In Moorman, 445 N.E.2d at 1122, the plaintiff, who was insured under a major medical policy containing an exclusion provision denying coverage for "any treatment of the teeth," had several teeth crowned as part of her treatment for temporomandibular joint syndrome (TMJ), a misalignment of a joint located in the jaw.Summary of this case from Park-Ohio Industries, v. Home Indem, Co.
Decided March 9, 1983.
Insurance — Health insurance policy — "Mouth conditions," construed.
CERTIFIED by the Court of Appeals for Montgomery County.
On May 28, 1981, appellee, Samuel L. Moorman, commenced this action against appellant, the Prudential Life Insurance Company of America, seeking recovery under a major medical expense insurance policy.
The pertinent and undisputed facts, as gleaned from the pleadings, are as follows. In February 1978, appellant executed and delivered to appellee a health insurance policy which covered appellee, his spouse, and his children. Appellee's spouse, in October 1979, consulted Harry Frontista, M.D., who diagnosed her problem as temporomandibular joint syndrome (TMJ), a misalignment of the temporomandibular joint which causes pain in the ear, jaw, head, neck or shoulder areas.
Upon Dr. Frontista's recommendation, Mrs. Moorman consulted with her dentist, Dr. James M. Shepler, who diagnosed her problem as myofacial pain syndrome. As part of his treatment, Dr. Shepler fitted Mrs. Moorman with a temporomandibular joint splint. In addition, Dr. Shepler crowned, both with gold and porcelain, some of Mrs. Moorman's teeth in order to restore proper occlusion and maintain proper alignment of the jaw joint. The propriety of this treatment is unquestioned.
Thereafter, in October 1979, appellee filed a claim with appellant, seeking reimbursement for the balance of the cost of services of Dr. Shepler in crowning Mrs. Moorman's teeth, appellant having previously paid for the TMJ splint. Appellee alleged coverage under subparagraph (3) of "Eligible Expenses" which provides as follows:
"Doctors' services for surgical procedures and other medical care."
Appellant rejected the balance of appellee's claim on March 30, 1980, asserting that coverage was specifically excluded, citing the "General Exclusions" clause which provides, in part, as follows:
"Mouth Conditions — Charges for doctors' services or X-ray examinations for mouth conditions due to periodontal or periapical disease or any treatment of the teeth, surrounding tissue or structure, the alveolar process on the gingival tissue, except for treatment or removal of malignant tumors." (Emphasis added.)
Appellee then filed suit in the Court of Common Pleas of Montgomery County. Appellant answered and subsequently filed a motion for summary judgment. Appellee responded with a counter-motion for summary judgment.
In granting appellee's counter-motion for summary judgment, the trial court noted that while doctors' services for medical care were included under "Eligible Expenses" the contract does not define the word "doctor." The court then reasoned that "[i]f the * * * [insurance company] had intended to exclude from coverage treatment by a dentist, the contract could have so stated or the word `doctor' defined. The treatment afforded * * * [Mrs. Moorman] was for a condition not specifically excluded under heading `General Exclusions.' In fact, the `Mouth Conditions' exclusion applies only to services, etc. for mouth conditions due to the enumerated conditions. The mouth condition for which * * * [Mrs. Moorman] was treated was not due to any of those specified conditions.
"Coverage being extended to * * * [Mrs. Moorman] under subparagraph (3) of `Eligible Expenses,' the burden shifted to the * * * [insurance company] to establish an exclusion. Where not clearly excluded, the presumption arises that the services are included in the coverage. (Citations omitted.) That burden not being overcome, * * * [Mrs. Moorman] is entitled to judgment against the * * * [insurance company]."
On appeal, the judgment of the trial court, and the rationale in support thereof, were affirmed.
The Court of Appeals for Montgomery County finding its judgment to be in conflict with the decision of the Court of Appeals for Hamilton County in Bernstein v. Fireman's Fund Ins. Co. (1970), 24 Ohio App.2d 103 [53 O.O.2d 287], certified the record of the case to this court for review and final determination.
