Blue Cross and Blue Shield of Ga., Inc. v. Shirley

Michna v. Blue Cross and Blue Shield of Ga., 288 Ga. App. 112 2007, which held that terms inpatient and outpatient are of common usage among lay people and, therefore, not ambiguous, controlled this case.

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A Gwinnett County jury awarded Melanie Suzanne Shirley $52,136.30 in damages in an action she brought against Blue Cross and Blue Shield of Georgia, Inc. “Blue Cross”, her insurer, for failure to pay a hospital bill. Blue Cross appeals from the judgment entered on the jury verdict, and the denial of its motion for judgment notwithstanding the verdict “j.n.o.v.”, or in the alternative, for a new trial. 1. Blue Cross argues that the trial court erred in denying its motion for j.n.o.v., or in the alternative, for a new trial on Shirley’s breach of contract claim. We find no error in the trial court’s denial of Blue Cross’s motion for j.n.o.v. on this issue, but we conclude that a new trial is required for reasons stated below.

The record here shows that at some time prior to June of 2006, Shirley purchased an Individual Hospital/Surgical Contract the “Contract” from Blue Cross. The first paragraph of the Contract provides as follows: This Contract is a LIMITED POLICY designed to offer you catastrophic coverage. The intent of this Contract is to provide benefits for basic impatient services and outpatient surgical care when medically necessary. Strict limitations apply to other outpatient services. For example, this Contract does NOT cover outpatient medical care including physician office visits, prescription or over-the-counter drugs, nervous and mental care, maternity conditions, physical therapy, durable medical equipment and many other services. Exclusions are explained more fully in the Contract. Section 3.3 1 in Article 3 of the Contract, which is entitled “Hospital Inpatient Services” essentially reiterates the introductory paragraph of the Contract, providing as follows:

Blue Cross and Blue Shield of Ga., Inc. v. Shirley

Michna v. Blue Cross and Blue Shield of Ga., 288 Ga. App. 112 2007, which held that terms inpatient and outpatient are of common usage among lay people and, therefore, not ambiguous, controlled this case.

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