Cabra v. Great American Reserve Insurance Co.

509 So. 2d 633, 1987 La. App. LEXIS 9509
CourtLouisiana Court of Appeal
DecidedMay 13, 1987
DocketNo. 86-488
StatusPublished
Cited by2 cases

This text of 509 So. 2d 633 (Cabra v. Great American Reserve Insurance 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
Cabra v. Great American Reserve Insurance Co., 509 So. 2d 633, 1987 La. App. LEXIS 9509 (La. Ct. App. 1987).

Opinion

STOKER, Judge.

The plaintiffs, Barney and Bettye Cabra, filed suit against the defendant, Great American Reserve Insurance Company, following its denial of coverage for medical and hospitalization benefits under a policy of health insurance previously issued to plaintiffs. The trial court awarded judgment in favor of the plaintiffs and against the defendant in the amount of $10,622.48, but denied the plaintiffs’ claim for penalties and attorney’s fees. The defendant has appealed the trial court’s judgment. The defendant asserts on appeal that:

(1) the trial court erred in finding that the plaintiffs had not intentionally misrepresented the claimant’s medical condition on the application for health insurance;
(2) the trial court erred in not finding that the claimant’s back condition was a “pre-existing condition” within the terms and provisions of the policy of health insurance;
(3) the trial court erred in basing its judgment, at least in part, on the alleged statement of one witness that he believed the claim should have been paid; and,
(4) the trial court erred in rendering judgment awarding to plaintiffs the sum [634]*634of $10,622.48, which sum exceeds the benefits payable pursuant to the policy of health insurance.

The issues presented for review are (1) whether Barney Cabra made misrepresentations with intent to deceive on an application for a policy of health insurance which materially affected either the acceptance of the risk or the hazard assumed by the insurer, and (2) whether Bettye Cabra’s degenerative disc disease is a preexisting condition within the terms and provisions of the policy of health insurance issued by the defendant.

FACTS

On February 18, 1985 Barney Cabra filled out an application for health insurance to be issued by Great American Reserve Insurance Company. Bruce Gandy, an agent with the Vandegaer Insurance Agency in Many, Louisiana, assisted Mr. Cabra in completing the application. The standard procedure was that the agent asked the questions on the application and filled in the responses as provided by the applicant. The insurance policy was to be issued to cover both Mr. and Mrs. Cabra. Mrs. Cabra, however, was not with her husband when the application was filled out. Mr. Cabra answered in the negative all of the questions concerning any history of disease, illness or treatment. In response to the question concerning any hospitalizations in the past five years, he listed his surgery in 1984. In response to the question concerning whether they , had been treated by or consulted with a physician in the past two years, he listed a doctor visit for Mrs. Cabra, which was for a physical checkup in 1984. He indicated that the report from the physician was good. Thereafter, a policy of health insurance was issued with an effective date of March 7, 1985.

Mrs. Cabra was admitted into Schumpert Medical Center in Shreveport on May 31, 1985, where she underwent surgery for the excision of a ruptured disc at L-4, L-5. Subsequent to her discharge from the hospital, Mrs. Cabra submitted a claim form to the defendant for hospitalization and medical benefits due under their policy. She indicated on the form that her problem began on approximately May 1, 1985, and that she first sought medical treatment for it on May 21, 1985. In response to the question concerning whether the claimant had received any other medical attention during the past five years, Mrs. Cabra answered no.

The defendant decided to investigate the claim further because the major surgery occurred so soon after the policy was issued. In the course of this investigation, a representative of the defendant telephoned Mrs. Cabra in September concerning the claim. Mrs. Cabra told this person that she had a deteriorating disc and that she had been seeing a chiropractor for years. It was discovered that Mrs. Cabra’s orthopedic surgeon had treated her for a problem with the L-4, L-5 disc in 1979 and 1980. Based upon the information which was obtained during the investigation, the defendant wrote to the plaintiffs informing them that the claim was being denied due to the fact that they had failed to disclose that Mrs. Cabra had been treated previously for the disc problem. The defendant gave the plaintiffs the option of maintaining the policy in force, subject to a rider which would exclude coverage for Mrs. Cabra’s back problems, or rescinding the contract and having their premiums returned. The plaintiffs did not sign and return the rider to the defendant; accordingly, the policy was canceled and the premiums were returned. This lawsuit was subsequently filed by the plaintiffs.

APPLICABLE LEGAL PRINCIPLES

Our brethren on the Second Circuit Court of Appeal recently summarized the legal principles applicable to an insurer’s defense available under LSA-R.S. 22:619 B in Jones v. United Savings Life Insurance Company, 486 So.2d 1110 (La.1986). The court said at pages 1113 and 1114:

“ ‘LSA-R.S. 22:619 provides:
A. Except as provided in Subsection B of this Section and R.S. 22:692, and R.S. 22:692.1, no oral or written misrepresentation or warranty made in the nego[635]*635tiation of an insurance contract, by the insured or in his behalf, shall be deemed material or defeat or void the contract or prevent it attaching, unless the misrepresentation or warranty is made with the intent to deceive.
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.’ ”
“To avoid liability on the grounds of misrepresentation in the application, it must be shown that the material misrepresentations were made fraudulently or with the intent to deceive the insurer and that the misrepresentations materially affected the risk assumed by the insurer. Louisiana jurisprudence requires proof of both factors and the burden of proof is on the insurer. Due to the inherent difficulties in proof of intent, strict proof of fraud is not required to show the applicant’s intent to deceive. The intent to deceive is determined from the surrounding circumstances which indicate the insured’s knowledge of the falsity of the representations made in the application and his recognition of the materiality of his misrepresentations or from circumstances which create a reasonable assumption that the insured recognized the materiality. In order for the misrepresentations made by the applicant to be found material, they must have affected the acceptance of the risk by the insurer. The test of materiality is whether the knowledge of the facts would have influenced the insurer in determining whether to assume the risk or in fixing premiums.
“Even if the information supplied by the applicant was false, if the insurer would have issued the policy anyway, then it is not material. False statements in answer to questions as to consultations with physicians and hospitizations have been held to be material.
“Therefore, the insurer bears a three-tiered burden of proof.

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Related

Viada v. Blue Cross of Louisiana
524 So. 2d 101 (Louisiana Court of Appeal, 1988)
Cabra v. Great American Reserve Insurance Co.
512 So. 2d 436 (Supreme Court of Louisiana, 1987)

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Bluebook (online)
509 So. 2d 633, 1987 La. App. LEXIS 9509, Counsel Stack Legal Research, https://law.counselstack.com/opinion/cabra-v-great-american-reserve-insurance-co-lactapp-1987.