Hilda Gradinger v. Washington National Ins. Co.

250 F. App'x 271
CourtCourt of Appeals for the Eleventh Circuit
DecidedOctober 4, 2007
Docket06-16164
StatusUnpublished
Cited by2 cases

This text of 250 F. App'x 271 (Hilda Gradinger v. Washington National Ins. Co.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Eleventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hilda Gradinger v. Washington National Ins. Co., 250 F. App'x 271 (11th Cir. 2007).

Opinion

PER CURIAM:

Edward B. Gradinger and Caryle R. Levine, as personal representatives of the Estate of Hilda Gradinger, appeal the district court’s grant of Washington National Insurance Company’s motion for final summary judgment and the denial of Mrs. Gradinger’s 1 motion for partial summary judgment. The parties do not dispute the facts or the applicable law in this case. They simply disagree on how the law applies to the facts. Because we find that there is more than one reasonable interpretation of the home health care insurance policy at issue, we must liberally construe it in favor of the insured. Thus, we reverse the district court’s order.

I. BACKGROUND

In November 1990, Mrs. Gradinger applied for home health care insurance with Pioneer Life Insurance Company. Pioneer issued a policy to Mrs. Gradinger, effective December 26, 1990, which included multiple pages: (a) introductory pages; (b) a one-page Certificate Schedule; (c) five printed pages detailing information such as policy definitions, benefits, exclusions, and pre-existing conditions limitations; (d) an endorsement page; (e) amendments to the policy; and (f) a copy of Mrs. Gradinger’s application for insurance. The introductory pages and five pages following the Certificate Schedule comprised a pre-printed, standard certificate of insurance. The Certificate Schedule, which details the amounts of coverage, was the only portion of the policy specially prepared for Mrs. Gradinger.

The schedule appears as follows:

CERTIFICATE SCHEDULE

HOME HEALTH CARE BENEFIT $180/DAY

LIFETIME MAXIMUM BENEFIT AMOUNT $250,000

PER OCCURRENCE MAXIMUM BENEFIT $150,000/ILLNESS

AUTOMATIC BENEFIT INCREASE PERCENTAGE Benefits increase by 8% each year

INSURED: Hilda Gradinger CERTIFICATE NO: PL0855783A

EFFECTIVE DATE: 12-26-90

INITIAL PREMIUM: $1,108.00

Additionally, the pre-printed pages contain the following relevant provisions:

HOME HEALTH CARE: We will pay 100% of the usual and customary charges for Home Health Care expenses if the care was pre-authorized. If the care was not pre-authorized we will pay 75% of the usual and customary charges for Home Health Care expenses incurred, up to 75% of the Daily Benefit *273 Amount shown in the schedule. These benefits will be paid up to the Home Health Care Daily Benefit shown in the schedule. All benefits will be limited to the Per Occurrence Maximum Benefit for each injury or sickness and the Lifetime Maximum Benefit Amount for ALL injuries and sicknesses which are shown in the certificate schedule.

AUTOMATIC DAILY BENEFIT INCREASE: On each policy anniversary, we will increase the Home Health Care Daily Benefit payable under this policy by the Automatic Benefit Increase Percentage shown on the schedule page.

LIFETIME MAXIMUM BENEFIT: This coverage shall terminate and no further benefits will be payable when the total sum of Home Health Care or Adult Day Care benefits paid equals the amount shown in the schedule for the Lifetime Maximum Benefit Amount. Any premium paid for a period after termination will be refunded.

After the policy was issued, Pioneer merged with Washington National Insurance Company. As a result of the merger, Washington National assumed all obligations under the policy.

In April 1998, Mrs. Gradinger submitted a claim for benefits under the policy because she was receiving medically necessitated home health care. The insurer paid home health care benefits on behalf of Mrs. Gradinger for approximately five years. In April 2003, the insurer ceased paying benefits under the policy and terminated coverage because it claimed that Mrs. Gradinger had reached the Lifetime Maximum Benefit amount of $250,000. 2 Mrs. Gradinger objected to the termination of her coverage, arguing that the liability limit under the policy had not been met because the Lifetime Maximum Benefit amount had increased by 8% each year. Subsequently, Mrs. Gradinger received and paid three premium bills totaling $2,649.75.

In January 2006, Mrs. Gradinger filed her lawsuit against Washington National in state court, alleging breach of contract (Count I) and waiver and estoppel (Count II). Washington National removed the case to federal district court pursuant to 28 U.S.C. § 1332.

In April 2006, Washington National remitted a check to Mrs. Gradinger for $669.98. An accompanying letter explained that the check was a refund of unearned premiums collected plus interest at the rate of 7%, minus an overpayment of claims in the amount of $1,995.50. Mrs. Gradinger accepted the reimbursement.

In September 2006, Mrs. Gradinger moved for partial summary judgment only on the liability aspect of the breach of contract claim. 3 Washington National moved for final summary judgment on both the breach of contract claim and the waiver and estoppel claim. The district court entered an order granting final summary judgment to Washington National and denying partial summary judgment to Mrs. Gradinger on October 30, 2006. Mrs. Gradinger appeals the district court’s dismissal of her breach of contract claim only. *274 She does not appeal the dismissal of her waiver and estoppel claim.

II. STANDARD OF REVIEW

We review the grant or denial of summary judgment de novo. Holloman v. Mail-Well Corp., 443 F.3d 832, 836 (11th Cir.2006). “Summary judgment is appropriate when no genuine issue of material fact exists and the moving party is entitled to judgment as a matter of law.” Elan Pharm. Research Corp. v. Employers Ins. of Wausau, 144 F.3d 1372, 1374-75 (11th Cir.1998) (citing Fed.R.Civ.P. 56(c)).

III. DISCUSSION

This matter is ripe for summary judgment because it involves a pure question of law. The parties do not dispute the relevant facts. They only dispute the proper interpretation of the Maximum Lifetime Benefit amount payable under the home health care insurance policy. Washington National argues that the policy caps the allowable Lifetime Benefit at $250,000. Mrs. Gradinger, on the other hand, asserts that the Maximum Lifetime Benefit should have increased 8% per year from the original $250,000. The district court held that the policy was unambiguous and the plain meaning supported Washington National’s interpretation of the of the policy. We disagree.

In this case, Florida law governs the interpretation of the home health care insurance policy. “Thus, we look at the policy as a whole and give every provision its full meaning and operative effect.” Hyman v. Nationwide Mut. Fire Ins. Co.,

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Related

Washington National Insurance v. Ruderman
117 So. 3d 943 (Supreme Court of Florida, 2013)
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263 F.R.D. 670 (S.D. Florida, 2010)

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Bluebook (online)
250 F. App'x 271, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hilda-gradinger-v-washington-national-ins-co-ca11-2007.