Lomma v. Ohio Nat'l Life Assurance Corp.
This text of 283 F. Supp. 3d 240 (Lomma v. Ohio Nat'l Life Assurance Corp.) is published on Counsel Stack Legal Research, covering District Court, M.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
Opinion
Robert D. Mariani, United States District Judge
Before the Court is Defendants', Ohio National Life Assurance Corporation and Ohio National Life Insurance Company, ("Defendants"), motion to dismiss pursuant to Federal Rule of Civil Procedure 12(b)(6). (Doc. 4). For the reasons that follow, Defendants' motion will be granted in part and denied in part.
I. INTRODUCTION AND PROCEDURAL HISTORY
Plaintiffs Nicholas Lomma and J.L., a minor, by his guardian, Anthony Lomma, ("Plaintiffs"), seek to recover $100, 000 as beneficiaries of a replacement term life insurance policy issued by Defendants (the "Replacement Policy") on the life of their mother, Lora Marie Lomma ("Ms. Lomma"). Ms. Lomma committed suicide in May of 2009 and Defendants have denied *245payment of full death benefits based on a suicide exclusion in the Replacement Policy.
Plaintiffs commenced this action on November 2, 2016, in the Court of Common Pleas of Lackawanna County. The complaint ("Complaint") asserts five causes of action: (1) breach of contract; (2) unjust enrichment; (3) promissory estoppel; (4) breach of implied covenant of good faith and fair dealing; and (5) statutory bad faith pursuant to 42 Pa. C. S. A. § 8371.1 (Doc. 1-4). Defendants removed the action to this Court on December 2, 2016, (Doc. 1), and promptly moved to dismiss the Complaint in its entirety on December 9, 2016. (Doc. 4).
II. FACTUAL ALLEGATIONS
Plaintiffs' Complaint and the exhibits attached thereto allege the following facts:
Plaintiffs, Nicholas Lomma and J. L., are or were minors residing in Scranton Pennsylvania and are the surviving children of Ms. Lomma. (Doc. 1-4, at ¶¶ 1-2). Anthony Lomma ("Mr. Lomma") is the natural parent of Nicholas Lomma and J. L and is the surviving former husband of Ms. Lomma and is also J. L.'s guardian. (Id. at ¶¶ 3-4). Defendants are Ohio corporations with registered addresses in Cincinnati, Ohio and are licensed to sell insurance in Pennsylvania. (Id. at ¶ 5).
In September 1986, Ms. Lomma applied for, and was issued, a life insurance policy (the "Original Policy") by Pennsylvania National Life Insurance Company with a coverage amount of $25, 000. (Id. at ¶ 6). The Original Policy contained a suicide exclusion.2 Although the facts surrounding Defendants' purchase of the Original Policy from Pennsylvania National Life Insurance Company are not entirely clear, Plaintiffs allege Defendants "purchased or otherwise acquired the Original Policy from Pennsylvania National Life Insurance Company." (Id. at ¶ 7).
On December 4, 1995, Ms. Lomma applied to increase the amount of coverage under the Original Policy from $25, 000 to $100, 000. (Id. at ¶ 8). In order to do so, she executed a "Request For Universal Life Policy Change" with Defendants. (Doc. 1-4 at 30-32). Ten days later Defendants informed Ms. Lomma that "[u]pon written request ... the stated amount is hereby increased from $25, 000 to $100,000 effective December 4, 1995." (Id. at 32). The Original Policy was set to expire on September 4, 2028.
Ms. Lomma filed an application for a new life insurance policy with Defendants with a coverage amount of $100, 000 on *246June 6, 2007.3 (Doc. 1-4 at 33-49). On the application, a box is checked indicating that the "proposed policy" would "replace or cause change in any existing policy." (Doc. 1-4 at 35). It identified the "existing policy" that the "proposed policy" would replace as "Ohio National," "Universal," "$100,000," and again a box is checked indicating that the existing policy will "be replaced." (Id. ) Written on the application was that the "replacement date" would be "upon issue of this policy." (Id. )
On August 15, 2007, Defendants issued the Replacement Policy to Ms. Lomma with a benefit value of $100,000. (Id. at ¶ 13). Both the amount of insurance coverage and the beneficiaries are identical to those under the Original Policy.4 (Id. ) The Replacement Policy identifies the "Contract Date" as August 10, 2007, and the "Issue Date" as August 15, 2007. (Doc. 1-4 at 51). It also contains a definition of "Contract Months and Years," and states: "[t]his contract takes effect on the contract date shown on page 3. Contract months and years are marked from the contract date. The first day of the contract year is the contract date and its anniversaries." (Id. at 60).
The Replacement Policy, like the Original Policy, contains a suicide exclusion. The two exclusions, however, do not contain the same language. The suicide exclusion in the Replacement Policy provides:
If the insured dies by suicide while sane or insane or by intentional self-destruction while insane, we will not pay any death proceed payable on amounts of insurance which have been in effect for less than 2 years. If the suicide or intentional self-destruction is within the first 2 contract years, we will pay as death proceeds the premiums you paid.
