American College of Surgeons v. Lumbermens Mutual Casualty Co.

491 N.E.2d 1179, 142 Ill. App. 3d 680, 96 Ill. Dec. 719, 1986 Ill. App. LEXIS 2099
CourtAppellate Court of Illinois
DecidedMarch 25, 1986
Docket83-3080
StatusPublished
Cited by30 cases

This text of 491 N.E.2d 1179 (American College of Surgeons v. Lumbermens Mutual Casualty Co.) is published on Counsel Stack Legal Research, covering Appellate Court of Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
American College of Surgeons v. Lumbermens Mutual Casualty Co., 491 N.E.2d 1179, 142 Ill. App. 3d 680, 96 Ill. Dec. 719, 1986 Ill. App. LEXIS 2099 (Ill. Ct. App. 1986).

Opinion

PRESIDING JUSTICE BILANDIC

delivered the opinion of the court:

Plaintiff, American College of Surgeons (hereinafter ACS), filed a breach of contract action against defendant Lumbermens Mutual Casualty Company (hereinafter LMC) alleging that defendant agreed to return to plaintiff “retention reserves” in the form of dividends for a period of 10 years after the policies terminated. ACS cancelled its policies in 1974 and, shortly thereafter, defendant informed ACS that its obligation to return reserves was only for a 20-month period after termination.

The trial court submitted to the jury the questions whether there was a contract, whether it met the requirements of the Statute of Frauds, and whether there was a breach by the defendant. The jury returned a verdict for plaintiff and awarded it $1,732,669 in damages. The trial court, which earlier had reserved ruling on defendant’s motion for a directed verdict, entered judgment notwithstanding the verdict (n.o.v.) for the defendant and, in the alternative, granted defendant’s motion for a new trial on the issue of damages. Defendant’s alternative motion for a new trial on all issues was denied.

ACS appealed from the order setting aside the jury’s verdict and entering judgment n.o.v. in favor of LMC and the alternative order granting LMC a new trial on the issue of damages. LMC filed a cross-appeal from the order denying its alternative motion for new trial on all issues.

The issues presented are: (1) whether it was error for the trial court to set aside the jury’s verdict for the plaintiff and to enter judgment n.o.v. for defendant; (2) whether it was error for the trial court to conditionally grant a new trial on the issue of damages; and (3) whether it was error for the trial court to deny defendant’s motion for a new trial on all issues.

This case presents a historical review of the inception, underwriting, and administration of the mass marketing of insurance policies. In the 1950’s, the insurance industry was emerging from what now appears to be a rather primitive method of having an insurance company agent or salesman sell a policy to a customer on an individual basis. A new breed of entrepreneur emerged that became known as the “Administrator.” He sought out large groups of potential insurance purchasers through their professional, trade, or craft associations, determined their insurance needs, and tailored a program to fit their requirements. Armed with this potential group sale, the Administrator shopped various insurance companies for the best deal in terms of benefits and cost. Ideally, everyone would benefit. The group members purchased insurance at lower prices than they could individually. Insurance companies that underwrote the group program benefited because they could put a block of business on the books at a lower acquisition cost per policy. Associations benefited by providing an additional service for their members, and the Administrator earned a fee or commission.

The Administrator sells the association on the idea of offering such a program and, if successful, “markets” the program among the members to induce them to place their insurance through the program. The Administrator receives the applications and the premiums, sends them on to the insurance company-underwriter, and ultimately returns certificates of insurance to the participating members. For these functions, the Administrator receives a commission on the premiums collected.

The insurance company-underwriter negotiates with the Administrator and the association with respect to the benefits and premium rates, and issues a “Master Benefits Policy” to the association. Upon receipt of applications for insurance from the Administrator, the insurance company determines whether to accept the applicant within the range of premiums and benefits defined in the master policy and issues a “Certificate of Insurance” for return to the association member. Out of the gross premium, the insurance company pays the Administrator’s commission, pays its own out-of-pocket expenses, and invests the remainder, called “reserves,” in income-producing securities. From the reserves and the investment income derived therefrom, the insurance company pays all claims under the policies, and, absent any agreement to the contrary, keeps any remainder as profit for itself.

Although the benefits of group insurance were obvious, the main concern of the insurance company-underwriter was fixing a premium that would be attractive to the group and profitable to the company. On the other hand, the association group was concerned with protecting its members against unreasonably high premiums and excessive profits by the Administrator and the insurance company-underwriter.

In the 1950’s, when the association group business first started, the practice of association policyholders’ seeking to limit the Administrator’s commissions or insurance company’s profits did not exist because no one realized that such programs would become so profitable; however, large association policyholders, such as ACS, began to make demands to limit profits so that the cost of the insurance would be reduced. During the 1960’s and 1970’s, agreements limiting commissions and insurance company profits and providing for refunds of any surplus or excess reserves to policyholders began to appear. Such arrangements became commonly known in the insurance industry as “retention basis underwriting” or “retention and dividend agreements.”

“Excess reserves” or “surplus” in a program are distinguished from “claim reserves.” The “claim reserves” are the portion of premium income which, according to the insurance company’s actuarial department, must be set aside to pay presently pending and future claims. The claim reserves are counted as being already among the “losses” under the program, even though the money has not yet been actually paid out. “Excess reserves,” “surplus,” or “contingency reserves” are the amounts remaining that are not considered necessary to pay present or expected claims.

“Retention” is the percentage of premium that by agreement is set aside to cover insurance company out-of-pocket expenses, including commissions paid, plus a certain percentage called the “insurance charge,” in order to provide an agreed-upon profit margin for the insurance company. The insurance company’s investment of the reserves remained an important source of its income in addition to the insurance charge.

Such retention and dividend agreements were negotiated and entered into through correspondence, memoranda, and accounting reports, and have never been written into the master policies themselves. Even when such a “retention and dividend” agreement existed, the master policies have continued to cover only insurance matters such as premium rates and the definitions of the benefits and exclusions under the policy.

ACS is a not-for-profit corporation headquartered in Chicago, whose members are 46,000 physicians who practice surgery throughout the world. LMC is an Illinois insurance corporation organized under the Illinois Insurance Code. It is headquartered in the Chicago area and is part of what is known as “The Kemper Group” of companies.

In the early 1950’s, insurance administrator Charles O. Finley sold the ACS on the concept of offering its members a group insurance program.

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Bluebook (online)
491 N.E.2d 1179, 142 Ill. App. 3d 680, 96 Ill. Dec. 719, 1986 Ill. App. LEXIS 2099, Counsel Stack Legal Research, https://law.counselstack.com/opinion/american-college-of-surgeons-v-lumbermens-mutual-casualty-co-illappct-1986.