Messrs. Cross Turner, Mr. Gerald L. Turner, Mr. Emerson R. Keck and Mr. Kevin Swick, for appellee.
Messrs. Pickrel, Schaeffer Ebeling, Mr. Andrew C. Storar and Mr. Paul J. Winterhalter, for appellant.
The sole issue presented is whether the charges for the crowning of teeth as part of the treatment for temporomandibular joint syndrome are excluded from coverage under the exclusionary provision dealing with "Mouth Conditions" in the insurance contract. For the reasons that follow, this court holds that such charges may be recovered under the terms of the policy.
At the outset, it is apposite to bear in mind that "[a] contract of insurance prepared and phrased by the insurer is to be construed liberally in favor of the insured and strictly against the insurer, where the meaning of the language used is doubtful, uncertain, or ambiguous." Munchick v. Fidelity Casualty Co. (1965), 2 Ohio St.2d 303 [31 O.O.2d 569], paragraph one of the syllabus. (Emphasis added.)
The exclusionary provision in this policy excludes costs of services for "Mouth Conditions" which includes "any treatment of the teeth." Appellant contends that since the crowning of the teeth is treatment of the teeth, the costs resulting therefrom are not covered.
Appellee, while conceding that the services in question affected Mrs. Moorman's teeth, nonetheless asserts that the costs for crowning of the teeth are covered because such service constituted treatment of a mispositioned jaw joint, a medical condition covered under the policy. Treatment of the jaw, appellee contends, is clearly distinct from treatment of the teeth.
As these arguments so demonstrate, the relevant exclusionary provision is susceptible of a number of constructions. The ordinary meaning of "treatment," as found in Black's Law Dictionary (5 Ed. 1979), lends support to appellant's interpretation: "A broad term covering all the steps taken to effect a cure of an injury or disease; including examination and diagnosis as well as application of remedies." The record, in contrast, supports appellee's position, for it clearly indicates that crowning of the teeth was one of the specific procedures used toward the cure of Mrs. Moorman's TMJ. Charges for treatment of the teeth are excluded under appellant's policy while charges for the treatment of TMJ are not excluded. Of course, the charges in both instances are for the same service — crowning of the teeth. Clearly, then, there is uncertainty as to whether costs for teeth crowning are ever covered under the policy, and applying the principles set forth in Munchick, supra, this court must adopt the construction most favorable to the insured which would allow recovery for teeth crowning where it is done in the course of the cure of TMJ.
This court is also mindful of the holding in Home Indemnity Co. v. Plymouth (1945), 146 Ohio St. 96 [32 O.O. 30], paragraph two of the syllabus, that:
"Where exceptions, qualifications or exemptions are introduced into an insurance contract, a general presumption arises to the effect that that which is not clearly excluded from the operation of such contract is included in the operation thereof." See, also, American Financial Corp. v. Fireman's Fund Ins. Co. (1968), 15 Ohio St.2d 171, 173 [44 O.O.2d 147].
The treatment afforded Mrs. Moorman was not specifically excluded from the operation of the policy. Indeed, nothing is mentioned in the "General Exclusions" clause about treatment of a jaw condition which necessitates treatment to the teeth. If it were intended that the exclusion should apply in this circumstance, then language so extending application of the exclusion could have been incorporated into the policy.
Furthermore, this court notes that this policy contains no definition of the term "doctor," which may or may not include a dentist, or of the term "treatment of the teeth." And, quite clearly, a jaw condition is not a mouth condition.
In arriving at the result herein, this court is impressed by the fact that the crowning of Mrs. Moorman's teeth was not an end in itself. The purpose of this treatment was to relieve the pain caused by the misalignment of her mandibular joint and not to correct a dental or mouth problem. Indeed, there was nothing wrong with Mrs. Moorman's teeth. Had it not been for the jaw condition, her teeth would not have required crowning.
For the foregoing reasons, the judgment of the court of appeals is affirmed.
CELEBREZZE, C.J., W. BROWN, SWEENEY, LOCHER, HOLMES and C. BROWN, JJ., concur.
J.P. CELEBREZZE, J., not participating.