Buell v. Security General Life Insurance

987 F.2d 1467
CourtCourt of Appeals for the Tenth Circuit
DecidedMarch 3, 1993
DocketNos. 92-1038, 92-1063, 92-1040 and 92-1058
StatusPublished
Cited by1 cases

This text of 987 F.2d 1467 (Buell v. Security General Life Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Tenth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Buell v. Security General Life Insurance, 987 F.2d 1467 (10th Cir. 1993).

Opinion

TACHA, Circuit Judge.

Patricia Buell, the plaintiff in the district court, brought suit against her health insurance provider, Security General Life Insurance Co., seeking a declaratory judg[1469]*1469ment that she is covered under her policy and seeking damages for breach of contract, breach of implied covenant of good faith and fair dealing, negligent misrepresentation, and outrageous conduct. The district court entered a declaratory judgment against defendant-appellant/cross-ap-pellee Security General finding that the policy at issue was ambiguous .and should therefore be construed in favor of coverage for plaintiff. 779 F.Supp. 1573. Memorandum Opinion and Order at 1-2, Appellant’s App., Vol. II at B432-33. Defendant appeals from this judgment. The court further held that, because defendant had continued to provide benefits to plaintiff during the course of the litigation, there had been no breach of contract, and that plaintiff had failed to demonstrate the presence of issues of material fact regarding her claims of breach of the implied covenant of good faith and fair dealing, negligent misrepresentation, and outrageous conduct. Id. at B433. Plaintiff appeals the district court’s grant of summary judgment to defendant on those issues, as well as the district court’s refusal to consider her additional evidence offered pursuant to Fed. R.Civ.P. 59(e). 784 F.Supp. 1533.1

In 1983, American Life and Casualty Insurance Company (American Life) delivered to Consumer Health Care Association (CHCA) a group health insurance policy. In 1984, plaintiff was issued a Certificate of Group Insurance as evidence of the insurance provided under the policy. Defendant Security General later purchased from American Life the rights and insurance liability risks represented by the policy.

In 1986, plaintiff was diagnosed with lung cancer, and in 1990, defendant terminated the group policy. Plaintiff brought a declaratory judgment action arguing that her benefits should continue despite this termination. The district court correctly concluded that, with regard to the coverage issue, the determining factor was whether the policy is one for “expenses” or one for “injury.” Id. at B436. If the policy is one for expenses, defendant is liable for medical and hospital related expenses as those expenses are incurred, and plaintiff loses the right to benefits when the policy terminates. Lister v. American United Life Ins. Co., 797 P.2d 832, 834 (Colo.Ct.App.1990). Alternatively, if the policy is an “injury” policy, it covers expenses arising from a covered injury if that injury occurs while the policy is in force. See Loesekan v. Benefit Trust Life Ins. Co., 37 Colo.App. 493, 552 P.2d 36, 37 (1976). Under an “injury” policy, expenses arising out of a covered injury which occurred while the policy was in force are paid even if the policy has terminated.

“An insurance policy is a contract which should be interpreted consistently with the well settled principles of contractual interpretation.” Chacon v. American Family Mut. Ins. Co., 788 P.2d 748, 750 (Colo. 1990). “Interpretation of a written contract is generally a question of law for the court subject to independent reevaluation by an appellate court.” Underdown v. Kissell, 817 P.2d 617, 618-19 (Colo.Ct.App.1991).

Whether the terms of a contract are ambiguous is a matter of law for the court to decide. To ascertain whether contract provisions are ambiguous, language must be construed according to the plain and generally accepted meaning of the words used, and reference must be made to all provisions of the agreement. A difference of opinion regarding the interpretation of an instrument does not, by itself, create an ambiguity.

Zimmerman Metals, Inc. v. United Eng’rs & Constructors, Inc., Sterns-Roger Div., 720 F.Supp. 859, 860 (D.Colo.1989) (construing Colorado law) (citations omitted). “Extrinsic evidence and presumptive rules in aid of construction may be used only if the instrument itself is ambiguous, unclear, or uncertain as to the meaning the parties intended by it.” Barnes v. Van Schaack Mortgage, a Div. of Van Schaack & Co., [1470]*1470787 P.2d 207, 209 (Colo.Ct.App.1990). Because the district court here considered the policy to be ambiguous, it went beyond the policy language and read the policy in conjunction with Colorado statutory law. The court also construed the policy in favor of the insured. See Chacon, 788 P.2d at 750.

The policy provides:

When as a result of sickness or accidental bodily injury, an Insured Person incurs Covered Expenses shown herein while this insurance is in force as to such Person, the Company will pay the applicable percentage, shown in the Policy Specifications, of such expenses incurred in excess of the Deductible Amount, not to exceed the Maximum Amount.

Appellant’s App., Vol. I at B074. Covered Expenses are defined as “the Usual and Customary charges for [specified] services, supplies and treatment when medically necessary and when ordered by a Physician and Surgeon_” Id. at B075. The district court concluded that the policy could reasonably be construed as either an expense policy or an injury policy. We disagree and reverse the district court’s declaratory judgment in favor of plaintiff.

Defendant correctly argues that the obligation to pay benefits under this policy is triggered only when an expense is incurred and not because an injury or illness has occurred during the life of the policy. Liability attaches only when the insured incurs “Covered Expenses ... while this insurance is in force.” “Covered Expenses,” defined as the charges for supplies and service, do not accrue prospectively for an illness that may have occurred during the coverage period. It is only when the insured actually incurs expense during the term of the policy that defendant is obligated to pay benefits. Because this policy provides coverage for expenses, as they are incurred, it is indistinguishable on that issue from the policy in Lister, and does not entitle plaintiff to post-termination benefits. See Lister, 797 P.2d at 834.

The district court identified no language in the policy which created an ambiguity, nor do we find any. Instead, the district court reasoned backwards from Colo.Rev. Stat. § 10-8-116(2)(b)(V) to conclude that this was an injury policy.2 The court reasoned that, because the statute requires expense policies to contain a conversion privilege, and because this policy did not contain such a privilege, it, therefore, was not an expense policy.

We acknowledge that, by operation of law, Colorado insurance statutes are an implied part of policies governed by Colorado law. Crowley v. Hardman Bros., 122 Colo. 489, 223 P.2d 1045, 1050 (1950) (“[legislation in force at the time of the issuance of the policy became part and parcel thereof as definitely as if written therein.”).

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987 F.2d 1467, Counsel Stack Legal Research, https://law.counselstack.com/opinion/buell-v-security-general-life-insurance-ca10-1993.