Dupuis v. Tiger Oil International, Inc.

444 So. 2d 1379, 1984 La. App. LEXIS 7987
CourtLouisiana Court of Appeal
DecidedFebruary 1, 1984
DocketNo. 83-395
StatusPublished
Cited by1 cases

This text of 444 So. 2d 1379 (Dupuis v. Tiger Oil International, Inc.) 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
Dupuis v. Tiger Oil International, Inc., 444 So. 2d 1379, 1984 La. App. LEXIS 7987 (La. Ct. App. 1984).

Opinion

KNOLL, Judge.

This case involves a determination of medical benefits due under a group hospitalization insurance policy. The trial court rendered judgment in favor of the insured, Noah Dupuis, and against his former employer, Tiger Oil Incorporated (hereafter Tiger Oil) and its group insurer, Prudential Insurance Company of America (hereafter Prudential), finding the defendants arbi[1381]*1381trary and capricious, and awarding $7,575.04 for past due medical bills and statutory penalties, together with an additional $5,000 for attorney’s fees.

Tiger Oil and Prudential suspensively appealed the judgment of the trial court, raising the following issues:

1. Whether the trial court erred in its determination that Tiger Oil’s group insurance policy with Prudential provided maternity benefits for Leah Dupuis and dependent’s coverage for her son, Derek Dupuis;
2. Whether the trial court erred in its calculation of medical benefits;
3. Whether the trial court erred in finding the defendants arbitrary and capricious under LSA-R.S. 22:657; and,
4. Whether the trial court erred in its allocation of court costs.

FACTS

Noah Dupuis was employed with Tiger Oil from February to August of 1979, and participated in the company’s group hospitalization program with Prudential. Leah Dupuis was a named dependent under her husband’s Prudential hospitalization policy. She became pregnant while her husband was employed by Tiger Oil. In August of 1979 Noah Dupuis left the employment of Tiger Oil and began to work for Merit Drilling Company. Before his departure from Tiger Oil, he requested that his group hospitalization policy be changed to a personal policy. Sue Manuel, an employee of Tiger Oil who took care of the insurance policies, claims, etc., told him that he did not have to convert because his wife had become pregnant while the Tiger Oil coverage was in effect. In August 1979, he enrolled in Merit’s group hospitalization program which was also with Prudential. Mrs. Dupuis was a named dependent under Merit’s Prudential policy. On January 31, 1980 Mrs. Dupuis gave birth to Derek by Cesarian section. Derek became eligible for health insurance through Merit’s hospitalization policy from the date of his birth.

INSURANCE COVERAGE

Noah Dupuis filed suit against Tiger Oil and its group insurer, Prudential, to recover maternity benefits incurred in connection with the birth of his son, Derek. The trial court determined that Tiger Oil and Prudential provided coverage for Leah Du-puis and Derek Dupuis under the Tiger Oil group policy.

Prudential initially denied maternity benefits under the Tiger Oil policy, but did pay some maternity benefits under the Merit policy. At trial Prudential conceded that its policy provided maternity coverage to Leah Dupuis. Prudential contended that although they were not contractually obligated to provide maternity benefits to Leah Dupuis under the Tiger Oil policy, maternity coverage had been extended to her through an administrative decision made by Prudential. Therefore, the trial court was correct in its determination that Prudential was responsible for Leah Dupuis’ maternity bills under the Tiger Oil policy.

Noah Dupuis contends that Tiger Oil’s group insurance policy with Prudential also provided coverage for Derek’s medical expenses. He testified that before he left Tiger Oil to begin employment elsewhere, he was told by Sue Manuel, the Tiger Oil employee who was in charge of insurance, that it was not necessary for him to convert his group hospitalization policy to individual coverage because his wife had become pregnant while he was working for the company. On the other hand, Prudential asserts that Derek could not have been covered under the Tiger Oil policy because he was not a named insured. Prudential further asserts that since Noah Dupuis’ insurance coverage through Tiger Oil terminated when he began working for Merit, Derek did not qualify as an eligible dependent at the time of his birth under the Tiger policy.

Shortly after Derek’s birth, he contracted an illness which required him to be rehospitalized for approximately one week. The bills for this illness were treated by the trial court as maternity benefits. The trial court’s decision turned on the statement [1382]*1382made by Sue Manuel to Mr. Dupuis that it was not necessary to convert to a personal policy. The trial court felt that this statement misled the plaintiff.

Under Prudential’s group insurance policy with Tiger Oil the maternity benefit’s provisions do not extend coverage to children at birth. Children are covered under the dependent’s provisions of the Prudential policy from the time of birth. Dependent’s coverage is also hinged on the existence of an insurance contract with the named insured. In the case sub judice Noah Dupuis was the named insured; at the time he terminated his employment with Tiger Oil he was no longer an insured under the company’s group insurance policy with Prudential. Accordingly, dependent’s coverage for Derek never existed under the Tiger policy because Derek was not a qualified dependent during the time that his father was insured under the Tiger Oil policy. Derek’s benefits fell under Merit's policy with Prudential which were timely paid.1 Therefore, the trial court was incorrect in its determination that Prudential was responsible to Noah Dupuis for Derek’s medical bills under the Tiger Oil policy.

Mrs. Dupuis incurred obstetrical expenses (prenatal care and delivery) together with charges for her hospitalization in connection with Derek’s birth. The trial court determined that Mrs. Dupuis’ medical expenses as proved at trial were as follows:

Women’s Clinic $1,000.00
Opelousas General Hospital 1,630.95
Dr. George Prather 100.00
Medical Center Laboratory, Inc. 48.00
Miscellaneous Prescriptive Drugs 163.03
Total $2,941.98

Prudential acknowledged receipt of bills totaling $2,641.88 submitted through Merit’s group policy for Mrs. Dupuis’ pregnancy and delivery. One of Prudential’s claim analysts determined that $124.64 of the bills submitted under the Merit policy was excludable as ineligible prescriptive drug charges. At trial Prudential offered proof that in March 1980 it had paid $1,496.39 under the Merit policy for maternity claims.

After suit was brought against Prudential under the Tiger Oil policy, Prudential deposited $1,022.04 into the registry of the court. This sum represented the amount which Prudential had determined was due under the Tiger Oil group policy.

Prudential argues that two policies of insurance applied to Mrs. Dupuis and payments made under Merit’s policy should have been credited against the Tiger Oil claim. Both group policies contained a provision for the coordination of benefits which stated that:

“Such benefits for a person may be subject to reduction if he is covered under two or more Plans (including this Plan).

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Related

Latiolais v. Home Ins. Co.
454 So. 2d 902 (Louisiana Court of Appeal, 1984)

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Bluebook (online)
444 So. 2d 1379, 1984 La. App. LEXIS 7987, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dupuis-v-tiger-oil-international-inc-lactapp-1984.