General American Life Insurance Co. v. Fisher

517 So. 2d 31, 12 Fla. L. Weekly 2575, 1987 Fla. App. LEXIS 10931, 1987 WL 1341
CourtDistrict Court of Appeal of Florida
DecidedNovember 10, 1987
DocketNos. 86-1422, 86-2019
StatusPublished
Cited by2 cases

This text of 517 So. 2d 31 (General American Life Insurance Co. v. Fisher) is published on Counsel Stack Legal Research, covering District Court of Appeal of Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
General American Life Insurance Co. v. Fisher, 517 So. 2d 31, 12 Fla. L. Weekly 2575, 1987 Fla. App. LEXIS 10931, 1987 WL 1341 (Fla. Ct. App. 1987).

Opinion

HENDRY, Judge.

This consolidated appeal arises out of a coverage dispute between the plaintiff, Eddie Fisher, and the defendant, General American Life Insurance Company. The trial court heard cross-motions for summary judgment, granting plaintiff's motion for summary judgment and denying defendant’s motion. We affirm.

The pertinent facts are as follows. Plaintiff and a coworker, while at work, played a practical joke on the shop manager. During the prank, a can of denatured alcohol exploded, badly burning plaintiff. Plaintiff initially filed a worker’s compensation claim, contending his injuries arose out of and in the course and scope of his employment. The industrial claims judge denied plaintiff’s claim, finding that the prank, “while occurring on the employer’s premises, had absolutely nothing to do with the work Mr. Fisher was engaged in, but was in fact a clear example of complete deviation from work.”

Subsequently, plaintiff filed a claim with General American, the insurance company providing group medical coverage for plaintiff’s employer. Although plaintiff was otherwise covered as an employee, General American denied plaintiff’s claim, contending that an exclusionary provision denied coverage. The provision states that benefits are not payable for:

11) sickness covered by Worker’s Compensation, occupational disease law or similar laws; or injury if it arises out of employment for pay, profit, or gain_

The plaintiff then filed this suit against General American, seeking to recover medical expenses and attorney’s fees. The trial court granted plaintiff’s motion for summary judgment, finding General American liable for medical expenses incurred by plaintiff. Defendant appealed.

The issue before this court focuses on the interpretation of the exclusionary provision. In his motion for summary judgment, as now on appeal, plaintiff argues that the provision creates a single exclusion which comes into play only when worker’s compensation benefits are recoverable for either injuries or illnesses. Plaintiff contends the provision was designed to avoid coverage when worker’s compensation is or should be present, so that the insurance policy cannot be used as a substitute for worker’s compensation or provide double coverage. In short, the purpose of the exclusion is to supplement worker's compensation coverage. When there is no recovery under worker’s compensation, the group insurance policy should protect the employee and pay benefits. In view of the fact that plaintiff was not entitled to receive benefits under the worker’s compensation laws, he maintains the exclusion does not apply. Accordingly, he claims entitlement to coverage under the group insurance policy.

Conversely, defendant contends the provision contains two separate and distinct exclusions. The first exclusion pertains to a sickness covered by worker’s compensation, while the second exclusion pertains to any injury arising out of employment, regardless of worker’s compensation coverage. The reference to worker’s compensation relates only to sickness, not both sickness and injuries. This distinction is evident by the use of the disjunctive “or” rather than the conjunctive “and” dividing the two clauses. Plaintiff was injured at the work site, while handling a flammable liquid he routinely used to perform his work. Defendant maintains that plaintiff’s injuries clearly arose out of his employ[33]*33ment; consequently, under the exclusion, plaintiff is not entitled to insurance coverage.

In General American Insurance Co. v. Yambo, 428 So.2d 300 (Fla. 3d DCA), review denied, 438 So.2d 835 (Fla.1983), this identical exclusionary provision was at issue, however, this court did not decide whether the provision excluded coverage for any injury occurring at work, regardless of worker’s compensation coverage. In Yambo, the court determined that plaintiff had received a lump sum settlement as a result of his worker’s compensation claim. The injuries sustained were also clearly work-related, therefore, plaintiff’s claim for insurance coverage was properly denied under the exclusionary provision. The court stated that the industrial claims judge did not find that the injuries did not arise out of or in the course of the plaintiff’s employment, thus the issue in the instant case was not present. In Fisher’s case, the industrial claims judge did find that the injuries did not arise out of or in the course of employment, thus worker's compensation benefits were denied.

Courts in other jurisdictions have been asked to construe the precise exclusionary provision here in question, but have reached contrary holdings. In Sanders v. General American Life Insurance Co., 364 So.2d 1373 (La.App. 3d Cir.1978), the court, after examining Louisiana's worker’s compensation laws, concluded that by employing the terms “sickness” and “injury” in the exclusionary provision, the insurer attempted to encompass all situations where an employee might recover under worker’s compensation laws, whether the claim be for personal injury or an occupational disease. Sanders, 364 So.2d at 1376. The essential question in determining whether the exclusionary provision should be applied, according to the Louisiana court, is whether the sickness or injury suffered by the employee is compensable under the worker’s compensation statutes. Sanders, 364 So.2d at 1377. If the claim is not compensable under worker’s compensation, the exclusion cannot be invoked.

A Georgia court in General American Life Insurance Co. v. Barth, 167 Ga.App. 605, 307 S.E.2d 113 (1983), interpreted the same provision found in Sanders and the instant case to consist of two separate and distinct exclusions. The court, after examining the punctuation dividing the two clauses, concluded that “the exclusion based upon coverage under worker’s compensation is separate from the exclusion relating solely to an injury arising out of ... employment.” Barth, 307 S.E.2d at 115. The Georgia court held that regardless of worker’s compensation coverage, no coverage existed under the exclusionary language of the policy if injury arose out of employment. Barth, 307 S.E.2d at 115.

Numerous jurisdictions have interpreted similar exclusionary provisions in other insurance policies, also reaching contrary holdings. In Prudential Insurance Co. of America v. Bellar, 391 So.2d 737 (Fla. 4th DCA 1980), a Florida court examined a provision with language similar to that found in the General American policy, but the Prudential policy also contained an (a) and (b) separating the two exclusionary clauses. The fourth district court concluded that the drafters, by using the separating devices (a) and (b), intended to create separate exclusions. Thus, “[t]he qualifying words of limitation relating to workmen’s compensation laws are properly restricted to the [clause relating to sickness] and do not limit or restrict the [clause relating to] injury.” Bellar, 391 So.2d at 738, (quoting Wilson v. Prudential Ins, Co. of Am., 528 P.2d 1135 (Okla.Ct.App.1974), aff’d, 645 P.2d 521 (Okla.1982)). See also Roskell v. Prudential Ins. Co. of Am., 529 F.2d 1 (10th Cir.1976). But see Montoya v. Travelers Ins. Co., 91 N.M.

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Bluebook (online)
517 So. 2d 31, 12 Fla. L. Weekly 2575, 1987 Fla. App. LEXIS 10931, 1987 WL 1341, Counsel Stack Legal Research, https://law.counselstack.com/opinion/general-american-life-insurance-co-v-fisher-fladistctapp-1987.