Gamino v. General American Life Insurance

671 A.2d 1108, 288 N.J. Super. 125, 1996 N.J. Super. LEXIS 103
CourtNew Jersey Superior Court Appellate Division
DecidedMarch 5, 1996
StatusPublished
Cited by1 cases

This text of 671 A.2d 1108 (Gamino v. General American Life Insurance) is published on Counsel Stack Legal Research, covering New Jersey Superior Court Appellate Division primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Gamino v. General American Life Insurance, 671 A.2d 1108, 288 N.J. Super. 125, 1996 N.J. Super. LEXIS 103 (N.J. Ct. App. 1996).

Opinion

The opinion of the court was delivered by

LANDAU, J.A.D.

This appeal by plaintiff Virginia Gamino raises the issue, novel in this jurisdiction, whether our insurance laws mandate continuation of a group accidental death benefit during the thirty-one day period statutorily allotted for conversion of a terminated employee’s group life insurance coverage to a policy of individual life insurance. We conclude that the statutory individual life insurance conversion privilege and automatic thirty-one day continuation of the insured’s life insurance benefit is not applicable to the accidental death and dismemberment benefits provided in a separate schedule of decedent’s group policy, and accordingly affirm the dismissal of Gamino’s complaint for failure to state a cause of action against defendant General American Life Insurance Company.

The Facts and Applicable Statutes

Luis G. Gomez died on September 11, 1992, within thirty-one days after the termination of his employment. He was covered under a group insurance policy purchased by his New Jersey [127]*127employer, Federal Warehouse, from defendant General American Life Insurance Company (General American). Under N.J.S.A. 17B:27-19, decedent had the right, without evidence of insurability, to purchase “an individual policy of life insurance without disability or other supplemental benefits ...” during the thirty-one day period following termination. The statute goes on to provide, in N.J.S.A. 17B:27-21, that when death ensues within the thirty-one day conversion envelope,

[t]here shall be a provision that if a person insured under the group policy dies during the period within which he would have been entitled to have an individual policy issued to him in accordance with section 17B:27-19 or section 17B:27-20 above and before such an individual policy shall have become effective, the amount of life insurance which he would have been entitled to have issued to him under such individual policy shall be payable as a claim under the group policy, whether or not application for the individual policy or the payment of the first premium therefor has been made.

The applicable group policy summary issued to decedent contains a schedule entitled “Life Insurance Benefits” and a separate schedule entitled “Accidental Death and Dismemberment.” The “Life Insurance Benefits” schedule sets forth the insured’s conversion privileges to an individual life insurance policy, advising that such individual policy “will not include disability or other supplemental benefits.” It also recites that if death occurs during the thirty-one days when the insured is eligible to apply for an individual policy of life insurance, the death benefit will be paid even if no conversion application is made.

By contrast, the separate “Accidental Death and Dismemberment” schedule in the policy summary specifically refers to its maximum amount as “equal to the amount of Life Insurance” and provides, “You may not convert this benefit to an individual policy.”

General American has paid the face amount of the life insurance benefit but not the accidental death benefit.

The Present Action

Plaintiff Virginia Gamino is the widow of Luis Gomez. She brought this action against General American seeking a [128]*128declaration that the conversion provision of the group policy is applicable to “life insurance as well as accidental death and dismemberment insurance” and an order declaring that Great American must pay benefits to her under the accidental death and dismemberment portion of the policy. The complaint points to the broad definition of “life insurance” in N.J.S.A 17B:17-3, which includes “provisions for ... additional benefits in event of death by accident or accidental means ... whether such provisions are incorporated in a policy or contract of life insurance or in a policy or contract supplemental thereto.” In consequence, Gamino says, the life insurance conversion privilege required by N.J.S.A 17B:27-19 and the automatic thirty-one day coverage provided under N.J.SA 17:27-21 must be deemed applicable to benefits under the Accidental Death and Dismemberment schedule of decedent’s group policy, notwithstanding the clear statement in that schedule that the Accidental Death and Dismemberment coverage may not be converted to an individual policy.

On motion by General American, the Law Division judge entered a R. 4:6-2(e) order dismissing the action for failure to state a claim for relief. He concluded, in reliance upon holdings in other jurisdictions with similar statutes, that the New Jersey Life and Health Insurance Code (N.J.S.A 17B.-17-1 to 36-4) (the Code) does not require General American to provide supplementary accidental death benefits, as distinct from the traditional group life insurance policy death benefits, when accidental death occurs during the thirty-one days following termination of employment.

In reviewing the dismissal order we think it important to emphasize that this is not a case of an insured’s detrimental reliance upon ambiguous terms of an insurance contract. Here, the insured was informed in unmistakable terms that the life insurance coverage set forth in the schedule was convertible, but without disability and supplementary benefits, essentially the same exclusionary words used in N.J.SA 17B:27-19. The accidental death and dismemberment schedule specifically advised that its coverage was not convertible. As the accidental death and [129]*129dismemberment benefits were unambiguously nonconvertible under the Great American schedule, they could not be payable as a N.J.S.A 17B:27-21 claim under the group policy for an accidental death during the thirty-one day conversion period unless the provisions of the group insurance contract violated the Code. We note that the accidental death and dismemberment schedule of the summary plan description given to the decedent refers to the maximum amount of insurance afforded thereunder in these words: “An amount equal to the amount of life insurance.” The same schedule states: “You may not convert this benefit to an individual policy.”

In essence, appellant urges that the breath of the definition of life insurance contained in N.J.S.A 17B:17-3 constitutes a demonstration of legislative intent that accidental death benefits be included within the scope of the N.J.S.A. 17B:27-19 conversion privilege for “life insurance without disability or other supplementary benefits,” and that this definition is sufficient to render unenforceable the plain text of the insured’s accidental death and dismemberment schedule. We find no such clearly defined legislative purpose. It is surely not expressed in the group policy conversion provisions, N.J.SA 17B:27-19, 20,21.

Unlike a life insurance policy, which is actuarially premised upon the time of an insured’s certain and inevitable death, an accidental death benefit is actuarially premised upon the wholly uncertain contingency of accident, and upon the further contingency that such accident produces death. This difference is recognized in the Code. It makes different provisions for companies not licensed as life insurers but who may be licensed to do the business of “health insurance” as defined in N.J.S.A. 17B:17-4. “Health insurance” is defined in that section of the Code as a

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Bluebook (online)
671 A.2d 1108, 288 N.J. Super. 125, 1996 N.J. Super. LEXIS 103, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gamino-v-general-american-life-insurance-njsuperctappdiv-1996.