American Investors Life Insurance v. Butler

65 S.W.3d 472, 76 Ark. App. 355, 2002 Ark. App. LEXIS 9
CourtCourt of Appeals of Arkansas
DecidedJanuary 23, 2002
DocketCA 01-533
StatusPublished
Cited by7 cases

This text of 65 S.W.3d 472 (American Investors Life Insurance v. Butler) is published on Counsel Stack Legal Research, covering Court of Appeals of Arkansas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
American Investors Life Insurance v. Butler, 65 S.W.3d 472, 76 Ark. App. 355, 2002 Ark. App. LEXIS 9 (Ark. Ct. App. 2002).

Opinion

Andree LAYTON Roaf, Judge.

Dianne Roxanne Butler, appellee, sued appellant, American Investors Life Insurance Company (“American Investors”), her health insurance provider, to recover medical expenses that she incurred for a procedure known as high dose chemotherapy autologous stem cell transplantation (“HDC”), which was recommended by her doctor for treatment of her metastatic breast cancer. The trial court denied American Investors’s motion for summary judgment and partially granted Buder’s motion for summary judgment because the insurance-policy exclusion dealing generally with experimental treatment was ambiguous and because American Investors had not relied on that exclusion. The jury returned a verdict in favor of Butler in the amount of $97,813.58, and judgment was entered in that amount plus a twelve-percent statutory penalty, prejudgment interest, costs, and attorney’s fees. American Investors brings this appeal, claiming that the trial court erred in granting summary judgment to Butler and in denying its motions for directed verdict and for judgment notwithstanding the verdict. We affirm on both points.

In April 1998, while insured under a health-insurance policy issued by American Investors, Butler, age 35, was diagnosed with breast cancer. Following surgery for removal of the breast cancer, Butler received standard-dose chemotherapy and radiation treatment. Butler consulted with Dr. William Walsh, an oncologist, who advocated that Butler also undergo HDC because the surgery indicated that she had metastatic cancer in five of her lymph nodes. In June 1998, a request for preauthorization for the HDC procedure was first submitted to American Investors. As required by the policy, Dr. Walsh forwarded information to American Investors informing them that Butler met each of the criteria necessary for preauthorization of HDC and that the procedure was medically necessary. Dr. Irvin Fleming and Dr. Christine Mroz also wrote letters to American Investors recommending HDC for Butler based on her disease characteristics. The HDC procedure was to begin in July 1998.

After obtaining independent reviews from two other medical oncologists, Dr. Joyce O’Shaughnessy and Dr. Christopher Desch, in October 1998, American Investors denied preauthorization for the procedure by letter dated November 4, 1998, stating that the medical data did not suggest that HDC was more beneficial than standard treatment. Butler underwent the HDC procedure in November and December 1998, despite American Investors’s denial of authorization, and filed suit to recover her medical expenses in the amount of $95,264.58. American Investors filed a motion for summary judgment, claiming that the policy provided no coverage for HDC in Butler’s case. The trial court denied this motion for summary judgment, but partially granted Butler’s motion for summary judgment, finding that language contained in a policy exclusion regarding experimental or investigational treatment was ambiguous. Further, the trial court found that American Investors did not rely on this exclusion in denying coverage. The jury returned a verdict in favor of Buder in the amount of $97,813.58, and the trial court entered judgment in this amount, plus a twelve-percent statutory penalty of $11,737.63, prejudgment interest of $11,673.31, costs of $5,928.61, and attorney’s fees of $36,000. American Investors brings this appeal from the judgment.

American Investors first argues that the trial court erred in granting summary judgment to Buder on the basis that the policy exclusion for experimental treatment was ambiguous and unenforceable. Summary judgment is to be granted by the trial court only when there are no genuine issues of material fact to be litigated, and the moving party is entitled to judgment' as a matter of law. Stockton v. Sentry Ins., 337 Ark. 507, 989 S.W.2d 914 (1999). In reviewing a grant of summary judgment, an appellate court determines if summary judgment was appropriate based on whether the evidentiary items presented by the moving party in support of the motion left a material question of fact unanswered. Id.

The trial court granted partial summary judgment to Butler, finding that the exclusion in the policy for experimental treatment did not apply as it was ambiguous, and that American Investors did not rely on that exclusion at the time of denial of Buder’s claim. The relevant provision of this exclusion is as follows:

Experimental or Investigational Treatment. Services and supplies that are, in [o]ur judgment, experimental or investigational for the diagnosis of the Insured Person being treated are excluded. Also excluded are services and supplies which support or are performed in connection with the experimental or investigational procedure. We shall have full discretion to determine whether services and supplies are experimental or investigational.

This provision further clarifies when a medical treatment may be deemed experimental or investigational, and in particular, states that a medical treatment that is the subject of ongoing phase I, II, or III clinical trials or is otherwise under study to determine its efficacy, as compared with a standard means of treatment, may be found to be experimental at American Investors’s discretion. The procedure at issue in this case, HDC, was the subject of phase III trials for breast cancer at Butler’s stage of development, and the trial court found that this procedure would be experimental under this provision, if it applied. However, the trial court found that the phrase “experimental or investigational for the diagnosis of the Insured Person” was ambiguous in that it was not clear whether “for the diagnosis” modified experimental, investigational, or both. Following the rule of insurance contract construction that requires the court to resolve ambiguities in the policy in favor of the insured, the trial court found that “for the diagnosis” modified experimental and investiga-tional, and because the procedure at issue was for the treatment, not the diagnosis, of the insured, found that this provision did not apply in this case.

American Investors argues that this provision is not ambiguous, and we agree. The construction and legal effect of a written contract is a matter to be determined by the court, not the jury, except when the meaning of the language depends upon disputed extrinsic evidence. Smith v. Prudential Property & Cas. Ins., 340 Ark. 225, 10 S.W.3d 846 (2000). Language is ambiguous when there is doubt or uncertainty as to its meaning or it is fairly susceptible of two interpretations. Id. Where the language in an insurance policy is ambiguous, the court must adopt the interpretation that is favorable to the insured. Id. However, language in an insurance policy should be construed in its plain, ordinary, and popular sense. Tri-State Ins. Co. v. Sing, 41 Ark. App. 142, 850 S.W.2d 6 (1993).

Here, it seems clear by reading the entire provision, including the caption, “Experimental or Investigational Treatment,” that “for the diagnosis” modifies only “investigational.” Otherwise, only diagnostic services and supplies would be excluded under this clause, when it clearly pertains to both treatment and diagnosis.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Shamburger v. Shamburger
2016 Ark. App. 57 (Court of Appeals of Arkansas, 2016)
Patel v. Lawyers Title Ins. Corp.
2013 Ark. App. 670 (Court of Appeals of Arkansas, 2013)
Millwood-RAB Marketing, Inc. v. Blackburn
236 S.W.3d 551 (Court of Appeals of Arkansas, 2006)
Denton v. Pennington
119 S.W.3d 519 (Court of Appeals of Arkansas, 2003)
Buie v. Certain Underwriters at Lloyds of London
87 S.W.3d 832 (Court of Appeals of Arkansas, 2002)
Rhodes v. Farmers Insurance Co.
86 S.W.3d 401 (Court of Appeals of Arkansas, 2002)

Cite This Page — Counsel Stack

Bluebook (online)
65 S.W.3d 472, 76 Ark. App. 355, 2002 Ark. App. LEXIS 9, Counsel Stack Legal Research, https://law.counselstack.com/opinion/american-investors-life-insurance-v-butler-arkctapp-2002.