(Doc. 1-4 at 62). Although the Replacement Policy defines the term "contract years," it does not contain a definition for "amounts or insurance" and does not provide guidance for determinations of whether those "amounts of insurance" have or have not "been in effect for less than 2 years." (Id. )
Ms. Lomma committed suicide on May 24, 2009. (Doc. 1-4 at ¶ 15). At the time of her death she had timely paid all premiums due under both the Original Policy and the Replacement Policy and no premiums were due. (Id. at ¶ 26). Shortly after her death, Mr. Lomma filed a claim for death benefits under the Replacement Policy on behalf of Nicholas Lomma and J.L., requesting the $100,000 full death benefit. (Id. at ¶ 16). On August 31, 2009, Defendants' informed Mr. Lomma that they were denying the claim "on the grounds that Ms. Lomma's suicide violated the provisions of the policy." (Id. at ¶ 17). Specifically, Defendants wrote that "[b]ased on the information we have received and in accordance with" the suicide exclusion in the Replacement Policy, "the death proceeds for death due to 'Suicide' within the first two contract years is a refund of *247premiums paid." (Doc. 1-4 at 69). Enclosed with the letter were two checks each in the amount of $144. 27 (totaling $288. 54) representing the premiums Ms. Lomma paid on the Replacement Policy plus 4. 5% interest. (Id. )
III. STANDARD OF REVIEW
A complaint must be dismissed under Federal Rule of Civil Procedure 12(b)(6) if it does not allege "enough facts to state a claim to relief that is plausible on its face." Bell Atl. Corp. v. Twombly ,
Free access — add to your briefcase to read the full text and ask questions with AI
Robert D. Mariani, United States District Judge
Before the Court is Defendants', Ohio National Life Assurance Corporation and Ohio National Life Insurance Company, ("Defendants"), motion to dismiss pursuant to Federal Rule of Civil Procedure 12(b)(6). (Doc. 4). For the reasons that follow, Defendants' motion will be granted in part and denied in part.
I. INTRODUCTION AND PROCEDURAL HISTORY
Plaintiffs Nicholas Lomma and J.L., a minor, by his guardian, Anthony Lomma, ("Plaintiffs"), seek to recover $100, 000 as beneficiaries of a replacement term life insurance policy issued by Defendants (the "Replacement Policy") on the life of their mother, Lora Marie Lomma ("Ms. Lomma"). Ms. Lomma committed suicide in May of 2009 and Defendants have denied *245payment of full death benefits based on a suicide exclusion in the Replacement Policy.
Plaintiffs commenced this action on November 2, 2016, in the Court of Common Pleas of Lackawanna County. The complaint ("Complaint") asserts five causes of action: (1) breach of contract; (2) unjust enrichment; (3) promissory estoppel; (4) breach of implied covenant of good faith and fair dealing; and (5) statutory bad faith pursuant to 42 Pa. C. S. A. § 8371.1 (Doc. 1-4). Defendants removed the action to this Court on December 2, 2016, (Doc. 1), and promptly moved to dismiss the Complaint in its entirety on December 9, 2016. (Doc. 4).
II. FACTUAL ALLEGATIONS
Plaintiffs' Complaint and the exhibits attached thereto allege the following facts:
Plaintiffs, Nicholas Lomma and J. L., are or were minors residing in Scranton Pennsylvania and are the surviving children of Ms. Lomma. (Doc. 1-4, at ¶¶ 1-2). Anthony Lomma ("Mr. Lomma") is the natural parent of Nicholas Lomma and J. L and is the surviving former husband of Ms. Lomma and is also J. L.'s guardian. (Id. at ¶¶ 3-4). Defendants are Ohio corporations with registered addresses in Cincinnati, Ohio and are licensed to sell insurance in Pennsylvania. (Id. at ¶ 5).
In September 1986, Ms. Lomma applied for, and was issued, a life insurance policy (the "Original Policy") by Pennsylvania National Life Insurance Company with a coverage amount of $25, 000. (Id. at ¶ 6). The Original Policy contained a suicide exclusion.2 Although the facts surrounding Defendants' purchase of the Original Policy from Pennsylvania National Life Insurance Company are not entirely clear, Plaintiffs allege Defendants "purchased or otherwise acquired the Original Policy from Pennsylvania National Life Insurance Company." (Id. at ¶ 7).
On December 4, 1995, Ms. Lomma applied to increase the amount of coverage under the Original Policy from $25, 000 to $100, 000. (Id. at ¶ 8). In order to do so, she executed a "Request For Universal Life Policy Change" with Defendants. (Doc. 1-4 at 30-32). Ten days later Defendants informed Ms. Lomma that "[u]pon written request ... the stated amount is hereby increased from $25, 000 to $100,000 effective December 4, 1995." (Id. at 32). The Original Policy was set to expire on September 4, 2028.
Ms. Lomma filed an application for a new life insurance policy with Defendants with a coverage amount of $100, 000 on *246June 6, 2007.3 (Doc. 1-4 at 33-49). On the application, a box is checked indicating that the "proposed policy" would "replace or cause change in any existing policy." (Doc. 1-4 at 35). It identified the "existing policy" that the "proposed policy" would replace as "Ohio National," "Universal," "$100,000," and again a box is checked indicating that the existing policy will "be replaced." (Id. ) Written on the application was that the "replacement date" would be "upon issue of this policy." (Id. )
On August 15, 2007, Defendants issued the Replacement Policy to Ms. Lomma with a benefit value of $100,000. (Id. at ¶ 13). Both the amount of insurance coverage and the beneficiaries are identical to those under the Original Policy.4 (Id. ) The Replacement Policy identifies the "Contract Date" as August 10, 2007, and the "Issue Date" as August 15, 2007. (Doc. 1-4 at 51). It also contains a definition of "Contract Months and Years," and states: "[t]his contract takes effect on the contract date shown on page 3. Contract months and years are marked from the contract date. The first day of the contract year is the contract date and its anniversaries." (Id. at 60).
The Replacement Policy, like the Original Policy, contains a suicide exclusion. The two exclusions, however, do not contain the same language. The suicide exclusion in the Replacement Policy provides:
If the insured dies by suicide while sane or insane or by intentional self-destruction while insane, we will not pay any death proceed payable on amounts of insurance which have been in effect for less than 2 years. If the suicide or intentional self-destruction is within the first 2 contract years, we will pay as death proceeds the premiums you paid.
