Fabacher v. Coastal States Life Insurance

220 So. 2d 99, 253 La. 852, 1969 La. LEXIS 3020
CourtSupreme Court of Louisiana
DecidedFebruary 24, 1969
DocketNo. 49278
StatusPublished
Cited by2 cases

This text of 220 So. 2d 99 (Fabacher v. Coastal States Life Insurance) is published on Counsel Stack Legal Research, covering Supreme Court of Louisiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Fabacher v. Coastal States Life Insurance, 220 So. 2d 99, 253 La. 852, 1969 La. LEXIS 3020 (La. 1969).

Opinion

SUMMERS, Justice.

Plaintiff Lawrence A. Fabacher brought this suit against defendant Coastal States Life Insurance Company to recover medical and hospital expenses, penalties and attorneys’ fees under a group health and accident policy issued by defendant. The policy insured the members of the Calcasieu Parish Police Jury and parish employees and covered loss of life, accidental death, loss of time, hospital, medical and surgical expense and related risks.

Judgment was rendered in the trial court in plaintiff’s favor awarding the medical and hospital expenses claimed. Penalties and attorneys’ fees were also awarded in accordance with Section 657 of Title 22 of [855]*855the Revised Statutes of Louisiana.1 On appeal to the Third Circuit, the judgment was affirmed. We granted writs to review the Court of Appeal judgment, limiting review to the issue of penalties.

At times which are pertinent, plaintiff was a duly elected member of the Police Jury of Calcasieu Parish. As such he was entitled to receive per diem for 76 days each year, allocated to meetings attended and for days devoted to road inspections. Per diqm received for these days was payable upon the warrant or requisition of each police jury member. Other than meeting days, the individual members of the police jury were at liberty to designate the days when per diem was due. This was done, according to the practice in Calcasieu Parish, at the end of each year.

Plaintiff had been employed for some time by Continental Oil Company as a watchman on a part time basis. On June 22, 1966 he worked for Continental until about 3 o’clock. He was not working for Continental on June 23, and, as was his habit, he drove to the Ward Four barn, inspecting a parish road enroute. Upon arrival at the barn he greeted the men employed by the parish and inquired about the progress of the work. Plaintiff then engaged in a number of telephone conversations relating to a fund raising drive being conducted to assist two local children, one with leukemia and another who was to undergo open heart surgery in Houston.

It was about 11:30 that morning while on his way to the courthouse, driving his pick-up truck toward Lake Charles, that plaintiff became involved in a head-on collision with another automobile and, as a result, suffered severe injuries. He was hospitalized and received extensive medical care and treatment. Charges for doctors, hospitals, drugs and related services totaled [857]*857$1,706.99. These charges are not disputed. The controversy arose over the coverage under the terms of the policy.

However, since we have limited this review to the issue of penalties, the question of coverage is no longer involved. The issue before us is whether, under Section 6S7 of Title 22 of the Revised Statutes and the facts and circumstances, the defendant had “just and reasonable grounds, such as would put a reasonable and prudent business man on his guard,” to warrant its refusal to pay plaintiff’s claim within thirty days as the statute requires. Resolution of the issue involves a consideration of certain exclusion clauses in the group accident and health policy written by defendant insuring the members of the police jury and employees of the parish.

First, the policy excluded coverage on account of disability where it is

“(1) Disability due to bodily injury arising during, from, or out of, or in the course of, employment, or during performance of any occupation for compensation or profit, whether or not covered by any Workmen’s Compensation act or similar law, * * * ”

Under other policy sections a similar exclusion is found, reading as follows:

“Exceptions and Limitations.
# * * * * *
(e) For any confinement for bodily injury arising during, from, or out of, or in the course of, employment, or during the performance of any occupation for compensation or profit, whether or not covered by any Workmen’s Compensation act or similar law.”

The application for insurance signed on behalf of the Calcasieu Parish Police Jury contained a negative reply to the question: “Do you wish occupational coverage ?” Thus, in addition to the terms of the policy excluding such coverage, there was no intention that the insurance in question would cover the employees of the parish or members of the police jury while engaged in their respective employments or occupations for compensation. In effect, an adjustment in the rates was bargained for by the application, the nonoccupational premium being about 10 percent lower.

On August 18, 1966 the defendant insurer first learned of plaintiff’s claims for disability benefits under the policy, and on the basis of plaintiff’s signed claim paid $200 as disability benefits for the eight-week period June 24, 1966 through August IS, 1966. Plaintiff’s claim was accompanied by the employer’s claim form and the report of the physician who admitted him to St. Patrick’s Hospital. Later the insurer learned that this $200 payment had been [859]*859made in error when it was discovered that the physician’s report disclosed plaintiff’s condition was due to an injury arising out of his employment.

A claim for hospitalization was received thereafter on September 6, 1966 from St. Patrick’s Plospital in Lake Charles. At the same time Dr. John D. Jackson, the attending physician at Ochsner’s Clinic; the radiologist at Lake Charles; and Dr. Gerald N. Weiss, the attending physician at St. Patrick’s Hospital, all submitted reports and statements. Of this group, only Dr. Weiss’ report referred to plaintiff’s employment at the time of the injury. According to his report the injury did not arise out of plaintiff’s employment.

The data contained in the report of St. Patrick’s Hospital included a notation that the plaintiff had other insurance with American Income Life Insurance Company. This information posed the question of the applicability of the pro rata clause in defendant’s policy and whether the hospital and medical expenses incurred should be paid in full or proportionately with American Income- Life. Defendant, therefore, set this claim aside and delayed normal processing in order that it might verify the existence of the additional insurance and determine its effect upon its obligations under the pro rata clause of its policy.

Shortly thereafter, on September 22, 1966, the defendant received another physician’s statement prepared by Dr. George p. Schneider. This statement also contained a notation that plaintiff’s injury arose out of his employment. With this information before it, defendant immediately ordered an investigation to determine the reliability of the information it had received that the insured had other insurance with American Income Life. The investigation was also undertaken to ascertain whether still other insurance existed covering plaintiff’s injuries.

The investigative report, received on September 26, 1966, disclosed that plaintiff was employed by Continental Oil Company and was driving a company truck when the accident occurred on June 23, 1966. It also concluded that, because of his part-time employment status, plaintiff was not eligible to participate in the group insurance program of Continental Oil Company written by Travelers Insurance Company.

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Related

Rippon v. Variable Protection Administrators, Inc.
537 So. 2d 262 (Louisiana Court of Appeal, 1988)
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272 So. 2d 37 (Louisiana Court of Appeal, 1973)

Cite This Page — Counsel Stack

Bluebook (online)
220 So. 2d 99, 253 La. 852, 1969 La. LEXIS 3020, Counsel Stack Legal Research, https://law.counselstack.com/opinion/fabacher-v-coastal-states-life-insurance-la-1969.