Milburn v. Life Investors Insurance Co. of America

511 F.3d 1285, 2008 U.S. App. LEXIS 448, 2008 WL 82478
CourtCourt of Appeals for the Tenth Circuit
DecidedJanuary 9, 2008
Docket05-6099
StatusPublished
Cited by3 cases

This text of 511 F.3d 1285 (Milburn v. Life Investors Insurance Co. of America) is published on Counsel Stack Legal Research, covering Court of Appeals for the Tenth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Milburn v. Life Investors Insurance Co. of America, 511 F.3d 1285, 2008 U.S. App. LEXIS 448, 2008 WL 82478 (10th Cir. 2008).

Opinions

PER CURIAM.

I. JURISDICTION FOR APPEAL

This appeal arises from the district court’s order entered December 17, 2004 granting partial summary judgment in favor of plaintiff on the issue of coverage under a Long Term Care Insurance Policy. See the “Order” found in App. Vol. Ill at 927-938.1 Following the entry of partial summary judgment and settlement of plaintiffs other claims, a final judgment in plaintiffs favor was entered on February 23, 2005. Defendant, Life Investors Insurance Company of America (“LUCA”), now appeals the entry of partial summary judgment and subsequent final judgment. Jurisdiction for the appeal lies under 28 U.S.C. § 1291.

II. SUMMARY OF CASE

The order granting partial summary judgment in this diversity case construed the insurance policy under applicable Oklahoma law to provide coverage for the type of care which plaintiff incurred, specifically care in an assisted living facility. Defendant contends that while the policy provided a “nursing home” benefit, as defined in the policy such benefit did not cover the type of care plaintiff was receiving and thus it properly denied coverage.

The district court found that the language of the policy was not ambiguous, and that the definition of “nursing home” contained in the policy covered the assisted living facility where plaintiff was receiving care. In so doing, the district court rejected defendant’s effort to apply various state statutory and regulatory provisions to provide definitions for terms used in the policy, ruling that such extraneous material was not necessary because the policy was not subject to conflicting interpretations.

On appeal the defendant does not argue that the definition of nursing home, as used in its policy, is ambiguous. Rather, it contends that Oklahoma provisions regulating nursing homes are relevant because the policy provides that in order for a facility to be covered under the policy it must be licensed by the appropriate licensing authority to engage primarily in nursing care and related services. Def.’s Brief at 19-23; 32-37. Plaintiff argues that the facility where she resided had the appropriate license and provided the type of care provided by a nursing home, and therefore the district court’s ruling correctly found that the policy covered the services provided. Pl.’s Brief at 7-21.

On December 12, 2005, after all appellate briefs in this case were submitted but prior to the oral argument, the Tenth Circuit issued its opinion in Gillogly v. General Electric Capital Assurance Co., 430 F.3d 1284 (10th Cir.2005). In an opinion [1287]*1287authored by Judge Ebel, the panel applied Oklahoma law to a long-term care policy issued by a different Oklahoma insurer, but which defined “nursing home” in exactly the same language as used in the LUCA policy. The panel in Gillogly found that the policy there did not provide coverage for the insured’s stay in a “residential care home” because such facility is not a nursing home licensed by the appropriate authority. 430 F.3d at 1290.

On December 21, 2005, appellant-defendant tendered the Gillogly case as supplemental authority, along with a motion for leave under Rule 28(j) to file a letter brief in excess of the word limit arguing that the Gillogly decision is dispositive here. That motion was referred to the panel but apparently not formally ruled on. On December 28, 2005, plaintiff-appellee filed a letter brief arguing that Gillogly does not dispose of this case. On September 19, 2006, prior to the oral argument, defendant filed a copy of the published decision in Gillogly as supplemental authority under Fed. R.App. P. 28(j). The defendant’s motion for leave to file the letter brief is granted and both post-briefing submissions from the parties have been considered by this panel.

III. UNDISPUTED FACTS

As the district court found, the essential facts underlying plaintiffs claims are not disputed. Plaintiff purchased the Long Term Care Insurance Policy at issue here (“policy”) from the defendant in 1993. In 1999, when plaintiff was approximately 89 years of age, she moved into a facility known as The Village on Lee (“The Village”), located in Lawton, Oklahoma. Plaintiff apparently did not make any claim for coverage under the policy between 1999 and 2002. In May 2002, plaintiff was hospitalized for physical ailments, and after her discharge returned to The Village where she required daily care in the activities of dressing, walking, bathing, getting in and out of bed, and later taking medication. The Village provides this form of daily care for a fee. At that time Plaintiff submitted two claims to defendant for benefits under the policy. The defendant denied both claims (Order at 1-2).

It is undisputed that the policy provides coverage for stays in a nursing home, referred to as the “nursing home benefit.” See App. Vol. II at 270, 276-77.2 The policy provides that it will “pay a benefit for each Day of Confinement, after the Policy Elimination Period, while you are confined in a Nursing Home during a Covered Period of Confinement.” App. Vol. II at 276. The definition section of the policy defines a “Nursing Home” as follows:

A facility or distinctly separate part of a hospital or other institution which is licensed by the appropriate licensing agency to engage primarily in providing nursing care and related services to inpatients and:
(1) Provides 24 hour-a-day nursing service under a planned program of policies and procedures which was developed with the advice of, and is periodically reviewed and executed by, a professional group of at least one Doctor and one Nurse; and
(2) Has a Doctor available to furnish medical care in case of emergency; and
(3) Has at least one Nurse who is employed there full time (or at least 24 hours per week if the facility has less than 10 beds); and
[1288]*1288(4) Has a Nurse on duty or on call at all times; and
(5) Maintains clinical records for all patients; and
(5) Has appropriate methods and procedures for handling and administering drugs and biologieals.
Note: These requirements are typically met by licensed skilled nursing facilities, comprehensive nursing care facilities and intermediate nursing care facilities; as well as some specialized wards, wings and units of hospitals. They are NOT met by: rehabilitation hospitals; rest homes; homes for the aged; sheltered living accommodations; residence homes or independent living units.

App. Vol. II at 274. The identical definition of “nursing home,” including the interpretive note, was used in the policy at issue in Gillogly. See 430 F.3d at 1286. The policy in the instant case, like the policy in Gillogly,

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Bluebook (online)
511 F.3d 1285, 2008 U.S. App. LEXIS 448, 2008 WL 82478, Counsel Stack Legal Research, https://law.counselstack.com/opinion/milburn-v-life-investors-insurance-co-of-america-ca10-2008.