(Doc. 1-4 at 62). Although the Replacement Policy defines the term "contract years," it does not contain a definition for "amounts or insurance" and does not provide guidance for determinations of whether those "amounts of insurance" have or have not "been in effect for less than 2 years." (Id. )
Ms. Lomma committed suicide on May 24, 2009. (Doc. 1-4 at ¶ 15). At the time of her death she had timely paid all premiums due under both the Original Policy and the Replacement Policy and no premiums were due. (Id. at ¶ 26). Shortly after her death, Mr. Lomma filed a claim for death benefits under the Replacement Policy on behalf of Nicholas Lomma and J.L., requesting the $100,000 full death benefit. (Id. at ¶ 16). On August 31, 2009, Defendants' informed Mr. Lomma that they were denying the claim "on the grounds that Ms. Lomma's suicide violated the provisions of the policy." (Id. at ¶ 17). Specifically, Defendants wrote that "[b]ased on the information we have received and in accordance with" the suicide exclusion in the Replacement Policy, "the death proceeds for death due to 'Suicide' within the first two contract years is a refund of *247premiums paid." (Doc. 1-4 at 69). Enclosed with the letter were two checks each in the amount of $144. 27 (totaling $288. 54) representing the premiums Ms. Lomma paid on the Replacement Policy plus 4. 5% interest. (Id. )
III. STANDARD OF REVIEW
A complaint must be dismissed under Federal Rule of Civil Procedure 12(b)(6) if it does not allege "enough facts to state a claim to relief that is plausible on its face." Bell Atl. Corp. v. Twombly ,
"While a complaint attacked by a Rule 12(b)(6) motion to dismiss does not need detailed factual allegations, a plaintiff's obligation to provide the 'grounds' of his 'entitlement to relief requires more than labels and conclusions, and a formulaic recitation of a cause of action's elements will not do." Twombly ,
Twombly and Iqbal require [a court] to take the following three steps to determine the sufficiency of a complaint; First, the court must take note of the elements a plaintiff must plead to state a claim. Second, the court should identify allegations that, because they are no more than conclusions, are not entitled to the assumption of truth. Finally, where there are well-pleaded factual allegations, a court should assume their veracity and then determine whether they plausibly give rise to an entitlement for relief.
Connelly v. Steel Valley Sch. Dist. ,
"Under Federal Rule of Civil Procedure 8, a complaint need not anticipate or overcome affirmative defenses; thus, a complaint does not fail to state a claim simply because it omits facts that would defeat" an affirmative defense. Schmidt v. Skolas ,
"To decide a motion to dismiss, courts generally consider only the allegations contained in the complaint, exhibits attached to the complaint and matters of public record." Pension Benefit Guar. Corp. v. White Consol. Indus., Inc. ,
IV. ANALYSIS
Defendants move pursuant to Rule 12(b)(6) to dismiss each of the five counts alleged in Plaintiffs' Complaint. In resolving Defendants' motion, the Court considers the following exhibits attached to the Complaint: (1) the Original Policy; (2) Ms. Lomma's 1995 application with Defendants to increase coverage under the Original Policy from $25,000 to $100,000; (3) Ms. Lomma's application to obtain the Replacement Policy; (4) the Replacement Policy; and (5) Defendants' letter denying Plaintiffs' claim. (Doc. 1-4 at 12-69). Defendants also attach these documents to their motion to dismiss.5 (Docs. 4-1 at 9-60; 4-2).
The Court has jurisdiction over this diversity action pursuant to
A. Breach of Contract
In Count I, Plaintiffs allege that Defendants breached the Replacement Policy by refusing to pay the full $100,000 death benefit upon Ms. Lomma's death. Defendants seek dismissal of Count I on the theory that the Replacement Policy's suicide exclusion unequivocally establishes that the $100,000 death benefit was not payable to Plaintiffs. In opposition to Defendants' motion. Plaintiffs raise two principal arguments. First, they claim the suicide exclusion is ambiguous and therefore must be construed against the Defendants. Second, Plaintiffs argue that the facts alleged in the Complaint and the totality of circumstances plausibly demonstrate that *249Ms. Lomma had a reasonable expectation of coverage. In either case, because Defendants are relying on affirmative defenses to defeat Count I, it is Plaintiffs' position that Defendants' Rule 12(b)(6) motion must be denied. Before addressing the parties' contentions, the Court will discuss Pennsylvania law governing the interpretation of insurance policies.
1. Pennsylvania Law
"Insurance policies are contracts, and the rules of contract interpretation provide that the mutual intention of the parties at the time they formed the contract govern its interpretation." Am. & Foreign Ins. Co. v. Jerry's Sports Ctr., Inc. ,
"The interpretation of an insurance contract regarding the existence or non-existence of coverage is generally performed by the court." Minnesota Fire & Cas. Co. v. Greenfield ,
If a term in an insurance policy is ambiguous, "parol evidence is admissible to explain or clarify or resolve the ambiguity, irrespective of whether the ambiguity is patent, created by the language of the instrument, or latent, created by extrinsic or collateral circumstances." Insurance Adjustment Bureau ,
Under Pennsylvania law, "the insurer bears the burden of proving the applicability of any exclusions or limitations on coverage, since disclaiming coverage on the basis of an exclusion is an affirmative defense." Koppers Co., Inc. v. Aetna Cas. & Sur. Co. ,
"[E]ven the most clearly written exclusion will not bind the insured where the insurer or its agent has created in the insured a reasonable expectation of coverage." Moessner ,
2. Defendants' Motion Must Be Denied Because The Suicide Exclusion Is Ambiguous And, Even If The Suicide Exclusion Was Unambiguous, Plaintiffs Have Alleged Sufficient Facts Demonstrating That Ms. Lomma Had A Reasonable Expectation Of Coverage
The parties propose two different interpretations of the Replacement Policy's suicide exclusion. The suicide exclusion consists of two sentences. The first sentence provides: "[i]f the insured dies by suicide while sane or insane or by intentional self-destruction while insane, we will not pay any death proceed payable on amounts of insurance which have been in effect for less than 2 years." (Doc. 1-4 at 62). The second sentence, in turn, states: "[i]f the suicide or intentional self-destruction is within the first 2 contract years, we will pay as death proceeds the premiums you paid." (Id. )
Defendants principally rely on the second sentence of the suicide exclusion in support of their motion. They claim the second sentence is clear and unambiguous and unequivocally requires dismissal of Count I. The second sentence of the suicide exclusion provides that in the event *251the insured commits suicide within the first two contract years, as explicitly defined in the Replacement Policy, Defendants will not pay the full death benefits due under the Replacement Policy. Instead, Defendants will only pay death benefits representing the premiums paid by the insured.
