Gillogly v. General Electric Capital Assurance Co.

430 F.3d 1284, 30 A.L.R. 6th 713, 2005 U.S. App. LEXIS 27097, 2005 WL 3367053
CourtCourt of Appeals for the Tenth Circuit
DecidedDecember 12, 2005
Docket04-7026, 04-7032, 04-7042
StatusPublished
Cited by16 cases

This text of 430 F.3d 1284 (Gillogly v. General Electric Capital Assurance Co.) 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
Gillogly v. General Electric Capital Assurance Co., 430 F.3d 1284, 30 A.L.R. 6th 713, 2005 U.S. App. LEXIS 27097, 2005 WL 3367053 (10th Cir. 2005).

Opinion

EBEL, Circuit Judge.

In these appeals, we interpret a long term care insurance policy that Plaintiff Russell Lee Gillogly (“Gillogly”) purchased from a predecessor to Defendant insurer General Electric Capital Assurance Company'(“GECA”). 1 We REVERSE the district court’s grant of summary judgment for Gillogly on his claim that GECA breached its contract with Gillogly when it denied his request for benefits under the policy. We also REVERSE the district court’s entry of judgment in favor of Gil-logly on his claim that GECA denied his request for benefits in bad faith. Finally, we AFFIRM the district court’s entry of judgment as a matter of law for GECA on Gillogly’s claim for punitive damages. Therefore, we REMAND the cáse to the district court with instructions to enter judgment for GECA on Gillogly’s claims that GECA breached its contract with Gil-logly and acted in bad faith.

BACKGROUND

In 1989 Gillogly purchased a “Long Term Care Insurance Nursing Home Indemnity Policy” (“Policy”) from AMEX Life Assurance Company. As a result of a 1996 merger, GECA assumed all of AMEX Life Assurance Company’s rights and obligations under the Policy.

The Policy provides a “Nursing. Home Benefit” — a fixed daily benefit of $60 per day for an inpatient stay .in a nursing home for up to 730 days after a deductible period of 100 days is reached. Specifically, the Policy states:

We will pay the Daily Benefit for each Day Of A Nursing Home Stay After the Deductible Period, if:
• the Policy is in force when the Nursing Home stay starts; and
• You are confined in the Nursing Home as an overnight resident patient and a room and board charge is made for that day; and
• Your Nursing Home Stay is Neces- . sary....
Your Nursing Home Stay Is Necessary as long as: (1) a Doctor certifies that Your admission is required due to injury or sickness; and (2) there exists a level of functional incapacity which makes your continued Nursing Home stay appropriate and reasonable.
This Policy makes no distinction, in the duration or amount of benefits You will be paid, for different levels of care (whether skilled, intermediate, or custodial) as long as Your Nursing Home Stay Is Necessary.

The Policy defines a “Nursing Home” as:

A facility or distinctly separate part of a hospital or other institution which is licensed by the appropriate licensing agency to engage primarily in providing nursing care and related services to inpatients and:
• Provides 24 hour a day nursing service under a planned program of policies and procedures which was developed with the advice of, and is periodically reviewed and executed by, a professional group of at least one physician and one Nurse; and
*1287 • Has a Doctor available ... in case of emergency; and
• Has at least one Nurse who is employed there full time ...; and
• Has a Nurse on duty or on call at all times; and
• Maintains clinical records for all patients; and
• Has appropriate methods and procedures for handling and administering drugs and biologieals.
NOTE: The above requirements are typically met by licensed skilled nursing-facilities, comprehensive nursing care facilities and intermediate nursing care facilities as well as some specialized wards, wings and units of hospitals. Those requirements are generally NOT met by: rest homes; homes for the aged; sheltered living accommodations; residence homes; or similar living arrangements.

The Policy does not define the term “nursing care and related services” used in the first part of the Policy’s definition of “Nursing Home.”

In 2001 Gillogly began residing at the Van Burén House (ICVBH”) of the McAles-ter Regional Health Center (“MRHC”) in Oklahoma. Gillogly thereafter sought benefits from GECA under the Policy to pay for his stay at VBH. GECA declined to award benefits because. GECA believed that VBH did not qualify as a “Nursing Home” under the Policy, stating in a letter to Gillogly that:

The referenced policy is a basic Nursing Home Indemnity Policy. It provides neither alternative care facility nor home health care benefits. Its principal focus is to indemnify stays in care facilities that satisfy the policy definition of a Nursing Home.
The term Nursing Home is defined in the policy as a facility licensed by the appropriate licensing agency to engage primarily in providing nursing care and related services to inpatients. The policy also requires the facility to provide certain services;. these are listed in a bulleted format.
... [T]he information submitted from the Van Burén House ... reflected they are not licensed by the appropriate licensing agency to engage primarily in providing nursing care. In fact, the care facility holds a license issued by the Oklahoma Department of Health to function as a Residential Care Home.
... The state of Oklahoma has provided a Residential Care Home license in order to allow the care facility in question to provide personal care services only.

Gillogly filed suit against GECA in the United States District Court for the Eastern District of Oklahoma, alleging that GECA had breached its contract and the covenant of good faith and fair dealing in denying his request for benefits under the Policy. 2 Gillogly sought both compensatory and punitive damages.

‘ GECA filed a motion for summary judgment, arguing that it had neither breached its contract with Gillogly nor acted in bad faith in denying Gillogly’s request for benefits. Gillogly filed a motion for partial summary judgment, seeking to establish that GECA was liable for breach of contract. The district court denied GECA’s motion and granted Gillogly’s motion, holding that GECA was hable for breach of contract. However, because damages for the breach had not been determined, the court did not enter judgment on the claim.

*1288 The parties proceeded to a jury trial on Gillogly’s claim that GECA had acted in bad faith in denying his request for benefits. At the close of all the evidence, the district court determined as a matter of law that GECA had acted in bad faith. The court also granted judgment as a matter of law to GECA on Gillogly’s claim for punitive damages. The jury then determined Gillogly’s actual damages on the claim that GECA had acted in bad faith to be $4 million. The district court entered judgment on that claim on January 12, 2004.

On March 15, 2004, fourteen days after the district court rejected GECA’s post-judgment motion for judgment as a matter of law, a new trial, or remittitur of the jury verdict, GECA filed a notice of appeal.

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Bluebook (online)
430 F.3d 1284, 30 A.L.R. 6th 713, 2005 U.S. App. LEXIS 27097, 2005 WL 3367053, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gillogly-v-general-electric-capital-assurance-co-ca10-2005.