East Texas Medical Center Regional Healthcare System v. Lexington Insurance

575 F.3d 520, 73 Fed. R. Serv. 3d 1427, 2009 U.S. App. LEXIS 15444, 2009 WL 1982368
CourtCourt of Appeals for the Fifth Circuit
DecidedJuly 10, 2009
Docket07-40904
StatusPublished
Cited by25 cases

This text of 575 F.3d 520 (East Texas Medical Center Regional Healthcare System v. Lexington Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
East Texas Medical Center Regional Healthcare System v. Lexington Insurance, 575 F.3d 520, 73 Fed. R. Serv. 3d 1427, 2009 U.S. App. LEXIS 15444, 2009 WL 1982368 (5th Cir. 2009).

Opinion

LESLIE H. SOUTHWICK, Circuit Judge:

East Texas Medical Center sued its insurer, Lexington Insurance Company, for failure to cover a claim filed against it by a patient. A jury found for the Medical Center. The district court then granted Lexington a judgment as a matter of law. The Medical Center appeals. For reasons we will explain, we VACATE and REMAND for additional proceedings.

I. FACTS

This case concerns Lexington’s denial of the Medical Center’s claim for coverage under a “elaims-made” liability insurance policy it purchased from Lexington. The dispute centers on the notice and reporting requirements of the policy. The specific issue is whether the Medical Center properly gave notice- of the claim and of a subsequent lawsuit to Lexington.

A. The Policy

Lexington issued a one-year, $5 million claims-made medical malpractice liability policy to the Medical Center. The policy period was from June 8, 2002, to June 8, 2003. The policy provided excess liability insurance coverage to the Medical Center, covering claims above a self-insured retention of $2 million per claim. The Medical Center also purchased excess coverage policies from other insurers to cover claims exceeding the policy’s $5 million coverage layer.

Under the Medical Center’s arrangement with its insurers, the Medical Center was the first link in its risk management chain. The Medical Center had responsibility for processing claims and monitoring all incidents potentially giving rise to medical malpractice claims (“medical incidents”). The Medical Center had discretion to resolve any claim within its $2 million retention. If a lawsuit was filed on any claim, the Medical Center could retain counsel of its own choosing for its defense. When Lexington was notified of a claim by the Medical Center, Lexington had discretion to decide which claims it would investigate or otherwise pursue.

The pertinent parts of the policy in dispute relate to the Medical Center’s notice responsibilities. If the Medical Center wanted coverage, it was required to provide “written notice” to Lexington of three different matters: medical incidents, claims, and lawsuits. The issues at trial concerned notice of claim and notice of lawsuit. No questions have been raised about notice of a medical incident.

In addition to being required to give notice of claims and lawsuits, the Medical Center also had to provide relevant documents. It was to send “immediately” to Lexington copies of any demands, notices, summonses, or legal papers received in connection with a claim or lawsuit.

B. The Underlying Claim

In March 2003, the Medical Center received a medical malpractice claim that was in the form of what is called a 4590i letter. 1 The claim was on behalf of David *524 Wayne Cornelius. This is the claim that has generated the present lawsuit. The letter indicated that Cornelius had suffered unspecified personal injuries, at the Medical Center’s Athens, Texas facility. In April 2003, the Medical Center entered information about the Cornelius claim on a computer-generated spreadsheet, which is referred to as a “loss run.” Each loss run document that is in the record contains entries for about 40 claimants.

A key dispute at trial was whether Lexington accepted loss runs as claim notice. There was evidence that Lexington acknowledged receipt of three other claims submitted on loss runs. Lexington did not acknowledge receipt of the Cornelius claim when it appeared on a loss run. The Cornelius claim was included on three different loss runs provided to Lexington before the policy period ended, each of which noted that there was a 4590i letter. 2 At the end of the policy period, the loss run remained the only notice given Lexington.

C. The Underlying Lawsuit

On May 27, 2003, Cornelius’s mother filed a medical malpractice lawsuit on his behalf in state court against the Medical Center. The Medical Center assigned defense of the case to an attorney. The suit was timely answered on behalf of the Medical Center. Less than two weeks later, on June 8, 2003, the policy period expired. At the time, the Medical Center did not consider the Cornelius lawsuit to be one with a high risk of exposure, nor did it believe that its liability for the claim would exceed its self-insured retention or impact the Lexington policy coverage layer and those of other excess insurers.

D. Notice of Claim and Lawsuit

Following depositions in the Cornelius lawsuit in December 2003, the Medical Center realized for the first time that its liability for the lawsuit was likely to exceed the Medical Center’s $2 million self-insured retention.

In January 2004, very soon after the depositions but about seven months after both the lawsuit was filed and the policy period expired, the Medical Center first gave written notice of the Cornelius lawsuit to Lexington. -It also sent copies of the claim and suit papers. Later that month, Lexington denied the claim, asserting that the Medical Center had failed to comply with the Lexington policy’s notice provisions.

E. Procedural History

The Medical Center brought this lawsuit against Lexington and other insurers 3 , alleging causes of action arising from Lexington’s denial of its claim in connection with the Cornelius lawsuit. The Medical Center’s claims against Lexington included breach of contract, violation of the Texas Insurance Code,, and negligent misrepresentation. Lexington counter-claimed, alleging breach of contract, asking for a declaration of noncoverage under the Lexington policy, and seeking reimbursement for settlement of the underlying Cornelius lawsuit. Before this coverage suit was tried, the Cornelius lawsuit was settled.

*525 The parties proceeded to trial. Before the case went to the jury, Lexington abandoned its request for a declaratory judgment. The jury returned a verdict in favor of the Medical Center on all claims. Awarded were approximately $1.7 million in damages. Lexington moved for a judgment as a matter of law. It asserted that there was insufficient evidence to support the jury findings on any of the claims. The district court granted the motion, rendering judgment in favor of Lexington and against the Medical Center on all claims.

II. DISCUSSION

This court gives de novo review to a district court’s ruling on a motion for a judgment as a matter of law (“JMOL”). Poliner v. Tex. Health Sys., 537 F.3d 368, 375-76 (5th Cir.2008). Such a judgment is appropriate when “a party has been fully heard on an issue during a jury trial and the court finds that a reasonable jury would not have a legally sufficient evidentiary basis to find for the party on that issue.” Fed.R.Civ.P.

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Cite This Page — Counsel Stack

Bluebook (online)
575 F.3d 520, 73 Fed. R. Serv. 3d 1427, 2009 U.S. App. LEXIS 15444, 2009 WL 1982368, Counsel Stack Legal Research, https://law.counselstack.com/opinion/east-texas-medical-center-regional-healthcare-system-v-lexington-insurance-ca5-2009.