PILOT LIFE INSURANCE COMPANY, A FOREIGN CORPORATION, APPELLANT,
v.
RENEE R. RYCEK, APPELLEE

Fla. 3d DCA | 1986-08-05
No. 85-186
Before HENDRY, NESBITT and FERGUSON, JJ.
498 So. 2d 458 Florida District Court of Appeal, Third District (1986) Caution
Cited by 2 cases

AI-generated. These summaries, headnotes, and key points are machine-generated and may contain errors or omissions. Always verify against the full opinion text below. Not legal advice.

Synopsis

Pilot Life Insurance Company appealed a judgment requiring it to cover dental expenses for an insured with myasthenia gravis. The court reversed, holding that the insurance policy's plain language excluded coverage for dental work not resulting from accidental injury, even when dental problems were indirectly caused by an underlying medical condition.


Holding

The court held that under the plain language of the insurance policy, coverage for dental expenses is excluded unless they result from accidental injury to natural teeth. Since Rycek's dental problems resulted from myasthenia gravis, a medical condition, rather than accidental injury, the dental work was not covered under the policy.


Headnotes

[1] An insurance policy exclusion for dental care or treatment, except for expenses due to accidental injury to natural teeth, bars coverage for dental problems arising from…

[2] Prospective or future medical expenses are not recoverable under an insurance policy unless the policy expressly provides for such coverage.

Previewing 2 of 2 headnotes on this case. FLexlaw’s editorially structured points of law — every proposition, pinpointed — are reserved for members.

Join FLexlaw to unlock all legal intelligence

Key Quotes

“The benefits of the policy are designed to provide, to persons insured, coverage for expenses incurred as a result of injury or sickness.”

This establishes the broad coverage language of the insurance policy.

Previewing 1 of 3 key quotes on this case — the court’s exact language, pinpointed for members.

Join FLexlaw to unlock all legal intelligence

Facts & Procedural History

In 1981, Rycek was diagnosed with myasthenia gravis, a neuromuscular condition causing abnormal muscle fatigue and decreased ability to chew and swall…

The full statement of facts, procedural history, and disposition for this case are member content.

Join FLexlaw to unlock all legal intelligence

© FLexlaw, Inc. — AI-generated enrichments are proprietary. All rights reserved.


Opinion of the Court
NESBITT, Judge.

NESBITT, Judge.

Pilot Life Insurance Company (Pilot) appeals a final judgment in favor of Rycek in ^ dispute over health insurance coverage. We reverse.

In 1981 Rycek discovered that she was suffering from myasthenia gravis, a neuromuscular condition which creates abnormal muscle fatigue. Those suffering from the condition experience a decreased ability to chew and swallow which often leads to malnutrition and dental decay. When Ry-cek developed dental problems she was referred to a dentist who outlined a treatment plan.

Rycek submitted the treatment plan to Pilot, her insurer under a group policy. Pilot responded by informing Rycek that the policy did not provide coverage for dental problems unless they resulted from accidental injury.

Rycek brought suit against Pilot seeking money damages for the expenses she had incurred and for the expenses estimated by the dentist in Rycek’s treatment plan. Pilot defended on two grounds: 1) that the dental work is excluded from coverage; and 2) even if there is coverage, it is only for expenses which have actually been incurred, not for prospective expenditures. After a non-jury trial, judgment was entered in favor of Rycek in the amount of $13,570, covering both expenses actually incurred and expenses for proposed future treatment. Because we find that the plain language of the policy excludes coverage for the dental work, we reverse.

The insurance contract provided coverage as follows:

The benefits of the policy are designed to provide, to persons insured, coverage for expenses incurred as a result of injury or sickness.

The policy contained an exclusion provision which stated that:

Benefits will not be paid for expenses:
8. for dental care or treatment, except expenses due to accidental injury to natural teeth.

Clearly coverage for medical expenses incurred as a result of accidental injury to natural teeth survives the exclusion. All other expenses for dental work are excluded. Since Rycek’s dental problems were indirectly caused by a medical condition, myasthenia gravis, as opposed to resulting from accidental injury, coverage for the dental work is excluded. See Bernstein v. Fireman’s Fund American Life Insurance Co., 24 Ohio App.2d 103, 264 N.E. 2d 915 (1970) (a similar policy provision excluded coverage for dental problems resulting from an impaired nutritional state caused by primary biliary sclerosis).1 Accordingly, the judgment under review is

Reversed.

HENDRY, J., concurs.

. We note that this is not a case in which the dental work is a method of treating the underlying condition such as occurs in cases involving temporomandibular joint syndrome. See Goss v. Medical Service, 462 A. 2d 442 (D.C.1983); Moorman v. Prudential Insurance Co. of America, 4 Ohio St.3d 20, 445 N.E. 2d 1122 (1983). In those cases the dental work corrects the syndrome. Here, there is no evidence that the dental work corrects, or in any way treats, the myasthenia gravis.

Dissent
FERGUSON, Judge

FERGUSON, Judge

(dissenting).

The dental disorder, as experienced by the appellee, was a natural and probable consequence of the covered illness, myasthenia gravis, and should for that reason also be covered. At least the contract is ambiguous as to the coverage issue and should be resolved in favor of the insured. Stuyvesant Insurance Co. v. Butler, 314 So. 2d 567 (Fla.1975); Travelers Insurance Co. v. Smith, 328 So. 2d 870 (Fla. 3d DCA 1976).


Cases With Similar Vibessemantic neighbors from the corpus


Citator

Cited By

  • Celtic Life Ins. Co. v. FOX, 544 So. 2d 245 (Fla. 2d DCA 1989)
    …ion an upper jawbone problem far removed from teeth.” To the extent the word “surrounding” is in this regard open to interpretation and thus ambiguous, it must, of course, be construed against appellant. Woodlief. Pilot Life Insurance Co. v. Rycek, 498 So. 2d 458 (Fla. 3d DCA 1986), cited by appellant, does not call for a different result. Rycek held that a dental care exclusion in an insurance policy precluded coverage for dental problems indirectly caused by a medical condition. However, in that case, in c…

Authorities Cited

Full citator, related cases, and AI research tools

Open in FLexlaw