The first sentence of the suicide exclusion is less clear. Unlike the term "contract years" in the second sentence, which is explicitly defined in the Replacement Policy, key terms in the first sentence of the suicide exclusion are not defined. The Replacement Policy neither defines "amounts of insurance" nor does it use a defined term like "contract years" to indicate whether those "amounts of insurance", which Defendants will not pay in the event of suicide, have or have not "been in effect for less than 2 years." (Id. ) Plaintiffs thus take the position that the first sentence renders the entire suicide exclusion ambiguous and, under Pennsylvania law, ambiguities in an instance policy must be interpreted against the insurer. They also claim that, because Ms. Lomma maintained $100,000 in life insurance coverage with Defendants since 1995, she had a reasonable expectation of coverage because the suicide exclusion would not apply.
Defendants, in contrast, interpret the first sentence as applying "if a policyholder increased his or her death benefits from $100,000 to $500,000 during the 25th year of the policy and then committed suicide within the next two years." (Doc. 11, at 3). They also argue that Plaintiffs' interpretation of the suicide exclusion is untenable because it would effectively nullify the second sentence of the suicide exclusion. In support, Defendants direct the Court to the Pennsylvania Supreme Court's decision in Capek v. Devito ,
As an initial matter, the Court rejects Defendants' reliance on Capek. The argument that Plaintiffs' proposed interpretation would, in effect, render the second sentence of the suicide exclusion a nullity does not mean that Defendants' interpretation, therefore, must prevail. In Capek , an attorney brought suit against his former client seeking recovery of a contingency fee and the Court was called upon to interpret the parties' contract. The Pennsylvania Supreme Court noted that when construing a contract, courts "must determine the intent of the parties and give effect to all the provisions therein." Capek ,
The Court must next look to Pennsylvania Supreme Court decisions interpreting suicide exclusions for guidance. When no case is directly on point, the court must predict how the Pennsylvania Supreme Court would rule. The parties do not cite to any Pennsylvania Supreme Court decision interpreting a suicide exclusion in an *252insurance policy. The Court, however, has located several cases where the Pennsylvania Supreme Court considered cases where, as here, an insurer relied on a suicide exclusion to deny payments to the beneficiaries under an insurance policy.
In Krebs v. Philadelphia Life Insurance Company ,
Although the printed language on the policy unambiguously provided that the policy date was October 1, 1913, the Pennsylvania Supreme Court held that the insured reasonably could have believed that the handwritten language, with a reference date of August 1, 1913, meant that the policy, with all in terms, was in force as of this date. In reaching this conclusion the Court noted:
It would have been an easy matter for the insurer to insert a provision to the effect that the date of the original policy should apply so far as the suicide clause was concerned, or that there was no exemption from suicide in the term policy. That was not done, and neither is there anything to show that a term policy meant something different from the contract, which was set forth in the printed form. The burden of showing this was on defendant, under the well-settled rule that, where there is an ambiguity in the conditions of a policy of insurance, its provisions will be construed most strongly against the insurer and in favor of the insured.
( Id. at 334-35,
In 1935 the Pennsylvania Supreme Court again construed a suicide exclusion in a life insurance policy. Ligouri v. Supreme Forest Woodmen Circle ,
In Harty v. Standard Accident Insurance Company ,
The defendant denied plaintiff's claim for death benefits. Plaintiff brought suit for breach of contract and judgment was entered in favor of the plaintiff beneficiary upon the jury's verdict. On appeal, the defendant insurer claimed there was insufficient evidence to sustain the verdict and also claimed it was entitled to a new trial based on the judge's statement that the change in the policy "should be construed strictly against it and in favor of the insured." ( Id. at 360,
The Supreme Court rejected the defendant's argument, holding that where the defendant relies on the defense that the original policy was ineffective because it had been cancelled, it bore the burden to prove the cancellation was effective and "must show strict compliance with the cancellation provisions." ( Id. at 361,
The Pennsylvania Supreme Court has cited to Harty on just one occasion. Isaac v. Continental Cas. Co. ,
Krebs, Ligouri, Harty , and Issac , while useful to guide the court's interpretation of Pennsylvania law as applied to the facts of this case, are not entirely on point. None of these cases addresses the replacement of a universal life insurance policy with a term policy in circumstances where the insured maintained the same amount of coverage and the insurer was relying on a suicide exclusion that would not be effective in the original policy to deny coverage under the replacement policy. The suicide exclusions at issue in those cases also did not contain the same language found in the Replacement Policy at issue here. More recent decisions of the Pennsylvania Supreme Court in related areas have addressed exclusions in insurance policies, supra at ---- - ----, and are consistent with Krebs, Ligouri, Harty , and Issac. Specifically, these cases confirm that Pennsylvania law not only requires courts to interpret ambiguous policy exclusions *254against the insurer, but also provides that unambiguous exclusions may not operate to free the insurer from liability for breach of contract unless the insurer can prove the insured had no reasonable expectation of coverage based on the totality of the circumstances. "When there is no Pennsylvania Supreme Court decision directly on point, we are charged with predicting how it would resolve the question at issue." Canal ,
Plaintiffs do not direct the Court to any decisional law of the Pennsylvania intermediate appellate courts to support its positions. Defendants, however, cite to a 1936 Pennsylvania Supreme Court decision to support the proposition that the inclusion of a two year suicide exclusion in a life insurance policy is not against Pennsylvania public policy. Longenberger v. Prudential Ins. Co. of Am. ,
In Dibble the plaintiff beneficiary and her deceased husband applied for mortgage life insurance in July, 1986.
