Insurance Commissioner v. Mutual Life Insurance Co. of New York

680 A.2d 584, 111 Md. App. 156, 1996 Md. App. LEXIS 103
Court of Special Appeals of Maryland·Decided June 28, 1996·No. 1566, Sept. Term, 1995·Published·Cited by 8 cases

Opinion

HARRELL, Judge.

This appeal requires us to determine if we shall recognize an “exist/manifest” distinction when interpreting the phrase “existed prior to”, in a statutorily required incontestability clause contained in a disability insurance policy. The statute prohibits an insurer from turning down any claim for disability (as defined in the policy), starting after two years from the policy’s inception, on the grounds that a disease or physical condition existed prior to the policy’s inception. The provisions of the policy at issue here define “disability” in terms of the insured having a sickness or disease that first manifests itself while the policy is in force. Appellee (cross-appellant), the Mutual Life Insurance Company of New York (“MONY”), filed a cross-appeal challenging the Circuit Court for Baltimore City’s affirmance of appellant’s (cross-appellee), the Insurance Commissioner of the State of Maryland (“the Commissioner”), interpretation of Md. Ann.Code art. 48A § 441 *159 (1957, 1994 Repl.Yol.) 1 in a manner that refused to recognize an “exist/manifest” distinction. The Commissioner appeals from the portion of the circuit court’s judgment that, based in part upon its finding that MONY did not violate the insurance code in maintaining its erroneous interpretation of the statute, reversed the Commissioner’s order requiring MONY to pay its insured all benefits due under her disability insurance policy. As we shall explain, we conclude that the circuit court’s interpretation of § 441, which did not recognize an “exist/manifest” distinction, was legally correct. Therefore, we shall affirm this portion of the lower court’s judgment. As to MONY’s obligation to pay benefits to its insured consonant with its statutory and contractual obligation, having interpreted § 441 against MONY’s position, we conclude that by virtue of a stipulation entered below by MONY and the Maryland Insurance Administration (“MIA”), MONY cannot now refuse the claim of its insured/Mary L. Holland, on the ground that her condition manifested itself before the issuance of her policy. Because that was the only apparent ground revealed by the record in this case upon which MONY denied the claim, it must now pay Ms. Holland’s claim in accordance with the terms of her policy.

ISSUES

MONY, as cross-appellant, raises the following issues, which have been rephrased:

I. Assuming that MONY was in full compliance with Article 48A, did the circuit court err in choosing to decide the merits of the underlying contractual issue?
II. Did the circuit court err in disagreeing with MONY’s interpretation of the policy definitions at issue as they relate to the incontestability clause?

The Commissioner raises the following questions for our consideration, which we have slightly rephrased:

*160 III. Did the Commissioner have the authority to order MONY to pay its insured’s disability claim, where MONY denied the claim based on an erroneous interpretation of § 441?
IV. Assuming it is finally determined that MONY’s interpretation and application of § 441 to its insured’s claim was contrary to Maryland law, is MONY obligated to pay this claim pursuant to the stipulation agreed upon by the parties?

FACTS

The facts before us are essentially undisputed and are for the most part contained in a stipulation that was agreed upon by the MIA and MONY before the Commissioner for the express purpose of attaining a formal interpretation of § 441. 2 On 27 November 1985, Ms. Holland (or “the insured”) executed an application for a disability income insurance policy to be issued by MONY. In this application, Ms. Holland denied, among other illnesses, any previous history of mental or nervous disorder during the past ten years. She did indicate that she had been treated for an ulcer. Based on this application, MONY issued Ms. Holland a disability income insurance policy. MONY expressly agreed not to contest the accuracy of the answers provided in Ms. Holland’s application.

Ms. Holland’s policy, by its terms, generally covered disabilities that “start[ed] while th[e] Policy ... [was] in force.” “Disability” was defined as “either a Total Disability or a Partial Disability, provided that in either case the Disability starts while this Policy is in force.” Both total and partial disability were defined in terms of the insured not being able to work “because of injury[ 3 ] or sickness.” “Sickness” was defined as a “sickness or disease which first manifests itself *161 while this Policy is in force.” In conformance with § 441, 4 the policy also contained the following provisions, under the heading “Incontestable”:

After this policy has been in force for 2 years during your lifetime, we may not contest any statements in the application. (We will not count as part of the 2 years any period when you are disabled.)[ 5 ]
* * * * * *
We may not reduce or turn down any claim for loss incurred [or] Disability [as defined in the policy] starting after two years from the Policy Date on the grounds that a disease or *162 physical condition existed prior to the Policy Date, unless that disease or physical condition is excluded from coverage by name or specific condition.

The policy also included a rider that expressly excluded loss for gastro-intestinal disease. It is undisputed that the form and content of Ms. Holland’s policy were filed with the MIA, where the policy received approval prior to MONY’s use of it in Maryland.

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Insurance Commissioner v. Mutual Life Insurance Co. of New York, 680 A.2d 584, 111 Md. App. 156, 1996 Md. App. LEXIS 103 (Md. Ct. App. 1996).

680 A.2d 584 (Insurance Commissioner v. Mutual Life Insurance Co. of New York) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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