Cataldie v. La. Health Service & Indem. Co.

433 So. 2d 367
CourtLouisiana Court of Appeal
DecidedMay 25, 1983
Docket83-50
StatusPublished
Cited by10 cases

This text of 433 So. 2d 367 (Cataldie v. La. Health Service & Indem. 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
Cataldie v. La. Health Service & Indem. Co., 433 So. 2d 367 (La. Ct. App. 1983).

Opinion

433 So.2d 367 (1983)

Sam V. CATALDIE, Jr., Individually and as Administrator of the Estate of his minor child, Amie Cataldie, Plaintiff-Appellee,
v.
LOUISIANA HEALTH SERVICE AND INDEMNITY COMPANY, Defendant-Appellant.

No. 83-50.

Court of Appeal of Louisiana, Third Circuit.

May 25, 1983.
Rehearing Denied July 14, 1983.

*368 Trimble, Randow, Percy, Smith, Wilson & Foote, Lon P. Wilson, Alexandria, for defendant-appellant.

Antoon, Dalrymple & Beck, Joseph T. Dalrymple, Alexandria, for plaintiff-appellee.

Before DOMENGEAUX, FORET and CUTRER, JJ.

DOMENGEAUX, Judge.

This suit was brought by Sam V. Cataldie, Jr., individually and as administrator of the estate of his minor child, Amie Cataldie, seeking a declaratory judgment on a policy of hospitalization insurance issued by the defendant, Louisiana Health Service and Indemnity Company. Pursuant to a stipulation of facts as agreed upon by the parties, the case was submitted to the trial court which subsequently rendered judgment in favor of the plaintiff. The defendant thereafter perfected this appeal.

The facts of this case are not in dispute. The plaintiff and defendant entered into a non-group family hospitalization and surgical medical contract, which policy went into effect on September 1, 1978. At the inception of the policy, it provided major medical coverage in the amount of $250,000.00 with a deductible of $100.00 and a quarterly premium of $244.67. As of March 15, 1981, the major medical deductible had increased to $300.00 with a $50.00 hospital deductible, and the quarterly premium had increased to $330.96. As of January 1, 1982, premiums were again raised to $346.02 per quarter. The premium payable on a single coverage policy as of that date was $161.73 per quarter.

Amie Cataldie was diagnosed as suffering from brain cancer in April of 1981, and treatment of the cancer was commenced thereafter. This treatment was started well after the inception of the contract between the plaintiff and the defendant under which Amie Cataldie was insured.

The defendant timely paid all benefits for services rendered to the plaintiff's daughter prior to May 15, 1982, the sum of which totalled $41,266.21. The amount of premiums paid by the Cataldies prior to that date totalled $4,189.08.

However, on May 15, 1982, the defendant substantially altered the terms of the plaintiff's policy, increasing the quarterly premium to $614.64, increasing the deductible to $5,000.00, and reducing major medical coverage to $20,000.00 lifetime coverage with maximum yearly coverage of $10,000.00. The validity of the notice given by the defendant to the plaintiff of the policy amendment and premium increase is not disputed. On June 1, 1982, apparently because of the drastic modification of the insurance contract by the defendant, the plaintiff cancelled the family coverage policy, but left Amie Cataldie covered under a single coverage policy.

Shortly after the amendment to the policy, the plaintiff instituted this suit for a declaratory judgment, seeking to determine whether or not the defendant could, upon giving timely and proper notice, amend or *369 cancel the coverage provided, and if so, whether this amendment or cancellation of coverage would apply to those services rendered to Amie Cataldie after the effective date of the amendment or termination of the policy. Judgment was rendered in favor of the plaintiff, thereby reinstating all health care benefits provided under the health and accident insurance policy between the plaintiff and defendant as it existed on the date of its inception (August 14, 1978, according to the judgment), with reinstatement of the initial premium as well (listed in the judgment as $246.13 per quarter).

The defendant makes several specifications of error on appeal, all but one of which are essentially undisputed by the plaintiff. Both parties are in agreement that the trial judge erred in specifying that the original insurance contract went into effect on August 14, 1978, rather than September 1, 1978, as stipulated by the parties. They also agree that the judge erred in stating that the initial premium was $246.13 per quarter rather than $244.67 per quarter. Furthermore, both parties recognize that the trial judge erred in reinstating the terms and conditions of the policy as it existed at its inception, when Amie Cataldie's illness was not diagnosed until April, 1981. Finally, the plaintiff and defendant acquiesced in the fact that the trial judge erred in apparently reinstating the insurance policy as to the entire Cataldie family when no member of that family other than Amie Cataldie was suffering from an illness or disease as of May 15, 1982, the day that the policy was substantially modified.

We agree that the district court was in error for the reasons specified, supra. Thus, we shall herein amend the judgment of the district court accordingly.

The key area of disagreement between the plaintiff and the defendant concerns whether or not the defendant had the right to terminate or modify the plaintiff's insurance policy at its own option upon giving the plaintiff timely notice of its intentions; and if so, whether or not expenses for services rendered to the plaintiff's daughter after the effective date of termination or modification of the policy pursuant to treatment of an illness contracted by her prior to such date were covered by the prior policy. We find herein that for reasons of public policy, the defendant was required to continue to provide coverage after May 15, 1982, under the terms of the insurance policy as it was written prior to that date, but only for those medical expenses incurred by Amie Cataldie pursuant to her ongoing treatment for cancer.

It is a well-settled legal principle that a valid insurance policy is a contract between the insured and the insurer, and as is true of all other contracts, it is the law between them. La.C.C. Article 1901; Hall v. National Life and Accident Insurance Company, 383 So.2d 74 (La.App. 3rd Cir. 1980). Where the language of the policy is free and clear of ambiguity, it constitutes the contract between the parties and must be enforced as written. In addition, insurers have the same rights as individuals to limit their liability and to impose whatever conditions they please upon their obligations under the policy in the absence of conflict with laws or public policy. Hall, supra.

La.R.S. 22:212(8) allows a policy of health and accident insurance to be subject to cancellation at the option of the insurer provided that "... there shall be prominently printed on the first page of such a policy a statement so informing the policyholder." The policy in question clearly provided on the first page that "The plan or the Member may cancel the Contract with 30 days written notice." This language is clear and unambiguous, and is in compliance with the above statutory provisions. The defendant maintains that if it can cancel a policy of hospitalization insurance upon giving notice, that it can certainly modify the policy upon providing the same notice. There is basically no disagreement between the plaintiff and the defendant on this particular issue.

The paramount issue in this case, therefore, is not whether the insurer has the right to cancel or modify a policy of *370 insurance simply by giving proper notice. Rather, the issue is whether or not an insurer may arbitrarily and without providing just cause

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