Kaplan v. Northwestern Mutual Life Insurance

65 P.3d 16, 115 Wash. App. 791
CourtCourt of Appeals of Washington
DecidedFebruary 24, 2003
DocketNo. 49198-9-I
StatusPublished
Cited by40 cases

This text of 65 P.3d 16 (Kaplan v. Northwestern Mutual Life Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals of Washington primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kaplan v. Northwestern Mutual Life Insurance, 65 P.3d 16, 115 Wash. App. 791 (Wash. Ct. App. 2003).

Opinion

Kennedy, J. —

Jerrold I. Kaplan and his disability insurance carrier, Northwestern Mutual Life Insurance Company, dispute whether Kaplan is entitled to disability benefits from a date approximately five years earlier than the date Northwestern Mutual established for onset of disability.1 The case was tried to a jury, which returned a verdict adverse to Kaplan. Kaplan argues in this appeal that the verdict was the product of two prejudicial legal errors requiring reversal. First, Kaplan contends that the trial court erred in denying his motion for summary judgment on the question of whether the “under the care of a licensed physician” clauses in his disability policies are ambiguous, and therefore must be construed in Kaplan’s favor as a matter of law (instead, the trial court sent the issue of whether Kaplan complied with the clauses to the jury for determination). Second, Kaplan contends that the trial court failed to properly instruct the jury that Northwestern Mutual had the burden of proving actual prejudice from any failure on Kaplan’s part to fulfill one or more of the conditions precedent to coverage for purposes of the disputed five-year period. Northwestern Mutual Life Insurance Company contends, inter alia, that neither of the claimed errors was preserved for review. We conclude that the first claim of error was preserved for review, although the second was not.2 Because the “under the care of a [795]*795licensed physician” clauses contained in the policies here at issue are subject to at least two reasonable interpretations, so that their actual meaning is unclear, they are ambiguous as a matter of law, and must be construed in Kaplan’s favor. Accordingly, the trial court erred in failing to grant Kaplan’s motion for summary judgment on that issue, and in submitting the issue of Kaplan’s fulfillment of that condition to the jury. We reverse and remand for a new trial on that basis.

FACTS

During the 1970s and 1980s, Jerrold Kaplan purchased six disability insurance policies from Northwestern Mutual Life Insurance Company: three series “KK” policies, issued on December 21, 1978, December 21, 1979, and February 25, 1981, respectively; two series “LL” policies, issued on February 15,1982, and December 9,1982, respectively; and one series “MM” policy, issued on July 30, 1985. It is undisputed that Kaplan suffers from severe, unrelenting, and treatment-resistant obsessive-compulsive disorder, a chronic psychiatric disorder characterized by repetitive behaviors and intrusive, anxiety-producing thoughts, and that he has been disabled by this condition since at least March 9,1994, when the condition was first diagnosed. It is also undisputed that Kaplan paid all premiums due under all six of the policies until Northwestern Mutual found him to be disabled, and waived further premiums. It is also undisputed that Kaplan has suffered from obsessive-compulsive disorder for many years, although Northwestern Mutual claims that it cannot determine the degree of Kaplan’s disability, if any, during the disputed five-year period because he was not being treated for obsessive-compulsive disorder by a licensed physician during that time. Kaplan was fired from his last steady job as a computer programmer on June 29,1989, for “unsatisfactory performance.” Except for a very short and unsuccessful stint as a telemarketer, Kaplan has been unemployed since that date.

[796]*796In 1992, after doing some reading on the subject of obsessive-compulsive disorder and suspecting that he might have the disorder, Kaplan applied to participate in an obsessive-compulsive disorder research study being conducted by Dr. Dane Wingerson of Harborview Medical Center. Dr. Wingerson interviewed Kaplan, but rejected him from the study, telling him that he did not have obsessive-compulsive disorder. In 1994, Kaplan responded to another advertisement for an obsessive-compulsive disorder study being conducted by Dr. Peter Londborg of the University of Washington. Dr. Londborg diagnosed Kaplan with obsessive-compulsive disorder on March 9, 1994, and accepted him into the study, which was for the purpose of testing a new drug developed by Pfizer. When it became apparent that the drug being tested was not helping Kaplan, Dr. Londborg removed him from the study for his own good, prescribed a different medication for him, and referred him to a different psychiatrist for ongoing treatment. Dr. Londborg believes that the disorder has been the major factor in Kaplan’s inability to work since 1989. Kaplan has testified that it was only after his final interview with Dr. Londborg, in July 1994, during which Dr. Londborg expressed his opinion of the seriousness of Kaplan’s illness, that Kaplan understood and accepted that he was disabled by obsessive-compulsive disorder.

Kaplan submitted notice of his claim of disability to Northwestern Mutual Life Insurance Company on August 6, 1994. He defined the onset date of his disability as June 29, 1989, the last day of his job as a computer programmer. However, Northwestern Mutual defined the onset date of disability as March 9, 1994, the date that Dr. Londborg diagnosed Kaplan as having obsessive-compulsive disorder, and denied Kaplan’s request to push back the onset date of disability to June 29, 1989, pointing to the notice and proof of claim sections of the policies. Northwestern Mutual also informed Kaplan that it would not pay benefits for any period before March 1994 because Kaplan had not been under the care of a licensed physician for the disorder until that time.

[797]*797Kaplan filed this lawsuit in March 1997, alleging, inter alia, that Northwestern Mutual had breached its insurance contracts by denying coverage for the disputed five-year period, and seeking to collect retroactive benefits from June 29, 1989, to March 9, 1994.3 Kaplan averred that he had submitted notice and proof of claim as soon as reasonably possible, as required by his disability insurance policies. He also contended that Northwestern Mutual was required to demonstrate that it had been prejudiced by his failure to make his claim any sooner.

Northwestern Mutual moved for summary judgment on the timely notice and proof of claim issues, arguing that Kaplan had violated the policy provisions requiring timely notice and proof of disability for purposes of the disputed period, as a matter of law. The trial court granted summary judgment in favor of Northwestern Mutual, and Kaplan appealed. We reversed and remanded for trial, holding that Northwestern Mutual had the burden of proving that it was prejudiced by Kaplan’s failure to sooner make and prove his claim, and that Kaplan had raised genuine issues of material fact regarding both prejudice and when a reasonable person suffering from obsessive-compulsive disorder — who was told by a physician that he did not have that disorder— would realize that he did have the disorder, and was disabled by it, so as to make a claim to his disability insurer. See Kaplan v. N.W. Mut. Life Ins. Co., 100 Wn. App. 571, 575-76, 579-80, 990 P.2d 991 (2000) (Kaplan I).

Following our remand, and after additional pretrial discovery, Kaplan moved for summary judgment on each of his substantive claims, reserving only the question of damages. Insofar as here relevant, Kaplan argued that the “under the care of a licensed physician” clauses contained in the insurance policies are subject to two conflicting reasonable meanings, so that the clauses are ambiguous as a matter of law, and must be strictly construed in favor of Kaplan.

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Cite This Page — Counsel Stack

Bluebook (online)
65 P.3d 16, 115 Wash. App. 791, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kaplan-v-northwestern-mutual-life-insurance-washctapp-2003.