Mutual Assurance Administrators, Inc. v. U.S. Risk Underwriters, Inc.

1999 OK CIV APP 129, 993 P.2d 795, 70 O.B.A.J. 3809, 1999 Okla. Civ. App. LEXIS 130, 1999 WL 1217943
CourtCourt of Civil Appeals of Oklahoma
DecidedSeptember 16, 1999
DocketNo. 92,943
StatusPublished
Cited by5 cases

This text of 1999 OK CIV APP 129 (Mutual Assurance Administrators, Inc. v. U.S. Risk Underwriters, Inc.) is published on Counsel Stack Legal Research, covering Court of Civil Appeals of Oklahoma primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mutual Assurance Administrators, Inc. v. U.S. Risk Underwriters, Inc., 1999 OK CIV APP 129, 993 P.2d 795, 70 O.B.A.J. 3809, 1999 Okla. Civ. App. LEXIS 130, 1999 WL 1217943 (Okla. Ct. App. 1999).

Opinion

OPINION

GARRETT, J:

¶ 1 Appellant, Mutual Assurance Administrators, Inc., is the insured under a Miscellaneous Professional Liability policy issued by Appellee, U.S. Risk Underwriters, Inc. The policy insured Appellant’s profession as a “Third Party Administrator” of group health plans. Appellant was sued by its agent for alleged misconduct in its solicitation and retention of clients. Appellee denied the claim because the alleged misconduct was based on intentional acts by Appellant, rather than professional negligence, and was excluded under the policy. Appellant appeals the judgment filed March 17, 1999, in which the trial court sustained Appellee’s motion for summary judgment and denied Appellant’s motion to compel.

¶ 2 For reversal, Appellant raises the following issues:

1. Did the trial court err in granting summary judgment when material disputes of fact existed?
a. Evidentiary materials were presented showing an issue of fact under the reasonable expectations doctrine that Appellant expected the policies to provide coverage for all of its business activities, including solicitation of and dealings with clients.
b. Appellant presented evidentiary materials to prove the claims for which it sought coverage were in the course of its conduct as a Third Party Administrator, within the broad policy coverage.
c. Appellant presented evidence that the claims for which it was seeking coverage included unintentional claims, which are covered by the policy.
2. Were the policies issued by Appellee ambiguous as to the type of activities which are covered by the term “conduct of the Insured’s Profession” as a “Third Party Administrator”? If so, summary judgment was improper, and evidence should have been permitted on the meaning and interpretation of those terms.

¶ 3 The claim for which Appellant sought coverage from Appellee arose in a lawsuit filed against Appellant by Walton-Stroup & Preston Insurance Agency, Inc., an Oklahoma corporation, and Edward M. Preston, individually, (collectively, Preston), case number CJ 95-1407, in the District Court of Oklahoma County, Oklahoma. In the petition, Preston alleged Appellant is an Oklahoma corporation and is licensed by the Oklahoma State Insurance Commission as a “third-party, fund administrator.” Preston described its relationship with Appellant and the nature of Appellant’s business in its petition, as follows:

Defendant acts as administrator for various Oklahoma employers and manages and administrates a private fund through which employees (sic) provide benefits to their employees in lieu of insurance carriers. Defendant, for a fee, arranges and supervises benefits packages to provide employees group health coverage and other benefits, partially covered by reinsurance and funded by payments to the third-party fund from the employer.

¶ 4 Preston alleged it was appointed and authorized by Appellant to market and solicit employers as clients for Appellant. Appellant paid Preston a commission on all third-party contracts between Appellant and clients solicited by Preston “pursuant to an established, unwritten agreement” between itself and Appellant. Preston also alleged it wrote two major accounts as Appellant’s agent, the “Bob Moore Employees Trust” and the “Jackie Cooper Employees Trust”. Preston alleged it learned Appellant made the decision to eliminate it as the agent-of-reeord for the Moore account. Preston alleged Appellant offered Moore a different plan with the same benefits, for a reduced premium, and accomplished this by eliminating agent commissions to Preston. Preston alleged Appellant stole the account by terminating it as agent-of-record and eliminating agent commissions.

[797]*797¶ 5 The “Insuring Agreements” Section of the professional liability policy issued to Appellant by Appellee contains the following:

1. ERRORS AND OMISSIONS.
To pay on behalf of the Insured all sums which the Insured shall become legally obligated to pay as Damages and Claims Expenses resulting from any Claim or Claims first made against the Insured and reported to the Underwriters during the Policy Period for any Wrongful Act of the Insured, or of any other person for whose actions the Insured is legally responsible, except as excluded or limited by the terms, conditions and exclusions of this Policy, solely in the conduct of the Insured’s Profession as stated in Item 6 of the Declarations. [Emphasis supplied.]

¶ 6 “Wrongful act” is defined by the policy as follows:

Wrongful Act means any actual or alleged breach of duty, neglect, act, error, misstatement, misleading statement or omission committed solely in the conduct of the Insured’s Profession as stated in Item 6 of the Declarations. [Emphasis supplied.]

¶ 7 Item VI” of the policy declarations is: “Insured Profession: Third Party Administrator.” The “Exclusions” under the policy include:

The coverage under this insurance does not apply to Damages or Claims Expenses incurred with respect:
a) ...
b) to any Claim arising out of any intentional, malicious, or deliberate Wrongful Act;....

¶ 8 In its motion for summary judgment, Appellee contended Appellant’s alleged misconduct did not involve professional services or the conduct of its profession, but that it “flowed from mere employment”, i.e., ordinary tasks performed by the business entity and its employees, which did not rise to the level of professional services. In response, Appellant contended the Preston litigation involved allegations relating to the operation of its business which were covered under the policy. It contended the solicitation and retention of clients is an inherent part “of this, or any other, business”, and that Appellee narrowly interpreted the policy terms and ignored the allegations in the Preston case. Additionally, Appellant argued (1) the allegations contained in the petition of the Preston case did arise out of its conduct as a third party administrator; (2) more than “intentional” acts were alleged; and (3) Appellant “reasonably expected” its claims involving efforts to solicit and retain clients would be covered by the policies. It also argued Ap-pellee ignored the precise policy language and, instead, focused on cases from other states involving narrower policy language than that at issue herein.

¶ 9 Appellant contended the policy language, “in the conduct of’ a third party administrator, clearly shows the intention to include all aspects of conduct of this profession. It argued that contact with its clients relating to their accounts and the handling of their accounts is an integral part of its profession as a third party administrator.

¶ 10 However, Appellant’s “contact with clients” was not the objectionable conduct alleged in the Preston case. It was its conduct with its agents, i.e., the alleged conversion of their commissions, which was the basis of that lawsuit. Moreover, as to its agents, Appellant is not a third party administrator; it is an employer. Its dealings with agents serve as a preliminary step to becoming a third party administrator as to others.

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Cite This Page — Counsel Stack

Bluebook (online)
1999 OK CIV APP 129, 993 P.2d 795, 70 O.B.A.J. 3809, 1999 Okla. Civ. App. LEXIS 130, 1999 WL 1217943, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mutual-assurance-administrators-inc-v-us-risk-underwriters-inc-oklacivapp-1999.