Metropolitan Life Insurance Company v. Russell D. Conger

474 F.3d 258, 2007 U.S. App. LEXIS 848, 2007 WL 91737
CourtCourt of Appeals for the Sixth Circuit
DecidedJanuary 16, 2007
Docket06-5009
StatusPublished
Cited by39 cases

This text of 474 F.3d 258 (Metropolitan Life Insurance Company v. Russell D. Conger) 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
Metropolitan Life Insurance Company v. Russell D. Conger, 474 F.3d 258, 2007 U.S. App. LEXIS 848, 2007 WL 91737 (6th Cir. 2007).

Opinion

*260 OPINION

KAREN NELSON MOORE, Circuit Judge.

In 2002, Plaintiff Russell D. Conger filled out an on-line application and purchased a long-term care insurance policy-under the Federal Long-Term Care Insurance Program (“FLTCIP”). When he sought to collect benefits, Metropolitan Life Insurance Company (“MetLife”) refused to pay, voided the policy, and then sued for rescission and declaratory relief. Because we conclude that MetLife abused its discretion by voiding the policy and that Conger had no independent duty to disclose information that MetLife neglected to request, we REVERSE the district court’s judgment and REMAND the case with instructions to dismiss MetLife’s complaint.

I. BACKGROUND

A. Statutory Background

In 2000, Congress passed the Long-Term Care Security Act (“LTCSA” or “the Act”), 5 U.S.C. §§ 9001-09, to ensure that long-term care insurance would be available to federal employees. “Long term care is chronic care that an individual may need for the rest of his or her entire life.” Gunson v. James, 364 F.Supp.2d 455, 458 (D.N.J.2005). By passing the LTCSA, Congress intended to create “affordable options for dealing with the catastrophic expenses of nursing home care, home care, assisted living, and other forms of long-term care services.” S.Rep. No. 106-344, 2000 WL 970179 at 18, quoted in Gunson, 364 F.Supp.2d at 458.

The Act gave the Office of Personnel Management (“OPM”) the responsibility to enter into group contracts (known as “master contracts”) with qualified insurance carriers, and thereby establish and administer a program through which federal employees could obtain long-term care insurance. 5 U.S.C. §§ 9002(a), 9003(a). The result was the FLTCIP. Gunson, 364 F.Supp.2d at 457-58.

Under the FLTCIP, the federal government does not pay for insurance, nor does it guarantee the availability of long-term care insurance to its employees. Id. at 458. Instead, the LTCSA merely “establishes minimal underwriting standards for master contracts, and delegates the establishment of further underwriting requirements to the qualified carriers and OPM.” Id. (citing 5 U.S.C. § 9002(e)). Ultimately, the carrier determines which employees are eligible for insurance under the program and makes this determination based on the guidelines negotiated with OPM. Id.

A. Factual Background
1. Conger’s Long-Term Care Insurance Application and Claim

On July 11, 2002, Conger, who was a 54-year-old employee of the National Weather Service at the time, applied for insurance under the FLTCIP by completing an online application. The application contained a series of questions necessary for a five-year coverage period, and a separate set of questions required of applicants seeking an unlimited coverage period. Question 5 in the latter group asked, “Within the last 10 years, have you had, been diagnosed with or been treated for any of the following conditions?” The conditions listed included:

• Diabetes (excluding gestational diabetes);
• Disorder of the Brain (e.g. tremor, seizure disorder, head injury, tumor, infection), Neuropathy, Syncope, Pa *261 ralysis, any Chronic or Progressive Neurological Disorder;
• Memory Loss; and
• Muscle Disorder (e.g., fibromyalgia, polymyalgia rheumatica, chronic fatigue syndrome).

Conger responded “NO” to each of the conditions listed under Question 5. Joint Appendix (“J.A.”) at 67.

On July 20, 2002, Long Term Care Partners (“LTCP”) sent Conger a letter approving his application, and indicating that the policy would be effective October 1, 2002. LTCP is a joint venture formed by John Hancock Life Insurance Company and MetLife for the sole purpose of providing and administering long-term care insurance under the FLTCIP. Gunson, 364 F.Supp.2d at 458-59. Each person enrolled for coverage under the FLTCIP receives insurance from one of the two companies. Conger received his coverage from MetLife, but LTCP administered the policy.

With the letter, LTCP enclosed a schedule of benefits and a benefit booklet. The benefit booklet’s first page of text states:

NOTICES: PLEASE READ CAREFULLY!
Important: Our decision to issue coverage was based upon your responses to the questions. on your application.... We may deny benefits or rescind your insurance coverage if your answers are incorrect or untrue for any reason.

J.A. at 73, 187. A later provision of the benefit booklet states that the insurer “ha[s] discretion to interpret the terms, conditions and provisions of the Group Policy, this Benefit Booklet and your Schedule of Benefits.” J.A. at 92, 218.

In April 2003, Conger retired from the National Weather Service after over thirty years of service. On August 29, 2003, he submitted a claim to LTCP for long-term care benefits stemming from difficulties with mobility and balance.

2. LTCP’s Investigation of Conger’s Past Medical History

LTCP initiated an investigation of Conger’s prior medical history. It discovered that Conger had experienced difficulties with his balance for at least five years and had sought medical attention for this problem. More specifically, LTCP learned that on September 4,1998, Conger sent a letter to Dr. Prospero Ishkanian stating,

I still have the balance problem and have to hold on to anything I can grab to move about. If I don’t hold onto something I feel like I will lose my balance completely.
I have- noticed that for the past 6 months to 1 year that my walking becomes more difficult after 6 hours on shift and gets progressively worse and by the time I work my entire shift my walking becomes very bad and seems to be related to poor balance.

J.A. at 134.

" These difficulties led Conger to seek medical help from a number of different doctors over the following four years. For instance, Conger made several visits to Dr. John R. Morris (an ear, nose, and throat specialist) in late 1998 and early 1999, apparently to determine whether sinus problems caused his unsteadiness. In December 1998, a doctor’s note after an MRI reported that Conger was suffering from “[ejxtensive sinusitis,” but also noted that Conger’s “[bjrain demonstrate^] no significant abnormality, essentially normal for patient’s age. Specifically, I see no cerebellar abnormality.” J.A. at 138.

Shortly thereafter, Conger began seeing a group of neurologists, including Drs. Robert S. Tillett and Walter G. McFar *262 land.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
474 F.3d 258, 2007 U.S. App. LEXIS 848, 2007 WL 91737, Counsel Stack Legal Research, https://law.counselstack.com/opinion/metropolitan-life-insurance-company-v-russell-d-conger-ca6-2007.