Flores v. Monumental Life Insurance

620 F.3d 1248, 2010 U.S. App. LEXIS 19938, 2010 WL 3733554
CourtCourt of Appeals for the Tenth Circuit
DecidedSeptember 27, 2010
Docket09-6107
StatusPublished
Cited by24 cases

This text of 620 F.3d 1248 (Flores v. Monumental Life Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Tenth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Flores v. Monumental Life Insurance, 620 F.3d 1248, 2010 U.S. App. LEXIS 19938, 2010 WL 3733554 (10th Cir. 2010).

Opinion

McKAY, Circuit Judge.

In this diversity case, Plaintiff Fred Flores appeals the district court’s grant of summary judgment to Defendant Monumental Life Insurance Company on Plaintiffs claims of breach of contract, bad faith, and negligence per se.

Background

Plaintiff Fred Flores and his wife, Sandra Flores, had two accidental death insurance certificates issued by Defendant, one certificate effective in May 2000 and the other effective in June 2003. Both policies provided that benefits would be paid only if the “death occurr[ed] as a direct result of an Injury.” (Appellant’s App. at 62, 76.) “Injury” was defined as “bodily injury caused by an accident.” (Appellant’s App. at 61, 75.) The policies explained that “[t]he Injury must be the direct cause of the Loss and must be independent of all other causes.” (Appellant’s App. at 61, 75.) The policies further provided that “[t]he Injury must not be caused by or contributed to by Sickness” (Appellant’s App. at 61, 75), and they included an exclusion for “Sickness or its medical or surgical treatment, including diagnosis” (Appellant’s App. at 63, 77). The policies then defined “Sickness” to be “an illness or disease which results in a covered Loss while insurance for the Covered Person is in force under this Policy.” (Appellant’s App. at 61, 76.)

For some years before her death, Mrs. Flores took the prescription medication Verapamil to control her hypertension. In May 2006, Mrs. Flores fell while using her walker and was admitted to a hospital where'she underwent surgery on her broken arm. After staying in the hospital for approximately ten days, she was discharged and transported to a rehabilitation center. A few hours after arriving at the *1250 rehabilitation center, she died as a result of Verapamil toxicity. The state medical examiner concluded Mrs. Flores suffered from chronic hepatitis and evolving cirrhosis of the liver, but he could not determine whether Mrs. Flores’s fatal Verapamil toxicity resulted from these liver problems or from an overdose of Verapamil.

Plaintiff submitted a claim to Defendant for accidental death benefits, and Defendant denied the claim. Specifically, Defendant concluded Plaintiff was not entitled to benefits because there was no evidence Mrs. Flores’s death had resulted from an accidental bodily injury independent of all other causes and, moreover, her death fell within the specific exclusion for sickness or its medical or surgical treatment.

Plaintiff then filed a state court action against Defendant alleging claims of breach of contract, bad faith, and negligence per se. Defendant removed the action to the federal district court based on diversity jurisdiction, and the district court concluded Defendant was entitled to summary judgment on all of Plaintiffs claims. This appeal followed.

Discussion

We review the district court’s summary judgment decision de novo, applying the same legal standard as the district court. See Padhiar v. State Farm Mut. Auto. Ins. Co., 479 F.3d 727, 732 (10th Cir.2007). Under this standard, summary judgment is only warranted “if the pleadings, the discovery and disclosure materials on file, and any affidavits show that there is no genuine issue as to any material fact and that the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(c)(2). The parties agree that the substantive law of Oklahoma governs our consideration of the merits of Plaintiffs claims. As a federal court sitting in diversity, our task is “simply to ‘ascertain and apply’ ” Oklahoma law, attempting to “predict what the state’s highest court would do” if faced with the specific issues before us on appeal. Wankier v. Crown Equip. Corp., 353 F.3d 862, 866 (10th Cir.2003) (quoting Huddleston v. Dwyer, 322 U.S. 232, 236, 64 S.Ct. 1015, 88 L.Ed. 1246 (1944)).

I. Insurance Coverage

Under Oklahoma law, unlike many of our federal ERISA cases, an insurer’s denial of benefits is entitled to no judicial deference, regardless of whether the plan administrator was given discretionary authority to deny benefits. See Cranfill v. Aetna Life Ins. Co., 49 P.3d 703, 707 (Okla. 2002). In considering the policy language at issue in this case, we are guided by the Oklahoma Supreme Court’s direction that “[t]he construction of an insurance policy should be a natural and reasonable one, fairly constructed to effectuate its purpose, and viewed in the light of common sense so as not to bring about an absurd result.” Wiley v. Travelers Ins. Co., 534 P.2d 1293, 1295 (Okla.1974). “The terms of the parties’ contract, if unambiguous, clear, and consistent, are accepted in their plain and ordinary sense, and the contract will be enforced to carry out the intention of the parties as it existed at the time the contract was negotiated.” Dodson v. St. Paul Ins. Co., 812 P.2d 372, 376 (Okla.1991). Where there is an ambiguity or conflict in the policy’s terms, however, “a policy of insurance is to be construed strictly against the insurer and in favor of the insured,” with the policy’s language construed to mean “not what the drafter intended it to mean, but what a reasonable person in the position of the insured would have understood it to mean.” Spears v. Shelter Mut. Ins. Co., 73 P.3d 865, 868 (Okla.2003).

A. Injury “independent of all other causes”

The policies’ coverage language provides for benefits if death occurs as a *1251 direct result of an injury. The policies explain that an injury is a “bodily injury caused by an accident” and that “[t]he injury must be the direct cause of the Loss and must be independent of all other causes.” 1 (Appellant’s App. at 61, 75.) “Loss” is defined as “the death of the Covered Person or any physical impairment, incurred expense, or other benefit covered under the terms of this Policy and any attached Riders.” (Appellant’s App. at 61, 75.) Although the policies do not define the word “accident,” the Oklahoma Supreme Court has held that this term is an unambiguous word describing “an event that is ‘unexpected, unintended and unforeseen in the eyes of the insured.’ ” Cranfill, 49 P.3d 703 at 706 (quoting Willard v. Kelley, 803 P.2d 1124, 1128-29 (Okla.1990)).

The district court agreed with Defendant that Plaintiffs claim for insurance benefits did not come within the coverage language of his policies because Mrs. Flores’s death was not independent of all other causes. Specifically, the court concluded that “Mrs. Flores’s high blood pressure and her treatment for that condition were at least contributing causes (or a contributing cause) of her death” because she would not have died from an overdose if Verapamil had not been prescribed for her. (Appellant’s App. at 407.) The court therefore concluded Mrs.

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620 F.3d 1248, 2010 U.S. App. LEXIS 19938, 2010 WL 3733554, Counsel Stack Legal Research, https://law.counselstack.com/opinion/flores-v-monumental-life-insurance-ca10-2010.