Miller v. Northwestern National Life Insurance

915 F.2d 1391
CourtCourt of Appeals for the Ninth Circuit
DecidedOctober 5, 1990
DocketNo. 89-15081
StatusPublished
Cited by1 cases

This text of 915 F.2d 1391 (Miller v. Northwestern National Life Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Ninth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Miller v. Northwestern National Life Insurance, 915 F.2d 1391 (9th Cir. 1990).

Opinion

BEEZER, Circuit Judge:

California Physicians’ Service, dba Blue Shield of California (“Blue Shield”) appeals the district court’s final judgment in favor of Northwestern National Life Insurance Co. (“Northwestern”). The district court decided that California’s insurance statutes, as interpreted by this court, require Blue Shield to reimburse Northwestern for medical benefits paid pursuant to a health insurance plan. We reverse.

I

Raymond Miller became totally disabled in April of 1983. At that time, he was covered primarily under his employer’s insurance plan and secondarily as a dependent under his wife’s insurance, issued by Northwestern. When Miller’s primary insurance proved to be inadequate, he sought benefits under Northwestern’s policy. That policy terminated on June 30, 1983, but it provided a one-year extension of benefits for totally disabled dependents covered under the policy. Blue Shield replaced Northwestern as of July 1, 1983, as Miller’s wife’s insurer.

Blue Shield paid for Miller’s medical services from July 1, 1983 to July 12, 1983, but did not make further payments. After unsuccessfully seeking benefits from various insurers, Miller brought suit against several parties, including Northwestern and Blue Shield, in May of 1985. Northwestern made payments in June of 1985 of over $300,000 for medical care rendered on behalf of Miller, and it sought partial reimbursement from Blue Shield.

The district judge found that roughly $114,000 of the amount paid by Northwestern was incurred between June 30, 1983 and July 1, 1984. He held that Northwestern was entitled to reimbursement from Blue Shield in that amount under this [1393]*1393court’s interpretation of the California Insurance Code. Blue Shield appeals. We review district court interpretations of state law de novo. Union Central Life Insurance Co. v. Wernick, 777 F.2d 499, 500 (9th Cir.1985).

II

Blue Shield argues that Northwestern failed to state a claim upon which relief could be granted because suits between fiduciaries for reimbursement do not arise under ERISA. See Call v. Sumitomo Bank of California, 881 F.2d 626, 631 (9th Cir.1989). Blue Shield further maintains that ERISA preempts any state claims that Northwestern may have against Blue Shield. 29 U.S.C. § 1144(a) (1982).

ERISA does not preempt state laws which regulate insurance. 29 U.S.C. § 1144(b)(2)(A) (1982). Northwestern’s claim arises under California statutes which regulate insurance, and a decision of this court interpreting those statutes. Cal. Insurance Code § 10128.3(c); Pacific Mutual Life Insurance Co. v. American Guaranty Life Insurance Co., 722 F.2d 1498 (9th Cir.1984). Because the district court’s jurisdiction was based in part on diversity, it had authority to hear Northwestern’s state law claim. We, therefore, need not address whether ERISA recognizes a cause of action for reimbursement between prior carriers and replacement carriers because Northwestern has stated a non-preempted state law claim.

III

The parties ask us to interpret California statutes enacted to protect totally disabled persons when group insurance coverage provided by one insurance carrier is discontinued and replaced with coverage by another insurer. Prior to the legislation, insurance carriers often did not provide benefits for totally disabled individuals after a policy’s termination date. Replacement carriers would then refuse to cover preexisting disabilities, and disabled employees and disabled dependents were left without insurance.

As part of the response to the problem, the California legislature required prior carriers to extend benefits after a policy’s termination date. During the period relevant to this appeal, the California Insurance Code provided that:

Every policy providing hospital, medical or surgical benefits shall be deemed to include a reasonable extension of such benefits upon discontinuance of the policy if it provides benefits for covered expenses directly relating to the condition causing total disability existing at the time premium payments for the employee or dependent cease and incurred during a period of not less than 12 months thereafter, which period shall not be interrupted by discontinuance of the policy.
Any extension of benefits may be terminated at such time as the employee or dependent is no longer totally disabled or at such time as coverage for the employee or dependent becomes effective under any replacement policy without limitation as to the disabling condition.

Cal.Insurance Code § 10128.2(d) (emphasis added).

The legislature also required replacement carriers to provide coverage without regard to preexisting disabilities:

No provision in a succeeding carrier’s policy or replacement coverage which would operate to reduce or exclude benefits on the basis that the condition giving rise to benefits preexisted the effective date of the succeeding carrier’s policy shall be applied with respect to those employees and dependents validly insured under the prior carrier’s policy on the date of discontinuance, except to the extent that benefits for such condition would have been reduced or excluded under the prior carrier’s policy.

Cal.Insurance Code § 10128.3(c) (emphasis added).

Unfortunately, the California legislature did not lucidly explain which of these provisions predominates. It is unlikely that the legislature intended to mandate prior carriers to provide an extension of benefits and at the same time require replacement [1394]*1394carriers to provide coverage for all preexisting conditions.

Although no California state court has construed the provisions of the California Insurance Code which govern this case, we examined the relevant statutes in Pacific Mutual Life Insurance Co. v. American Guaranty Life Insurance Co., 722 F.2d 1498 (9th Cir.1984). The district court in Pacific Mutual had held that a prior carrier of group medical coverage could “terminate an extension of benefits to a totally disabled insured when replacement insurance becomes effective, shifting responsibility for payment of benefits to the replacement insurer.” Id. at 1499. Because the district judge’s interpretation of California law was not clearly wrong, we affirmed.

We reasoned that the extension of benefits provision could apply when employers do not obtain replacement coverage in the 60 day period. We noted that the extension of benefits terminates when “coverage for the employee or dependent becomes effective under any replacement policy without limitation as to the disabling condition.” Cal.Insurance Code § 10128.2(d).

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915 F.2d 1391, Counsel Stack Legal Research, https://law.counselstack.com/opinion/miller-v-northwestern-national-life-insurance-ca9-1990.