Co. v. American Empire Ins. Co., 503 Pa. 300, 469 A.2d 563 (1983).

 Defendant relies on a statement in the court's memorandum dated January 26, 1993, that there is an issue of fact as to "whether plaintiff suffered partial disability during the two year incontestability period from diabetes." Memorandum and Order at 15. On review of all the submissions in this case, the court concludes that the statement was made in error. There is no evidence from which to conclude that there is a question of fact as to partial disability of the plaintiff from diabetes during the two year incontestability period. The evidence as to disability during that period relates solely to plaintiff's coronary by-pass surgery.

 While the reasons discussed above are sufficient in themselves to warrant the denial of defendant's motion for reconsideration, there are additional reasons in support of denial.

 Even if there were evidence of a temporary period of disability due to diabetes during the two-year window, there is nothing in the policy that clearly disqualifies a claimant who has a temporary but resolved disability, as opposed to a continuous disability, starting within the two-year window. If plaintiff suffered a temporary period of disability due to diabetes during the two year period, followed by a period of health, and then suffered permanent disability after the expiration of the two-year period, plaintiff would have a valid claim for permanent disability. Under subsection (b) of the incontestability clause, quoted above, such a claim is not clearly excluded. The most defendant could claim is that the subsection is ambiguous on this point, which means that it must be construed in favor of coverage for the insured. The only section of the policy that specifically discusses recurrent disability states:

 

After a period of Disability for which We paid Benefits ends and You become Disabled again from the same or related causes, We will consider it a continuation of the prior period of Disability unless You have Monthly Earned Income for six months at least equal to Your Average Monthly Earned Income Before Disability began. (emphasis added)

 Income Protection Policy at 8. It is undisputed in this case that no benefits were paid under the policy prior to the claim at issue in this suit; therefore, this section dealing with recurrent disabilities does not apply by its specific terms.

 Moreover, plaintiff disclosed on his application that diabetes was a pre-existing condition, and defendant did not exclude diabetes from its coverage. Subsection (b) prevents the denial of claims for disability beginning after the two-year window period unless the precipitating condition has been excluded. This does not necessarily mean that even when the disability begins during the two-year period and continues thereafter, the claim is barred. Defendant included the mandatory statutory language of the subsection quoted above, with regard to disability for a non-excluded pre-existing condition beginning after the two-year period, but neglected to say in the policy what would be done in the case of a disability for a disclosed but non-excluded pre-existing condition that began during the two-year period. The defendant contends that in such a case, it can deny the claim. The cover sheet to the policy seems to imply the opposite of what defendant would have us to find the policy means, although the factual situation to which the the cover sheet refers is not present in this case. It says the following:

 

Pre-Existing Conditions Limitation - During the first two years from the Date of Issue shown on Page Three, We will not pay Benefits for a Disability caused by a Pre-Existing Condition if it was not disclosed on Your Application. Also, We will not pay Benefits for any loss We have excluded by name or specific description.

 Disability Income Policy, Cover Sheet. This suggests, by implication, the opposite of what defendant contends. It suggests that if the pre-existing condition was disclosed on the application, and in this case it was, that the company will pay benefits even during the first two years.

 For the reasons stated above, the court concludes that the partial summary judgment for plaintiff under the income protection policy was properly granted. An appropriate order follows.

 ORDER

 AND NOW, this 2nd day of February, 1993, upon consideration of defendant's motion for reconsideration and defendant's accompanying brief, it is hereby ORDERED that defendant's motion shall be and is hereby DENIED.

 William H. Yohn, Jr., Judge

19930202

© 1992-2004 VersusLaw Inc.



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