In re: Life Investors Insurance v.

CourtCourt of Appeals for the Sixth Circuit
DecidedDecember 17, 2009
Docket09-5598
StatusPublished

This text of In re: Life Investors Insurance v. (In re: Life Investors Insurance v.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
In re: Life Investors Insurance v., (6th Cir. 2009).

Opinion

RECOMMENDED FOR FULL-TEXT PUBLICATION Pursuant to Sixth Circuit Rule 206 File Name: 09a0428p.06

UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT _________________

X In re: LIFE INVESTORS INSURANCE COMPANY - No. 09-5598 - OF AMERICA; AEGON USA, INC., - Petitioners. - Nos. 09-5598/5868/6357 _____________________________________ ,> - - - Nos. 09-5868/6357 - ANTHONY E. GOOCH, Plaintiff-Appellee, - - - - v. - LIFE INVESTORS INSURANCE COMPANY OF - - Defendants-Appellants. - AMERICA and AEGON, INC., - - N Appeal from the United States District Court for the Middle District of Tennessee at Columbia. No. 07-00016—William J. Haynes, Jr., District Judge. Argued: November 19, 2009 Decided and Filed: December 17, 2009 Before: MARTIN, BOGGS, and COLE, Circuit Judges.

_________________

COUNSEL ARGUED: Markham R. Leventhal, JORDEN BURT LLP, Miami, Florida, for Appellants. Thomas O. Sinclair, LEITMAN SIEGAL PAYNE & CAMPBELL, P.C., Birmingham, Alabama, for Appellee. ON BRIEF: Markham R. Leventhal, Julianna Thomas McCabe, Richard J. Ovelmen, JORDEN BURT LLP, Miami, Florida, Thomas H. Dundon, A. Scott Ross, NEAL AND HARWELL, PLC, Nashville, Tennessee, for Appellants. Thomas O. Sinclair, Miles Clayborn Williams, LEITMAN SIEGAL PAYNE & CAMPBELL, P.C., Birmingham, Alabama, Eric L. Buchanan, ERIC BUCHANAN & ASSOCIATES, Chattanooga, Tennessee, for Appellee.

1 Nos. 09-5598/5868/6357 Gooch v. Life Investors Ins. Co., et al. Page 2

OPINION _________________

BOYCE F. MARTIN, JR., Circuit Judge. In Case Number 09-5598, defendants- petitioners Life Investors Insurance Company of America and its parent company AEGON 1 USA, Inc. seek various forms of mandamus relief from the district court’s orders and general case management approach. In Case Number 09-5868, the Company appeals the order of the district court enjoining the Company from continuing with the settlement process in a parallel class action in Arkansas state court. Finally, seven days prior to oral argument on Case Numbers 09-5598 and 09-5868, the Company filed a third appeal, Case Number 09-6357, this time taking issue with the district court’s denial without prejudice of the Company’s motion to dissolve a preliminary injunction. For the reasons set forth below, we DENY mandamus relief in No. 09-5598, REVERSE and VACATE the injunction in No. 09-5868, and AFFIRM in No. 09-6357.

I.

Because this case comes before us on interlocutory review, the facts do not provide the fixed target that we prefer when setting forth the factual and procedural history of a case on appeal. Thus, we provide only a brief summary of the allegations and an overview of where the litigation stands and then incorporate additional facts where necessary in the analysis.

The substance of this case revolves around how the Company administers supplemental “cancer only” insurance policies that it has sold to individuals, such as plaintiff Anthony Gooch, and specifically how it calculates reimbursement for certain costs. Although some of the reimbursements provided under the policy are in fixed amounts, other reimbursements are keyed to the “actual charges”2 incurred by the

1 Life Investors Insurance Company of America now trades as Transamerica Life Insurance Company. For purposes of this opinion, we refer to this entity and AEGON collectively as the Company. 2 The term “actual charges” comes directly from the insurance policy, and it is the meaning of this term that is the heart of this case. Nos. 09-5598/5868/6357 Gooch v. Life Investors Ins. Co., et al. Page 3

insured for certain services, such as radiation, chemotherapy, or ambulance transportation.

The Company contends that for several years it accepted, as proof of “actual charges,” statements from hospitals and doctors that set forth “list prices” for a given treatment or service. The Company further contends that these “list prices” are pure fiction because they are not actually billed to anyone, and no one actually pays those prices. Instead, the Company contends, hospitals and doctors routinely agree to accept a lesser amount from the patient’s primary insurer, similar to the difference between the sticker price for a car and the price that people actually pay for that car. Thus, the Company claims that it was erroneously providing windfalls to its customers by reimbursing them based on the list price when they actually only incurred costs based on the amount the doctor or hospital agreed to accept. The Company alleges that, after it realized this error during the course of an investigation into why premiums were rising, it changed its practice to require a showing of actual proof of loss for reimbursement. Now, the Company claims that instead of reimbursing the insured based on the list price, the Company reimburses based on whatever the medical provider agreed to accept as payment in full. The Company asserts that this is in complete accord with the terms of the insurance policies.

Gooch disagrees. In short, he contends that the policies require that the Company reimburse policyholders for the amount the medical provider says it is owed, regardless of whether the provider subsequently agrees to accept less from the insured’s primary insurer. He further contends that, even if the provider agrees to accept less than its full price from an insurance company, the individual still remains liable for the difference. Thus, Gooch asserts that the Company breached its policy when it began refusing to reimburse for whatever amount the provider initially says that it is owed.

Gooch therefore brought this suit seeking declaratory, injunctive, and monetary relief from the Company’s alleged breach of the insurance contract. He also seeks to pursue these claims on behalf of a nationwide class of individuals that had purchased identical policies from the Company. Gooch filed his complaint on March 30, 2007. Nos. 09-5598/5868/6357 Gooch v. Life Investors Ins. Co., et al. Page 4

The early months of the case saw a flurry of activity, including a motion to dismiss from the Company and motions for partial summary judgment on the meaning of the policy, a preliminary injunction, and class certification from Gooch. However, the case has languished for more than two years, with numerous partial or complete stays punctuated by random bursts of rulings, orders, and discovery. From our review of the docket sheet, it appears that a substantial amount of discovery and pretrial filings remains before this matter is ready for trial.

II.

A. Case Number 09-5598 - Petition for Writ of Mandamus

In May of 2009, the Company petitioned this Court for a writ of mandamus. The issues for which the Company seeks mandamus relief may be broken up into three general categories: (1) the district court’s ruling granting partial summary judgment to Gooch on the interpretation of the policy, and its treatment of that ruling as “law of the case”; (2) the district court’s decision to defer ruling on the Company’s motion to dissolve a preliminary injunction, requiring the Company to continue reimbursing Gooch according to the old method, until a hearing on class certification and permanent class- wide injunctive relief; and (3) the district court’s various discovery rulings, which the Company describes as one-sided. Before we address these three issues, however, we review the general standards concerning the availability of mandamus relief, taken from our recent decision in In re Professionals Direct Insurance Co., 578 F.3d 432 (6th Cir. 2009):

This Court has authority to issue a writ of mandamus under 28 U.S.C. § 1651

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