Hargroder v. Protective Life Ins. Co.

556 So. 2d 991, 1990 La. App. LEXIS 221, 1990 WL 9707
CourtLouisiana Court of Appeal
DecidedFebruary 7, 1990
Docket88-1005
StatusPublished
Cited by12 cases

This text of 556 So. 2d 991 (Hargroder v. Protective Life Ins. Co.) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hargroder v. Protective Life Ins. Co., 556 So. 2d 991, 1990 La. App. LEXIS 221, 1990 WL 9707 (La. Ct. App. 1990).

Opinion

556 So.2d 991 (1990)

Larry HARGRODER Plaintiff-Appellee,
v.
PROTECTIVE LIFE INSURANCE COMPANY Defendant-Appellant.

No. 88-1005.

Court of Appeals of Louisiana, Third Circuit.

February 7, 1990.
Writ Denied April 16, 1990.

*993 Brinkhaus, Dauzat & Falgoust, James Dauzat, Opelousas, for plaintiff/appellee.

Dubuisson & Dubuisson, Edward Dubuisson, Opelousas, for defendant/appellant

Before GUIDRY, STOKER and YELVERTON, JJ.

STOKER, Judge.

This is a suit by Larry Hargroder to recover benefits, penalties and attorney's fees from Protective Life Insurance Company under a group hospitalization policy which was issued to the St. Landry Parish School Board covering teachers employed in its system. Larry is an employed, tenured teacher.

Larry alleges that the policy provides coverage for reimbursement of medical expenses incurred by him for himself and his family for the calendar years of 1983 and 1984. Protective made some payments under The Plan to Larry for medical expenses incurred for himself, his son Marty, his daughter Leslie, and his wife Norma, but denied coverage for the major portion of the expenses on the grounds that the expenses for treatment of alcoholism and drug abuse were excluded from coverage under The Plan or because the facility in which treatment was rendered was not a hospital. The trial court held in favor of plaintiffs, except as to Norma Hargroder's medical expenses, and awarded penalties and attorney's fees. Protective Life appeals the award of medical expenses for Larry, Marty and Leslie Hargroder and the award of penalties and attorney's fees. We affirm.

FACTS

Larry Hargroder was employed by the St. Landry School Board as a tenured teacher in 1983 and 1984 and he and his wife and dependent children were insured under The Plan for those years. The evidence at trial established that the expenses Protective has resisted paying are for the treatment of alcoholism, drug abuse and related mental disorders.

The evidence established that Larry was an alcoholic and his unpaid expenses were entirely for the treatment of that malady. Larry claims he incurred $1,171.50 for treatment in 1983 and $1,350.50 in 1984, and Protective has paid $256.20 toward liquidation of that claim. Protective resisted payment of Larry's claim because of the alcoholism exclusion under The Plan.

Marty Hargroder, Larry's dependent and insured son, allegedly incurred $7740 in 1983 and $4696 in 1984 for treatment of substance abuse. Protective paid $330 on the 1983 expenses, but later tried to retrieve the money it had paid, and it paid nothing on the 1984 expenses. Payment was denied by Protective because treatment was for drug abuse.

Leslie Hargroder, Larry's dependent and insured daughter, allegedly incurred $195 in 1983 and $4,437.50 in 1984 for treatment of substance abuse. Protective paid $105 on the 1984 expenses, nothing on those incurred in 1983 and resisted the balance on the ground that there was no coverage.

The trial court held that the exclusion of alcohol and drug abuse treatment is invalid because rejection of the coverage was made by the Superintendent of Schools for St. Landry Parish rather than by the School Board, as required by LSA-R.S. 17:83 and 17:1221. Therefore, coverage was legally imposed under LSA-R.S. 22:215.5.

ASSIGNMENTS OF ERROR

Protective Life Insurance appeals the trial court's judgment, assigning as errors the following:

1. The trial court erred in holding that the alcohol and drug abuse exclusion in *994 Protective Life Insurance Company's group policy was not effective. (LSA-R.S. 22:215.5)

2. The trial court erred in the amounts awarded to the plaintiff because the award was based only on an unsubstantiated summary of bills allegedly incurred by the Hargroder family and not on what was actually submitted to Protective Life Insurance Company.

3. The trial judge erred in assessing penalties and attorney's fees in this case. (LSA-R.S. 17:83, LSA-R.S. 22:657)

4. The judgment provides for interest at the rate of 12 percent per annum, and this should be adjusted, in the event that the award is affirmed, to reflect the charge in legal interest set out in Louisiana Civil Code Article 2924.

Plaintiff has not appealed the judgment insofar as it held against coverage of Norma Hargroder's medical expenses.

OPINION

COVERAGE

Protective Life contends the trial court erred in holding that the alcohol and drug abuse exclusion in the group policy was not effective. The trial court has set forth excellent written reasons for judgment on this issue which we set forth here in part:

APPLICATION OF THE EXCLUSION TO LARRY, MARTY AND LESLIE AND ITS EFFECTIVENESS

"R.S. 22:215.5 as of October 1, 1982 made it mandatory that any group health insurance policy issued under R.S. 22:215 must contain an `... option to be exercised by the policy holder covered benefits for the treatment of alcoholism and drug abuse, rendered or prescribed by a physician licensed in this state, received in any licensed hospital or in any other public or private facility ... including freestanding, non-hospital chemical dependency units.' Subparagraph B of that section directed any insurer that had issued a covered policy prior to October 1, 1982 to convert it to conform with the statute.
"The policy in this case (The Plan) was issued January 1, 1981 with an effective date of January 15, 1981 (Exhibit P-1). The St. Landry Parish School Board is the `policyholder'. The policy under the section captioned `Schedule of Insurance' (p.2) `Major Medical Expense Benefits' for calendar year maximum of $2500 for mental or nervous disorders. The term `mental or nervous condition' is defined by the policy as `... a neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind.' (Policy p. 9). Payment of major medical benefits for a `mental or nervous condition' was limited to 50% of the total expenses for a calendar year limited to a maximum of $2500.00 per calendar year per covered family member. (Policy p. 21).
"Treatment for alcoholism and drug abuse is not an excluded item under the `Exclusions, Limitations and Deductions' portion of the policy (Policy pp. 25-25). [sic] But Protective had issued a booklet labeled `Group Insurance Booklet—Certificate'. (Court # 3). Treatment for alcoholism or drug abuse is excluded from coverage. (Booket [sic] p. 26). The booklet states, however, at page 1 that the benefits and provisions described in it are subject to the terms and conditions of the policy, and the policy alone constitutes the entire contract. In the beginning portion of the policy (P-1) there is an undated sheet of paper under Protective's letterhead which sets out the optional coverage for alcoholism and drug abuse as provided for by the statute. The option `No' is selected in both instances and is signed `St. Landry—Policyholder by Henry Monteilh Title—Superintendent.' (P-8) It was stipulated that Protective received this ostensible exercise of optional coverage. The plaintiff offered P-8 which was an option exercise dated `10/11/82' which the Court construes as the one that is applicable to this case. Bryant Goudeau, a retired school teacher and now a member of the school board testified that Henry *995 Monteilh did not have the authority to execute the option for coverage. (P-8) Robert Meadors, Protective's representative, testified that his company received nothing from the St.

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Bluebook (online)
556 So. 2d 991, 1990 La. App. LEXIS 221, 1990 WL 9707, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hargroder-v-protective-life-ins-co-lactapp-1990.