On August 11, 1986, the insurer accepted the insureds' premium payments and the Dibbles continued to make timely premium payments each month thereafter. The policy was formally approved on September 8, 1986. it included the same language found in the application regarding the effective date of the insurance, which the defendants claimed unambiguously was identified as October 1, 1986. The policy contained a suicide exclusion, providing:
If an Insured Mortgagor, whether sane or insane, shall die by suicide while insured hereunder, it is the intent of the Company to pay only the amount of insurance, or portion thereof, which has been in force for more than two years from its effective date. Any premium contributed by the Insured Mortgagor for any insurance benefit which is denied due to this limitation shall be returned by the Company.
On these facts, the Superior Court affirmed the trial judge's grant of summary judgment to the plaintiff beneficiary and rejected the defendant's arguments. In doing so, the Court conceded that the language in the suicide exclusion was unambiguous. Despite the unambiguous language of the suicide exclusion, "[o]ur Supreme Court has indicated that the proper focus regarding issues of coverage under insurance contracts is the reasonable expectations of the insured." (
In the instant situation, the Dibbles could have reasonably believed that when they paid the first premium on August 11, 1986, that the mortgage life insurance policy became effective at that time. By simply directing us to unambiguous language in the application and policy, Security of America has not established by clear and convincing evidence that the Dibbles were unreasonable in believing that coverage began upon their payment of the first premium. The Collister court held that only after an unequivocal showing that the consumer is to be given no immediate benefits in return for his premium prepayment , can it be said that the insurer has sustained its burden....
A review of the record reveals that Security of America made no effort to notify the Dibbles, beyond the notice printed on the application and policy, that they were making advance premium payments but getting nothing in return. According to Collister , such notice did not amount to an 'unequivocal showing' that the Dibbles were not receiving immediate benefits in return for their premium pre-payment.
(
Before Dibble , the Superior Court addressed whether a union's bylaws permitted the denial of death benefits to a beneficiary of a deceased member who committed suicide. Steel v. Driver Salesmen's Union Local No. 463 ,
Federal courts applying Pennsylvania law have also interpreted suicide exclusions in insurance policies. For example, in Oakes v. Franklin Life Insurance Company ,
Suicide: If within 2 years from the date of issue the insured (whether sane or insane) shall die by suicide, this policy shall automatically terminate and the amount payable in lieu of all other benefits shall be limited to the premiums paid.
(
The plaintiff beneficiary took the position that the insurer provided temporary coverage on the date of application because it accepted the decedent's premium payment which the beneficiary alleged "created an ambiguity as to the date of issue." (
There is no ambiguity. The suicide clause is tied clearly to the 'date of issue' which is the specific operative language. The designation, 'Date of Issue,' is set out on the face of the contract of insurance under Policy Data and the date of August 24, 1977 is typed in bold type next to the designation. The date of issue corresponds with the commencement of the 'First Policy Year,' the 'Maturity Date,' and the 'Expiring Date' of the policy. The schedule of death benefits was premised on the policy year commencing August 24, 1977. The annual premium due date likewise commenced August 24, 1977. The first premium deposit was applied to the period commencing August 24. The incontestability date under the policy was the 'date of issue.' In short, all operative dates within the policy, including the grace period, are tied to August 24, 1977.
(
The Pennsylvania Superior Court, in Dibble , expressly rejected Oakes holding in this respect. Specifically, the Court found:
Not only does the Oakes court ignore the reasonable expectations test set forth in Collister , it also purports to restrict Collister 's application to cases 1) which involve accidental deaths; and 2) which involve issues of coverage during the interim period between application and issuance of the policy. This is not what the Collister court intended, nor is it what Pennsylvania courts have consistently held since the decision was filed in 1977.
Dibble ,
Defendants' brief in support of their motion cites to a Third Circuit non-precedential opinion in which the Circuit considered a suicide exclusion in a life insurance policy. Am. Gen. Life Ins. Co. v. Shenkman ,
Suicide Exclusion: If the Insured takes his or her own life, while sane or insane, within 2 years from the Date of Issue, We will limit the Death Benefit Proceeds to the premiums paid less any policy loans and less any partial case surrenders paid
Am. General Life Ins. Co. v. Shenkman , Civil Action No. 09-3191,
In affirming the district court's order, the Third Circuit held that the unambiguous *258language of the replacement policy could not reasonably be interpreted "to have a date of issue other than the date of delivery, December 12, 2006, or the express date of issue, December 19, 2006." (
What the Court finds particularly enlightening from its review of the case law on suicide exclusions is that not a single decision was resolved at the pleading stage. Defendants did not cite, and the Court was unable to locate, any decision applying Pennsylvania law that granted an insurer's motion to dismiss a breach of contract claim based on the application of a suicide exclusion. Although not in the context of suicide exclusions, Bensalem Township v. International Surplus Lines Insurance Company ,
In reversing and remanding, the Third Circuit concluded that "the district court should not have dismissed the complaint without allowing discovery on the issue of whether the new language added to the insurance policy's prior litigation exclusion clause is inconsistent with Township's reasonable expectation of the type of coverage provided under the agreement." (
The Court of Appeals thus rejected an argument by the insurer, which was identical to the argument advanced by Defendants in this case, that the plaintiffs breach of contract claim must be dismissed at the pleading stage because the language of the exclusion provision was clear and unambiguous and, as such, Pennsylvania does not permit the court to "consider what the parties' reasonable expectations might have been." (
[W]e believe that Township could conceivably prove that it had a reasonable expectation of coverage despite policy language that appears to those not familiar with its relationship with Insurers unambiguously to preclude coverage, and that it therefore might be able to obtain coverage. We stress, however, that our holding must not be overstated. If Township was aware of the change in the exclusion provision before it elected to renew its policy with Insurers and Insurers made no representation that the scope of coverage would not be reduced, or if after Township agreed to renew Insurers informed Township of the change and its significance, then Insurers must prevail because, in our view, the policy unambiguously excludes coverage for claims such as the one at issue here.
