Carsten v. Aetna Life Insurance Co.

247 N.W.2d 679, 1976 S.D. LEXIS 149
CourtSouth Dakota Supreme Court
DecidedDecember 16, 1976
DocketNo. 11702
StatusPublished
Cited by2 cases

This text of 247 N.W.2d 679 (Carsten v. Aetna Life Insurance Co.) is published on Counsel Stack Legal Research, covering South Dakota Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Carsten v. Aetna Life Insurance Co., 247 N.W.2d 679, 1976 S.D. LEXIS 149 (S.D. 1976).

Opinions

WINANS, Justice.

This is an appeal from an order granting summary judgment to defendant, Aetna Life Insurance Company. Plaintiff, Guy Carsten, alleges error because a genuine issue of material fact exists that prevents entry of judgment as a matter of law. We agree.

We examine the evidence, as we must, in a light most favorable to the non-moving party. Wilson v. Great Northern Railway Co., 1968, 83 S.D. 207, 157 N.W.2d 19. On March 1, 1968 Aetna issued a group policy (# 58520) to C. P. Clare & Co., Rapid City, South Dakota. On February 10,1969, plaintiffs wife was employed by C. P. Clare and applied for group coverage on March 1, 1970. Mrs. Carsten went to see Dr. E. T. Ruud of Rapid City on March 26, 1971; he discovered that she had transitional cell carcinoma of the right frontal sinuses. The records of C. P. Clare show that Mrs. Car-sten worked a full day on March 26th and part of the day on March 27, 1971. On March 31,1971 her termination papers were completed; the form showed that termination was voluntary and by way of explanation stated “Doctor’s orders due to illness.”

Shortly thereafter Mrs. Carsten completed an application for a life conversion policy which was available under the provisions of the group plan. Although the application was dated April 30, 1971, which would be too late to effectuate a conversion, the premium check was dated April 13. The life conversion policy was later issued effective May 1, 1971 (Policy # N 2,762,690); the policy was for $4,000.00 and listed the plaintiff as beneficiary.

On May 17, 1971 Juliette Theroux, Group Services Department, Fall River, Mass., acknowledged receipt of the conversion application but requested information on the date of cancellation and amount of coverage before processing the conversion. On May 26,1971 she received the reply from C. P. Clare & Co. listing termination as of March 27,1971. On June 8th the Fall River office notified the Chicago office that the conversion application was refused because not made within the 31 days allowed by the group policy.

On June 30, 1971 Mr. Carsten sent a letter to Ronald Karlic, Senior Field Underwriter in the Chicago office, asking why he had not received the life conversion policy. He pointed out that the premium check dated April 13th had been cashed. Mr. Carsten also wrote to the claim office in Minneapolis, Minn., submitting medical bills for an operation performed on Mrs. Carsten in Rochester. (The health provisions of the group plan were converted on March 28, 1971 — policy # GHC 617040).

On July 17,1971 Ms. Theroux, responding to an inquiry from Debbie Goralski of the Chicago Life Underwriting office which sought the whereabouts of the life conver[681]*681sion policy, wrote that the application had been denied as not timely and directed the refund of premiums. Ms. Goralski responded on July 19 that April 13 was the proper application date; this prompted Theroux to request a copy of the premium check on August 8, 1971. Finally on August 25, Theroux notified the Chicago office that the conversion application was accepted. The Life Underwriting Department issued the policy September 2, 1971, effective May 1, 1971.

In the meantime Ms. Betty Wagner, Group Claims Dept, in Minneapolis was handling the medical claims. On July 7, 1971 she requested an operative report from Dr. Zanka, who had performed the Rochester operation on Mrs. Carsten. She also informed Mrs. Carsten that she was working on the claim. On August 3, she received some forms she had evidently requested from Mr. Carsten; he also informed her that he was sending two disability reports to Mr. Karlic in Chicago. Ms. Wagner contacted Mr. Karlic on August 12, explaining that a conversion policy was in effect; that Mr. Carsten felt extended benefits might be available under the group plan; and asking for a decision on the availability of extended medical coverage through C. P. Clare & Co. Karlic replied on August 19 that it was not his decision whether extended benefits were available. “I am just a life agent with the Aetna Life agency which handled the conversion of her life insurance policy.” He included two doctor’s reports: one dated July 20, 1971 from Dr. Kenneth Devine in Rochester, Minn., which stated “Mrs. Carsten is indefinitely disabled . . . one dated July 30, from Dr. Ruud which dated disability from March 26, 1971.

Ms. Wagner advised Mr. Carsten of this correspondence on September 2, 1971 and requested a letter from C. P. Clare & Co. on whether there was extended coverage eligibility. She said it was their decision. C. P. Clare & Co. then referred the matter to Clifton Smiley, Claim Coordinator for Group Claims, Elmhurst, Ill. After reviewing the file, he notified C. P. Clare on October 13, 1971 that “we have no choice but to deny any liability for disability benefits.” Because he thought March 26 to be the last day of work, as well as the date of disability, he reasoned that total disability did not exist at termination, else Mrs. Car-sten could not have worked a full day. He acknowledged Dr. Ruud’s opinion but stated, “the diagnosis is of a type that would not be immediately disabling.”

On October 14, 1971 Ms. Wagner wrote Mr. Carsten that she had still received no decision from C. P. Clare and that she could not process the medical claims until she knew whether extended benefits were available. On November 19, 1971 Mr. Car-sten wrote to Smiley referring to the latter’s letter to C. P. Clare. He enclosed a November 11 letter by Dr. Ruud which explained that Mrs. Carsten was totally disabled as of March 26. Smiley requested information on the first time Mrs. Carsten had seen a physician and the number of physicians she had seen from Dr. Ruud, who responded on December 16 that first contact was March 26 and that he was the only physician prior to that time.

On January 3,1972 Smiley again wrote to C. P. Clare explaining why extended benefits were denied. He indicated a different result might follow if Mrs. Carsten had not worked a full day on her last day of work. On January 5, the company’s termination report was sent to Smiley indicating that Mrs. Carsten had worked a full day on March 26 and a copy was sent to Mrs. Carsten. As a result of a telephone conversation with Mr. Carsten, it was determined that March 27 was the proper date of termination and that this had not been a full day of work. Consequently, Smiley notified Mrs. Carsten on January 17 that there would now be extended coverage available and asking whether she had purchased a group conversion policy.

Mr. Carsten provided Smiley with the policy number of the medical conversion policy as well as a list of premiums paid on January 25,1972. He also included a list of premium payments on the converted life policy and requested a refund of all premi[682]*682ums. On February 3, he received a letter from Mrs. Wagner stating that extended medical benefits were available, but that there could be no premium refunds. She advised him to' write to the office that issued the policy about the premiums. On February 4 Smiley wrote a similar letter to Mrs. Carsten saying that the reimbursement question had been directed to Ms. Wagner. “It is quite possible that no reimbursement will be available.” He said that it was for the home office to verify this position.

The next correspondence was not until May 20, 1972 when Mr. Carsten sent a letter to C. P. Clare & Co.

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Bluebook (online)
247 N.W.2d 679, 1976 S.D. LEXIS 149, Counsel Stack Legal Research, https://law.counselstack.com/opinion/carsten-v-aetna-life-insurance-co-sd-1976.