Bischoff v. Old Southern Life Ins. Co.

502 So. 2d 181, 1987 La. App. LEXIS 11202
CourtLouisiana Court of Appeal
DecidedFebruary 4, 1987
Docket86-151
StatusPublished
Cited by13 cases

This text of 502 So. 2d 181 (Bischoff v. Old Southern Life Ins. Co.) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bischoff v. Old Southern Life Ins. Co., 502 So. 2d 181, 1987 La. App. LEXIS 11202 (La. Ct. App. 1987).

Opinion

502 So.2d 181 (1987)

Frederick BISCHOFF, et ux. Plaintiffs-Appellees,
v.
OLD SOUTHERN LIFE INSURANCE COMPANY, Defendant-Appellant.

No. 86-151.

Court of Appeal of Louisiana, Third Circuit.

February 4, 1987.

*182 Brame, Bergstedt (David A. Fraser), Lake Charles, for defendant-appellant.

Kenneth Pitre of Pitre & Assoc., Eunice, for plaintiffs-appellees.

Before DOMENGEAUX, GUIDRY and KNOLL, JJ.

DOMENGEAUX, Judge.

The plaintiffs, Frederick and Bessie Bischoff, brought this suit to recover benefits allegedly due them as insureds under two medical policies issued by the defendant. The trial judge awarded plaintiffs benefits totalling $10,608.57, and pursuant to La. R.S. 22:657, awarded a like amount as penalties and $3,500.00 in attorney's fees.

From this judgment, defendant has appealed. Plaintiffs have answered this appeal and request an increase in the amount of penalties and attorney's fees as well as additional attorney's fees on appeal.

The facts show that in March of 1982, Don Nelson, an agent for Old Southern Life Insurance Company, called upon the plaintiffs at their residence to sell medical insurance to them. The plaintiffs agreed to purchase two policies whereupon the agent began asking questions of the plaintiffs in order for him to fill out their application. He questioned the Bischoffs as to the number of persons to be covered under the policies, specific health questions of each covered family member including prior medical conditions, and he discussed rates and premiums.

It is obvious from the record that Mrs. Bischoff's prior medical history is extensive. She suffers or has suffered from such conditions as diabetes, high blood pressure, phlebitus, stomach and intestional disorders, a heart condition, back problems, nervous condition, gall bladder disorder and obesity. Mrs. Bischoff stated that when the agent completed the application, she informed him of these problems. The agent, however, submitted a "clean" application listing no illnesses or pre-existing conditions on Mrs. Bischoff or any family member.

In September of 1982 and thereafter, the Bischoffs filed a total of six claims with the defendant, five of which were filed on behalf of Mrs. Bischoff and one claim relating to the Bischoff's son. The record indicates that only $1,401.75 was paid to and accepted by the plaintiffs from Old Southern. After sending demand letters to the *183 defendant for payment under the terms of the policy, this action was commenced.

The issues for our determination are:

(1) Whether the policy exclusion for "pre-existing conditions" should bar some or all of the claims made by the plaintiffs;

(2) If not, to what extent do the policies afford coverage;

(3) Whether the trial judge erred in finding that the defendant was arbitrary in failing to timely pay all of the asserted claims thereby subjecting it to penalties and attorney's fees under La.R.S. 22:657;

(4) Whether La.R.S. 22:657 should be interpreted to hold an insurer liable for penalties under the statute equal to 200% rather than 100% of the benefits due under the terms of the policy; and

(5) Whether the attorney's fees awarded should be increased and whether additional attorney's fees should be awarded on appeal.

Concerning the first issue, the defendant contends that the plaintiffs should be denied coverage because of the two year pre-existing condition exclusion, despite the fact that their application listed no prior medical conditions for Mrs. Bischoff or any other family member. Stated another way, the defendant asserts that the plaintiffs made material misrepresentations in their applications by not noting Mrs. Bischoff's prior medical conditions. With respect to the defendant's contention, we are guided by La.R.S. 22:619, which in part provides:

"B. In any application for life or health and accident insurance made in writing by the insured, all statements therein made by the insured shall, in the absence of fraud, be deemed representations and not warranties. The falsity of any such statement shall not bar the right to recovery under the contract unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer." (Emphasis supplied).

In Johnson v. Occidental Life Insurance Company of California, 368 So.2d 1032 (La.1979), the Supreme Court enunciated the burden of proof under La.R.S. 22:619(B) as follows:

"Under this statute, as interpreted by this court in Gay v. United Benefit Life Insurance Co., 233 La. 226, 96 So.2d 497 (1957), the insurer must prove that the applicant's false statements were made with the intent to deceive and that they materially affected the acceptance of the risk or the hazard assumed by the insurer." [Citations omitted].

From the record, it is evident that the applications for insurance are not entirely accurate and that Mrs. Bischoff has consulted or been treated by several physicians in the past five years. The record indicates, however, that the Bischoffs' applications were not completed by them, but by the insurance agent. It is interesting to note that the insurance agent who called on the Bischoffs did not testify in the present case. According to both Mr. and Mrs. Bischoff, the agent asked all of the questions, including the questions concerning their health. Mrs. Bischoff testified that the agent told her that he was only concerned with medical conditions which were treated within the last three years.[1] According to Mrs. Bischoff, she never tried to mislead the agent regarding her earlier illnesses and in fact answered the questions truthfully as posed to her by the agent. Despite her testimony that she related her entire medical history, the agent nevertheless submitted a "clean" application to the defendant.

It is well-settled that the acts of an insurance agent in filling out an application form falsely are the acts of his principal, the insurer, and that they do not bind the *184 innocent insured nor do they bar recovery by him or his beneficiaries. Coolman v. Transworld Life Insurance Company, 482 So.2d 979 (La.App. 3rd Cir.1986); Ryan v. Security Industrial Insurance Company, 386 So.2d 939 (La.App. 3rd Cir.1980); Cloud v. Security General Life Insurance Company, 352 So.2d 406 (La.App. 3rd Cir. 1977); Fruge v. Woodmen of the World Life Insurance Society, 170 So.2d 539 (La. App. 3rd Cir.1965).

The record reflects that the application form did contain false statements. The inaccurate statements, however, were the result of the agent filling out the application falsely and not the applicants. The defendant, thus, has not shown that the plaintiffs made any false representations with an intent to deceive. Inasmuch as the defendant failed in its burden of proving an actual intent to deceive on the part of the plaintiffs, it is unnecessary to determine whether the false statements materially affected the acceptance of the risk or the hazard assumed by the defendant. The defendant's contention that the plaintiffs' claims should be barred are therefore without merit.

Having found that the plaintiffs' claims are not to be barred in this case, we must determine what amount the defendant owes under the two insurance policies. The first policy is a "Hospital and Surgical Expense Policy" and the second is entitled "Excess Major Medical Expense Policy".

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Bluebook (online)
502 So. 2d 181, 1987 La. App. LEXIS 11202, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bischoff-v-old-southern-life-ins-co-lactapp-1987.