Michael G. Baker and Cheryl Ann Baker, Cross-Appellants v. Washington National Insurance Company, Cross-Appellee

823 F.2d 156, 8 Employee Benefits Cas. (BNA) 2143, 1987 U.S. App. LEXIS 10297, 56 U.S.L.W. 2132
CourtCourt of Appeals for the Fifth Circuit
DecidedAugust 5, 1987
Docket86-4826
StatusPublished
Cited by7 cases

This text of 823 F.2d 156 (Michael G. Baker and Cheryl Ann Baker, Cross-Appellants v. Washington National Insurance Company, Cross-Appellee) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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Michael G. Baker and Cheryl Ann Baker, Cross-Appellants v. Washington National Insurance Company, Cross-Appellee, 823 F.2d 156, 8 Employee Benefits Cas. (BNA) 2143, 1987 U.S. App. LEXIS 10297, 56 U.S.L.W. 2132 (5th Cir. 1987).

Opinion

CLARK, Chief Judge:

We affirm the district court’s construction of the meaning of a conversion privilege extended as a part of a group health insurance contract, and its refusal to grant punitive damages.

*157 I.

While Michael Baker was employed by Biloxi Freezing Company (Biloxi Freezing), he enrolled himself and his dependents in the employer’s group life and health plan with Washington National Insurance Company (Washington National). Normal pregnancy benefits were incorporated into the group policy by an amendment, effective on the same date the certificate was issued to the Bakers. The certificate of insurance and the master policy issued to Biloxi Freezing also contained a conversion privilege amendment. That amendment provided:

The privilege of conversion from the group insurance provided by the group policy to an individual policy of health shall be available to an insured person and/or his dependents under the circumstances specified in Sections A and B below. If proper application is made within the conversion period [31 days immediately following termination of insurance under the group policy] and if appropriate premium is remitted, the company will issue its then current conversion policy to a person entitled to the conversion privilege. The conversion policy shall be issued without further evidence of insurability and the premium shall be applicable to the class of risk to which the persons to be insured belong. The effective date of the conversion policy shall be the day after insurance under the group policy terminates.

Baker and his wife were within the circumstances specified in Sections A and B and were entitled to exercise the conversion privilege.

Michael Baker worked at Biloxi Freezing, submitting claims and receiving benefits for himself and his dependents under the instant policy, until he was terminated by his employer. At the time Michael Baker ceased active work on July 8, 1983, his wife was approximately three months pregnant.

Washington National acknowledged responsibility for the Bakers’ claims for pregnancy benefits until July 31. At that time it terminated coverage under the group policy because Michael Baker was no longer eligible for employee coverage. The Bakers made a timely and sufficient tender in an effort to exercise the conversion privilege in anticipation of the continuing expenses of maternity care and delivery of the child, but Washington National advised them that normal maternity benefits would not be covered by its conversion policy.

II.

The district court concluded that the conversion privilege language quoted above obligated Washington National to offer the Bakers the same coverage for pregnancy expense as was afforded in the group policy. This conclusion was based on the construction of the term “conversion” in Moore v. John Hancock Mutual Life Insurance Co,, 436 F.2d 823 (5th Cir.1971), and Aetna Life Insurance Co. v. Dunken, 266 U.S. 389, 45 S.Ct. 129, 69 L.Ed. 342 (1924). In the alternative, the court concluded the Bakers’ claim for maternity benefits had matured prior to the time their coverage under the group policy was terminated under the authority of Benefit Trust Life Insurance Co. v. Lee, 248 Miss. 715, 160 So.2d 909, 916 (1964).

III.

Washington National contends the policy provision requiring it to issue its “then current conversion policy” was unambiguous and gave it the option to control the type of coverage it wished to offer. Therefore, the court’s construction of the policy provision as restricting any conversion policy to the same terms as those contained in the group policy had the effect of writing a new contract for the parties. Washington National would distinguish Moore as a life insurance case the outcome of which was driven by the effect of Florida statutes on the language used in the conversion privilege in Moore’s policy. It would distinguish Dunken as involving a specific contractual undertaking to replace a seven-year term life insurance contract with a twenty-payment life insurance policy. It also maintains that Moore and Dunken are distinguishable because the original policies in these cases did not continue in effect and *158 because the contracting parties in both replacement policies were identical to those in each original policy. Finally, Washington National contends that its group policy form was approved by Mississippi insurance regulatory authorities and that the district court’s construction would have far-reaching adverse effects on both insurers and insureds. We affirm the judgment of the district court.

IV.

The contractual commitments in the group health insurance policy issued to Biloxi Freezing were three-sided, not two-sided. The group policy issued to Biloxi Freezing was for the express benefit and coverage of employees such as Baker and his dependents. More significantly, the amendment providing the conversion privilege is a direct undertaking by Washington National to offer an individual policy of insurance to an employee because of his status as an insured under the group policy.

Washington National’s commitment to the Bakers in the conversion privilege amendment was set out in broad general language — to issue its then current conversion policy. Neither the form nor the content of the conversion policy which would be issued was identified by attachment, reference or description. The district court looked to precedent to determine whether the term “conversion” had an ordinary or commonly understood meaning. This examination disclosed that in both Dunken and Moore, courts faced with equally opaque conversion terminology in life insurance policies concluded a bare promise to convert was a promise to continue the coverage provided by the basic contract. In Dunken, the Supreme Court refused to allow an intervening change of domicile to confer statutory penalties and attorneys’ fees which would not be applicable under the original contract. In Moore, this court refused to restart the basic policy’s completed period for contestability.

Washington National would distinguish Moore because it arose in Florida and its language was governed by the statutes of that state. The Moore conversion privilege — which granted the right to obtain an individual policy in “any one of the forms then customarily issued by the Company, except term insurance” — was rescripted from § 627.0415, Florida Statutes Annotated. However, neither the statute nor any Florida rules of construction affected Moore’s holding that the ordinary meaning of the right of “conversion” was a right to “continue” the basic coverage in another type of policy. Indeed, the Moore court expressly observed

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823 F.2d 156, 8 Employee Benefits Cas. (BNA) 2143, 1987 U.S. App. LEXIS 10297, 56 U.S.L.W. 2132, Counsel Stack Legal Research, https://law.counselstack.com/opinion/michael-g-baker-and-cheryl-ann-baker-cross-appellants-v-washington-ca5-1987.