We are thus persuaded by the Township's argument that dismissal pursuant to Rule 12(b)(6) was inappropriate. Before the district court denied the motion to amend and dismissed Township's complaint for failure to state a claim, it should have allowed discovery to enable it to review the circumstances surrounding the insurance agreement in order to determine whether Township might have had a reasonable expectation of coverage in this situation despite the language in the policy. We will therefore reverse and remand so that the district court can take these additional steps.
(
Turning to the Defendants' motion to dismiss Count I, a review of Pennsylvania case law on suicide exclusions and the decisions of courts in this Circuit applying Pennsylvania law, make it abundantly clear that the Court cannot resolve Defendants' affirmative defenses to Count I on a 12(b)(6) motion for at least two reasons. First, the suicide exclusion were ambiguous. Because the suicide exclusion is ambiguous, Pennsylvania law dictates that it must be interpreted against the Defendants. Second, even if the suicide exclusion is unambiguous, Plaintiffs plausibly allege that Ms. Lomma had a reasonable expectation of coverage based on the totality of the circumstances. In either case, Defendants' affirmative defenses based on the language of the suicide exclusion and course of dealing between the parties does not warrant dismissal of Count I.
The Court's review of the suicide exclusion shows it is ambiguous, both facially, and as applied to Plaintiffs. The suicide exclusion provides:
If the insured dies by suicide while sane or insane or by intentional self-destruction while insane, we will not pay any death proceed payable on amounts of insurance which have been in effect for less than 2 years. If the suicide or intentional self-destruction is within the first 2 contract years, we will pay as death proceeds the premiums you paid.
(Doc. 1-4 at 62). "Contractual language is ambiguous if it is reasonably susceptible of different constructions and capable of being understood in more than one sense." Canal ,
Plaintiffs argue that the suicide exclusion is ambiguous because, not only are various terms undefined, but the wording *260of the first sentence suggests that Defendants would pay full death benefits on "amounts of insurance" which had been in effect with the Defendants for more than two years. It is reasonable, according to Plaintiffs, "to interpret the 2 year suicide exclusion as beginning when Ms. Lomma first obtained $100,000.00 in coverage from Ohio National." (Doc. 10, at 2-3). The Court agrees. The language of the suicide exclusion, both in isolation and when considering the Replacement Policy as a whole, is capable of being understood in more than one sense and it is plausible that Defendants intended to pay full death benefits to Plaintiffs regardless of whether Ms. Lomma committed suicide within two contract years of the of the Replacement Policy because she consistently held $100,000 in life insurance through Defendants from 1995 through 2009. The first sentence of the suicide exclusion, unlike the second sentence, fails to reference the "contract year" or "effective date" but simply states that in the event insured commits suicide, the Defendants would not pay "amounts of insurance" that had been "in effect for less than 2 years."
Defendants do not appear to contest that Ms. Lomma was insured through them since 1995 in the amount of $100,000 and do not dispute she timely paid all premiums under the Original and Replacement Policies. Defendants, however, interpret the first sentence of the suicide exclusion as applying only to an existing policyholder who increases his or her amount of insurance and then commits suicide within two years of the contract date. While Defendants' interpretation presents another facially reasonable interpretation, even if the Defendants' interpretation may be the more reasonable one, this does not permit the Court to resolve this issue in Defendants' favor on their motion to dismiss.
That Defendants' interpretation cannot prevail over Plaintiffs' at this stage is highlighted by the Defendants' argument that the suicide exclusion in the Replacement Policy is a "standard" suicide exclusion used in the insurance industry. While suicide exclusions are no doubt "standard" in the insurance industry, a review of the case law shows that the language in the suicide exclusion, considered in the context of the Replacement Policy as a whole, is anything but a "standard" suicide exclusion. Many key dates necessary to both provide notice to Ms. Lomma and aid in the Court's interpretation are not referenced in the suicide exclusion. See Meyer v. CUNA Mut. Ins. Soc'y ,
Defendants do not dispute that the first sentence of the suicide exclusion, unlike the second sentence, provides no metric from which to determine whether an "amount of insurance" has or has not been "in effect for two years." Instead, they claim the amount of insurance referenced in the first sentence applies only to amounts under the Replacement Policy and that Ms. Lomma could not reasonably believe otherwise. The Court thoroughly rejects this argument. Defendants' draftsmanship resulted in a suicide exclusion that is both facially ambiguous and ambiguous as applied.8 A clearly worded and *261unambiguous suicide exclusion referencing specifically defined terms, like the suicide exclusion courts in Pennsylvania have been interpreting for over a hundred years and like the suicide exclusion in the Original Policy, could easily have been inserted into the Replacement Policy. But it was not.
