Century Medical Health Plan, Inc. v. North Shore Medical Center, Inc.
Docket: No. 96-572
Court: District Court of Appeal of Florida; February 25, 1997; Florida; State Appellate Court
North Shore Medical Center, Inc. (North Shore) initiated legal action against Olga Garcia and her health insurer, Century Medical Health Plan, Inc. (now PCA Family Health Plan, Inc.), for unpaid medical services. Garcia, acknowledging her debt to North Shore, settled and agreed to an installment payment plan while assigning her insurance benefits to North Shore. Following this, North Shore filed for summary judgment against PCA, which was granted, resulting in a judgment of $19,896.75 against PCA. PCA is appealing this decision.
Garcia, a member of PCA since 1990, underwent elective cosmetic surgery in February 1993, which resulted in complications requiring emergency medical attention at North Shore. PCA contends that the surgery and its complications are not covered under Garcia's insurance contract due to specific exclusions, including services not listed in the contract and cosmetic procedures. North Shore counters that the insurance contract ambiguously defines "emergency care" and argues that Garcia's condition upon arrival at the hospital constituted an emergency, necessitating coverage as outlined in the contract. The contract stipulates that emergency services, even when obtained outside the network, are covered if they meet the definition of emergency care.
Health Plan is obligated to cover or reimburse Members for costs associated with Covered Services, following the provisions outlined in Section IV of the Contract. North Shore argues that these provisions are ambiguous and should be interpreted in favor of the insurer, referencing case law. However, the court disagrees, finding the contract terms to be specific rather than ambiguous. Notably, North Shore's complaint pertains to a section that applies only to "Non-Participating" providers, while North Shore is classified as a "Participating" hospital in its relationship with PCA. Consequently, any potential ambiguity regarding this section would not affect North Shore. The court reverses the previous Final Judgment and instructs that a Final Summary Judgment be entered in favor of PCA. The court does not consider the other ten affirmative defenses raised by PCA, as the issue of ambiguity is decisive.
