Crutchfield ex rel. Crutchfield v. Transamerica Occidental Life Insurance

894 F. Supp. 2d 971, 2012 WL 4212354, 2012 U.S. Dist. LEXIS 133983
CourtDistrict Court, W.D. Kentucky
DecidedSeptember 19, 2012
DocketCivil Action No. 3:10-CV-777-H
StatusPublished
Cited by3 cases

This text of 894 F. Supp. 2d 971 (Crutchfield ex rel. Crutchfield v. Transamerica Occidental Life Insurance) is published on Counsel Stack Legal Research, covering District Court, W.D. Kentucky primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Crutchfield ex rel. Crutchfield v. Transamerica Occidental Life Insurance, 894 F. Supp. 2d 971, 2012 WL 4212354, 2012 U.S. Dist. LEXIS 133983 (W.D. Ky. 2012).

Opinion

MEMORANDUM OPINION AND ORDER

JOHN G. HEYBURN II, District Judge.

Plaintiff brought this lawsuit to recover the cost of her nursing care under her long-term care insurance policy issued by Transamerica Occidental Life Insurance Company (“Transamerica”). Presently before the Court are Plaintiffs Motion for Partial Summary Judgment on this issue and Defendant’s Motion for Summary Judgment on all of Plaintiffs claims. Both motions are fully briefed and the Court will analyze them below.

The central issue disputed is whether Transameriea’s Long-Term Care Insurance Policy (the “Policy”) covers the care Plaintiff has received at Barton House for Alzheimer’s disease. This is a difficult issue because Plaintiff probably would have anticipated coverage in these circumstances. However, the Policy’s specific provisions define its coverage in a manner which does not include Barton House. The Court is left to conclude that Kentucky courts would not extend the doctrine of reasonable expectations to control over the Policy’s unambiguous definitional provisions.

I.

In 1992, Plaintiff purchased the Policy from Defendant, which covers long-term care for necessary diagnostic, therapeutic, rehabilitative, maintenance, and personal care services. The Policy specifically provides a specific monthly payment as a partial reimbursement for Nursing Home Care, Adult Day Care, and Home Health Care as defined in the Policy. Plaintiff has paid all premiums due under the Policy for the past seventeen years.

In 2009, Plaintiff 'was diagnosed with Alzheimer’s disease and became a full-time patient of Barton House. Barton House is a facility licensed to treat and care for Alzheimer’s patients, and it provides 24-hour service with nurses on-duty during day shifts and nurses on-call at all other times. Plaintiff requested benefit payments from Defendant for her care. Defendant denied the request on the basis [974]*974that Barton House was not a facility covered by the Policy.

Plaintiff then filed this action, alleging that the Policy’s Nursing Home Benefits covered her stay and care at Barton House and that Transamerica wrongfully denied those benefits. In her subsequent amended Complaints, Plaintiff alleges that the Policy should cover her care under its Adult Day Care and Home Health Care provisions. She alleges that Defendant’s denial of benefits constitutes a breach of the duties of good faith and fair dealing, misrepresentation, and violations of Kentucky’s Unfair Claims Settlement Practices Act and Kentucky’s Consumer Protection Act.

A motion for summary judgment should be granted where “there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(a). When deciding on a motion for summary judgment, courts “view the factual evidence and draw all reasonable inferences in favor of the nonmoving party.” Banks v. Wolfe Cnty. Bd. of Educ., 330 F.3d 888, 892 (6th Cir.2003) (citing Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 587, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986)).

II.

The central focus of the case is Plaintiffs argument that she is entitled to coverage for care she received at Barton House under the Policy’s Nursing Home Benefits. The construction of an insurance contract begins with the text of the policy itself. If the words employed in it are clear and unambiguous, the Court must apply the terms as written. Nationwide Mut. Ins. Co. v. Nolan, 10 S.W.3d 129, 131 (Ky.1999); see Hugenberg v. West American Ins. Co., 249 S.W.3d 174 (Ky.App.2006) (stating insurance policies should be construed according to the parties’ mutual understanding at the time they entered into the contract, deduced from the language of the contract itself). In the absence of ambiguity, a reasonable interpretation of an insurance contract must be consistent with the parties’ intent as expressed in the plain language of the contract. Brown v. Indiana Ins. Co., 184 S.W.3d 528 (Ky.2005).

A.

The Policy provides three types of long term care benefits and specifically defines each. The pertinent provisions of the Policy that define the Nursing Home Benefits are as follows:

Nursing Home Benefit Conditions. To receive Nursing Home Benefits: 1. Your Physician must initially certify that Your treatment is Medically Appropriate. We may require Your Physician to periodically recertify that Your treatment continues to be Medically Appropriate, but not more frequently than once every 3 months; 2. The charges must be incurred while this Policy is in force; and 3. The care or services must be Provided in a Nursing Home. Prior approval of Nursing Home care is not required. However, care received at a nursing facility which is not in full compliance with the definition of a Nursing Home will still meet the requirements of this Policy, but only if Our Personal Care Advis- or pre-certifies that the facility substantially complies.
Nursing Home. Defined as “A facility, or that part of one, which: 1. is operating under a license issued by the appropriate licensing agency; 2. is engaged in providing, in addition to room and board accommodation, nursing care and related services on a continuing inpatient basis to 6 or more individuals; 3. provides, on a formal prearranged basis, a Nurse who is on duty or on call at all [975]*975times; 4. has a planned program of policies and procedures developed with the advice of, and periodically reviewed by, at least one Physician; and 5. maintains a clinical record of each patient.

These provisions are quite unambiguous by themselves and their application to the Barton House are equally clear. The Policy makes Nursing Home Benefits available in one of two ways: in a facility that is in strict compliance with the Policy’s “Nursing Home” definition or in a nursing facility pre-certified by a Transamerica Personal Care Advisor as substantially complying with the Policy’s “Nursing Home” definition.

Barton House does not satisfy the Policy’s clear definitional requirements of a “Nursing Home.” The parties agree or concede that Barton House lacks “planned procedures developed with the advice of, and periodically reviewed by, at least one Physician.” Eric Vadden, Barton House’s Administrator, noted this deficiency in a Facility Questionnaire submitted in May 2009. On this basis alone, it fails to meet the definition of a “Nursing Home” contained in the Policy. The parties dispute whether Barton House provides “nursing care ... on a continuing inpatient basis” or “maintains a clinical record of each patient.” Consequently, it is also unclear whether Barton House would substantially comply with the Policy’s definitional requirements for a nursing home. Regardless, the Policy unambiguously states that coverage is provided under the substantial compliance provision only if

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Bluebook (online)
894 F. Supp. 2d 971, 2012 WL 4212354, 2012 U.S. Dist. LEXIS 133983, Counsel Stack Legal Research, https://law.counselstack.com/opinion/crutchfield-ex-rel-crutchfield-v-transamerica-occidental-life-insurance-kywd-2012.