"The goal of interpreting an insurance policy, like that of any other contract, is to determine the intent of the parties." Meyer ,
Second, even if the suicide exclusion is unambiguous, dismissal at the pleading stage would still be unwarranted. "[E]ven the most clearly written exclusion will not bind the insured where the insurer or his agent has created in the insured a reasonable expectation of coverage." Moessner ,
Defendants do not cite to a single case where a Court granted an insurer's Rule 12(b)(6) motion to dismiss a breach of contract claim based on the application of an exclusion provision in any insurance policy, let alone a suicide exclusion in a replacement life insurance policy where various key terms are undefined. Instead, Defendants cite cases exclusion provision in a replacement life insurance policy precluded payment of full death benefits. And the Court can conceive of no circumstances where Rule 12(b)(6) permits dismissal of a breach of contract claim, where, as here, the beneficiaries plausibly allege that the insured and insurer had a pre-existing contractual relationship and the insurer is relying on an exclusion in a replacement life insurance policy to deny benefits that plaintiffs allege the insurer would be obligated to pay under the original policy.
In sum, Defendants have not satisfied their burden to show that on the face of the Complaint and the documents attached thereto that any of its affirmative defenses *263will be obviously be successful.10 The language of the suicide exclusion in the Replacement Policy where courts granted Rule 12(b)(6) motions based on the statute of limitations or qualified immunity. (Doc. 11, at 3 n.3). Only where it is "apparent on the face of the complaint" or other documents properly considered on a motion to dismiss, can an affirmative defense "afford the basis for a dismissal of the complaint under Rule 12(b)(6)." Robinson ,
It is not a mere coincidence that no case Defendants rely on to support their interpretation of the suicide exclusion was resolved at the pleading stage. Rather, it is entirely consistent with the Court's review of case law interpreting suicide exclusions in insurance policies. The Court was unable to locate a single case where a federal court applying Pennsylvania law in a dispute over the applicability of a suicide exclusion in an insurance policy granted (or considered) an insurer's 12(b)(6) motion to dismiss. Defendants will bear the burden to prove that Ms. Lomma had no reasonable expectation of coverage. They may satisfy that burden only after consideration of the totality of circumstances. In most cases, this will be an issue to be resolved by the factfinder. Only in the rarest of circumstances, if at all, is it appropriate for a federal court applying Pennsylvania law to grant an insurer's Rule 12(b)(6) motion to dismiss an insured's breach of contract claim where the insurer's sole argument in support of dismissal is that a suicide is ambiguous and, *264even if it could be considered unambiguous, Plaintiffs allege sufficient facts plausibly establishing a reasonable expectation of coverage. Defendants' motion to dismiss Count l, therefore, will be denied.11
B. Unjust Enrichment And Promissory Estoppel
In Counts II and III of the Complaint Plaintiffs brings claims for unjust enrichment and promissory estoppel under Pennsylvania law. Defendants seek dismissal of Counts II and III on the theory that Pennsylvania law forbids both causes of action where, as here, the relationship between the parties is governed by an express contract. (Doc. 4 at ¶¶ 15-19). Plaintiffs do not dispute that they "may not recover on the equitable claims of unjust enrichment and promissory estoppel where an express contract exists." (Doc. 10, at 8). They claim, however, it is permissible to plead, in the alternative, claims for unjust enrichment and promissory estoppel. Specifically, Plaintiffs allege:
Here, there has been no stipulation, verified pleading, or other statement by the Defendants admitting the existence and validity of the contract. Nothing would prevent Defendants from disputing the contract's validity in their Answer. Plaintiffs do not ask nor expect to recover under these alternative theories, as they are inconsistent. But at this stage of litigation, they can coexist. This rule is consistent with preventing piecemeal litigation-if no valid contract is found, a party can proceed via equity claims rather than filing a new case. Accordingly, Defendants' motion to dismiss must be denied.
(Id. ). To support this proposition, Plaintiffs direct the Court to Alpart v. General Land Partners, Inc. ,
"To plead unjust enrichment, a plaintiff must allege that: (1) the plaintiff conferred benefits upon the defendant; (2) the defendant appreciated and accepted such benefits; and (3) it would be inequitable for the defendant to retain the benefit without payment of the value." (
In order to maintain a cause of action for promissory estoppel, Plaintiffs must show that "1) the promisor made a *265promise that he should have reasonably expected to induce action or forbearance on the part of the promisee; 2) the promisee actually took action or refrained from taking action in reliance on the promise; and 3) justice can be avoided only be enforcing the promise." Crouse v. Cyclops Indus. ,
The Court agrees with the Defendants that Plaintiffs' reliance on Alpart is misplaced, and that Counts II and III of the Complaint must be dismissed. In Alpart , three individuals entered into an oral partnership agreement to acquire and develop a parcel of land. The parties also entered into a written agreement establishing a limited partnership. The Court granted in part and denied in part that defendants' motion to dismiss the unjust enrichment claim. Specifically, the court granted the motion with respect to a cause of action for unjust enrichment arising out of the express written contract, but denied it with respect to the alleged oral contract. Judge Brody's decision was informed by the fact that it had yet to be determined whether the contract was, in fact, a contract. Alpart ,
Alpart does not apply to the facts of this case.12 Plaintiffs' Complaint alleges the existence of an express written contract between Ms. Lomma and the Defendants do not deny that the Replacement Policy "is a valid, written, enforceable contract." (Doc. 11, at 4). Because it is undisputed that the relationship between the parties is governed by an express written contract, Plaintiffs' claims for unjust enrichment and promissory estoppel must necessarily fail.13 Defendants' motion to dismiss Counts II and III of the Complaint will be granted.
