Breeding v. Fireman's Fund American Life Insurance

499 N.E.2d 890, 27 Ohio App. 3d 81, 27 Ohio B. 101, 1985 Ohio App. LEXIS 10288
CourtOhio Court of Appeals
DecidedAugust 15, 1985
Docket9365
StatusPublished
Cited by3 cases

This text of 499 N.E.2d 890 (Breeding v. Fireman's Fund American Life Insurance) is published on Counsel Stack Legal Research, covering Ohio Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Breeding v. Fireman's Fund American Life Insurance, 499 N.E.2d 890, 27 Ohio App. 3d 81, 27 Ohio B. 101, 1985 Ohio App. LEXIS 10288 (Ohio Ct. App. 1985).

Opinion

Wolff, J.

The appellant, Edward Breeding, appeals from the judgment of the common pleas court sustaining ap-pellee Fireman’s Fund American Life Insurance Company’s (“Fireman’s”) motion for summary judgment, and overruling his motion for summary judgment.

He assigns as error the sustaining of Fireman’s motion for summary judgment and the overruling of his motion for summary judgment.

Breeding’s complaint alleged that Fireman’s had violated R.C. 3917.06(E) and 3923.122(A), but Breeding has limited his appeal to whether the trial court correctly concluded that Fireman’s had complied with R.C. 3923.122(A), which provides:

“Every policy of group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only, and delivered, issued for delivery, or renewed in this state on or after January 1, 1976, shall include a provision giving each insured the option to convert to any of the individual policies of hospital, surgical, or medical expense insurance then being issued by the insurer with benefit limits not to exceed those in effect under the group policy.” (Emphasis added.)

The controversy is whether Fireman’s issues more than one individual policy of hospital, surgical, or medical expense insurance.

From the affidavit in support of Fireman’s motion for summary judgment, it is evident that Fireman’s claims it issues only one individual policy of medical insurance in Ohio.

From the affidavits in support of Breeding’s motion for summary judgment, it appears that in addition to the policy claimed by Fireman’s to be its sole individual policy, Fireman’s issues a “Mini Fund” policy, and that Fireman’s sent a brochure about the Mini Fund policy to a lawyer associated with Breeding’s counsel in response to that lawyer’s phone call to Fireman’s main business office and statement to one Kathy Fitzgerald of that office “that I wanted to purchase an individual policy of hospital and medical insurance.”

Breeding claims the Mini Fund is an individual policy, and that Fireman’s denied him the statutorily mandated “option to convert to any of the in *83 dividual policies * * * issued by the insurer.”

Fireman’s claims the Mini Fund is a group policy, although, according to the affidavit of Kristeen Labutzke, Fireman’s Assistant Vice President, Group Underwriting, it is “sold to groups of one or more employees” (emphasis added).

Breeding is unemployed.

Breeding argues that the Mini Fund is an individual policy because it does not meet the statutory definition of group insurance found at R.C. 3923.12(A):

“Group sickness and accident insurance is that form of sickness and accident insurance covering groups of persons, with or without one or more of their dependents and members of their immediate families, and issued upon one of the following bases:
“(1) Under a policy issued to an employer, who shall be deemed the policyholder, insuring at least ten employees of such employer, for the benefit of persons other than the employer;
“(2) Under a policy issued to an association, including a labor union, which has a constitution and bylaws and which has been organized and is maintained in good faith for purposes other than that of obtaining insurance, insuring at least twenty-five members of the association for the benefit of persons other than the association or its officers or trustees, as such;
“(3) Under a policy issued to any other substantially similar group which, in the discretion of the superintendent of insurance, may be subject to the issuance of a group sickness and accident policy;
“(4) Under a policy issued in accordance with section 3923.121 of the Revised Code.” (Emphasis added.)

Breeding argues that a “group of one” is a contradiction in terms. Furthermore, he argues that the Mini Fund is not a third-party beneficiary arrangement that characterizes most group policies, and specifically characterizes the group insurance definitions at R.C. 3923.12(A)(1) and (2).

Fireman’s argues that the Mini Fund qualifies as group insurance under R.C. 3923.12(A)(3). Utilizing descriptive material presented in the trial court, consisting of attachments 1 and 2 to the Labutzke affidavit, Fireman’s points out that eligibility is extended to gainfully employed persons who work at least thirty hours per week, forty-eight weeks per year; that insureds have group numbers; that the Mini Fund provides for conversion to individual policies upon termination of employment; and that the Mini Fund plan is uniquely designed to provide group insurance to employed persons who would not otherwise qualify for a group plan because of minimum size, participation and contribution requirements.

Furthermore, Fireman’s claims that because there is no evidence of disapproval by the Superintendent of Insurance of the Mini Fund pursuant to R.C. 3923.02, it follows that the Mini Fund is “group insurance” under 3923.12(A)(3).

The trial court issued a terse ruling finding that there was no genuine issue as to any material fact in regards to Fireman’s compliance with its policy requirements and the statutory provisions contained in R.C. 3917.06 and 3923.122.

Implicit in the trial court’s finding was the fact that the Mini Fund is a group policy.

The question on appeal is whether there was a material issue of fact upon which reasonable minds might disagree on this matter.

Unquestionably, the Mini Fund is promoted as group insurance. The materials before the trial court are replete with language describing the Mini Fund as group insurance. To be sure, the Mini Fund is available to “groups of one,” but these groups of one *84 must be employed. While the Mini Fund provides for groups of one, the emphasis is on larger groups:

“Renewal premiums may be increased on any premium due date, but not until a participating employer [not employee] has participated under the policy for 12 consecutive months. (It is possible for an insured’s premium to increase during the first 12 months that he is insured if he joins the group after the initial enrollment for that group.)” (Emphasis added.)
“Writing the Group(.) 1) Complete Mini Fund Application for Insurance. A. All applicants must be gainfully employed (working a minimum of 30 hours per week) * * * 2) Complete Mini Fund Employer Group Application. Must be signed by employer, or person authorized to purchase insurance for the firm, if not self-employed.”
“CONVERSION: If employment terminates any covered individual who has been insured for the applicable time period set forth in the master policy may convert their [sic]

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

Related

Deutsche Bank National Trust Co. v. Pevarski
932 N.E.2d 887 (Ohio Court of Appeals, 2010)
Bengala v. Doe, Unpublished Decision (12-24-2003)
2003 Ohio 7104 (Ohio Court of Appeals, 2003)
Schnabel v. Philadelphia American Life Insurance
795 F. Supp. 816 (S.D. Texas, 1992)

Cite This Page — Counsel Stack

Bluebook (online)
499 N.E.2d 890, 27 Ohio App. 3d 81, 27 Ohio B. 101, 1985 Ohio App. LEXIS 10288, Counsel Stack Legal Research, https://law.counselstack.com/opinion/breeding-v-firemans-fund-american-life-insurance-ohioctapp-1985.