*266C. Breach of Implied Covenant Of Good Faith And Fair Dealing
Defendants also move to dismiss Count IV of the Complaint in which Plaintiffs allege they breached the implied covenant of good faith and fair dealing. Specifically, Plaintiffs claim that Defendants "breached the implied covenant of good faith and fair dealing by denying payment of the benefit amount in clear violation of the plain language" of the Replacement Policy. (Doc. 1-4 at ¶ 44). Defendants evade the issue of whether Pennsylvania law implies such a duty, but instead argue that even if an implied covenant of good faith and fair dealing exists in the Replacement Policy, Count IV must nevertheless be dismissed because Count IV "is subsumed by the breach of contract claim." (Doc. 4, at 4). Plaintiffs do not dispute that a first party cause of action in which the insured alleges breach of the implied covenant of good faith and fair dealing would be subsumed by the insured's breach of contract claim. They nevertheless argue that because they are pursuing Count IV as third party beneficiaries, their claims are separate and distinct, and cannot be subsumed by the breach of contract claim. (Doc. 10, at 8-9). Plaintiffs do not cite any case law to support this proposition.
"The covenant of good faith and fair dealing involves an implied duty to bring about a condition or to exercise discretion in a reasonable way." USX Corp. v. Prime Leasing Inc. ,
In Pennsylvania, "a duty of good faith and fair dealing is implicit in an insurance contract." Smith v. Allstate Ins. Co. ,
Nothing in the case law, however, bars a plaintiff from bringing a cause of action for breach of contract and a cause of action for breach of the duty of good faith and fair dealing when those two actions are based on separate conduct. See Clunie-Haskins v. State Farm Fire & Cas. Co. ,
In paragraph 36 of the Plaintiffs' Complaint, they allege that "Ohio Life promised Ms. Lomma to pay the benefit amount of $100,000 upon her death in exchange for the payment of premiums." (Doc. 1-4, at 6).
Plaintiffs further allege that it was "reasonable for Ms. Lomma to rely on this promise," (Id. at ¶ 37), and that "in reliance on this promise, Ms. Lomma made substantial premium payments to Ohio Life throughout the duration of the policies." (Id. at ¶ 38).
These allegations were preceded with Plaintiffs' allegation in paragraph 28 of their Complaint that "[t]he amount of coverage was $100,000 at the time of Ms. Lomma's death. This amount of coverage had been in effect since December 4, 1995, over thirteen (13) years prior to her death."
Each of these allegations were incorporated by reference in Count IV for breach of the implied covenant of good faith and fair dealing. Plaintiffs then allege that the implied covenant of good faith and fair dealing was breached by Ohio Life when it "denied payment of the benefit amount in clear violation of the plain language of the Second Policy." (Id. at ¶ 44). From these spare, but pointed allegations, it cannot be said that the Plaintiffs' cause of action for breach of the covenant of good faith in fair dealing is based on the same conduct which forms Plaintiffs' claim for breach of contract with respect to the express provisions of the policy itself. Therefore, the Court will not dismiss Plaintiffs' claim for breach of the covenant of fair dealing at the pleading stage in that the law stated above herein makes clear that a plaintiff is not barred from bringing a cause of action for breach of contract and a cause of action for breach of the duty of good faith and fair dealing when those two actions are based on separate conduct. Accordingly, the Defendants' motion to dismiss Count III will be denied.
D. Statutory Bad Faith
Finally, Defendants seek dismissal of Count V of the Complaint (which Plaintiffs incorrectly label as Count IV). In Count V, Plaintiffs allege Defendants violated Pennsylvania's bad faith statute, 42 Pa. C.S.A. § 8371, "by denying payment of the benefit amount in clear violation of the plain language" of the Replacement Policy. According to Plaintiffs, the "clear violation" is based on the first sentence of the suicide exclusion "which states that, in the event of suicide," the Defendants "would pay 'amounts of insurance' which had been in effect for two years or more. (Doc. 1-4, at ¶ 48). Because Ms. Lomma maintained $100,000 in coverage with Defendants since 1995, Plaintiffs allege that Defendants' "stated reason for the denial is manifestly unreasonable, and constitutes a *268frivolous and unfounded refusal to pay because it is directly contradicted by the language of the policy." (Id. at ¶ 49). Plaintiffs further allege that Defendants knew, or should have known, that their "refusal to pay was unreasonable, frivolous and unfounded." (Id. at ¶ 50).
Defendants seek dismissal of Count V on the theory that their "determination that the beneficiaries of the policy at issue were only entitled to the premiums paid was based on the second sentence of the suicide exclusion." (Doc. 4, at ¶ 29). They further note that "[m]ore fundamentally, Plaintiffs' allegations that [Defendants] acted knowingly or with reckless disregard in evaluating and denying the claim is based solely on the Complaint's failure to completely state the relevant suicide provision in the Policy." (Id. at ¶ 31). Thus, because the plain language of the [Replacement] Policy provided Defendants "a reasonable basis for its coverage determination," they claim Count V must be dismissed. (Id. at ¶ 32).
The Pennsylvania legislature has enacted a statute permitting a cause of action against an insurance company based on the insurer's bad faith. It provides:
In an action arising under an insurance policy, if the court finds that the insurer has acted in bad faith toward the insured, the court may take all of the following action:
(1) Award interest on the amount of the claim from the date the claim was made by the insured in an amount equal to the prime rate of interest plus 3%.
(2) Award punitive damages against the insurer.
(3) Assess court costs and attorney fees against the insurer.
42 Pa. C.S.A. § 8371. "To establish a bad-faith claim, the beneficiary must prove, by clear and convincing evidence, that the insurer did not have a reasonable basis for denying benefits under the policy and that the insurer knew of or recklessly disregarded its lack of reasonable basis in denying the claim." Lincoln Benefit Life Co. v. Bowman ,
At this early stage of the proceedings, Plaintiffs plausibly allege facts, which the Court must accept as true, supporting the statutory bad faith claim alleged in Count V. Defendants' motion to dismiss Count V will therefore be denied.
V. CONCLUSION
For the foregoing reasons, Defendants' motion to dismiss will be granted in part and denied in part. A separate Order follows.
Related
Cite This Page — Counsel Stack
283 F. Supp. 3d 240, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lomma-v-ohio-natl-life-assurance-corp-pamd-2017.