Nelson v. Continental Cas. Co.

412 So. 2d 701
CourtLouisiana Court of Appeal
DecidedMarch 2, 1982
Docket14803
StatusPublished
Cited by7 cases

This text of 412 So. 2d 701 (Nelson v. Continental Cas. Co.) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Nelson v. Continental Cas. Co., 412 So. 2d 701 (La. Ct. App. 1982).

Opinion

412 So.2d 701 (1982)

William J. NELSON, Plaintiff-Appellant,
v.
CONTINENTAL CASUALTY COMPANY d/b/a CNA Insurance and the State of Louisiana Employees Uniform Group Insurance Program, Defendants-Appellants.

No. 14803.

Court of Appeal of Louisiana, Second Circuit.

March 2, 1982.
Writ Denied April 21, 1982.

Jack D. Barnett, Shreveport, for plaintiff-appellant.

William J. Guste, Jr., Atty. Gen. by Tommy D. Teague, Baton Rouge, for defendants-appellants.

Before HALL, JASPER E. JONES and NORRIS, JJ.

HALL, Judge.

The State of Louisiana appeals from a judgment awarding plaintiff penalties of $12,108.80 and attorney fees of $2,500 under LSA-R.S. 22:657 for defendant's arbitrary failure to pay health and accident benefits under the State Employees Uniform Group Benefits Program within 30 days after proof of loss was filed. The state's assignments of error specify that the trial court erred in (1) holding that Act 240 of 1979, which amended LSA-R.S. 22:657 to make the penalty and attorney fees provisions of the statute applicable to the State of Louisiana, was interpretive legislation and, therefore, should be given retroactive effect so as to be applicable to plaintiff's claim which was filed and paid prior to the effective date of the amendment; (2) finding that the action of the state in delaying payment for approximately 90 days after proof of loss was filed was arbitrary and capricious; and (3) awarding an excessive amount of attorney fees.

The plaintiff also appeals contending that: (1) the trial court erred in failing to also render judgment against Continental Casualty Company, the administrator of the state program; and (2) the award of attorney fees should be increased for the services rendered on appeal.

For the reasons expressed in this opinion we reverse the judgment of the district *702 court and render judgment rejecting plaintiff's demands for penalties and attorney fees.

Facts

Plaintiff, employed as an investigator for the Alcoholic Beverage Control Commission of the State of Louisiana, suffered a heart attack while working on September 19, 1978. He was hospitalized until October 16, 1978 during which time he underwent a bypass operation and incurred hospital, surgical, and medical expenses totaling $15,028.10.

At the time the expenses were incurred plaintiff was covered under the State of Louisiana Employees Uniform Group Benefits Program, a self-funded program by which the state provides health and accident medical benefits for its employees. Continental Casualty Company (CNA), a commercial insurance company, was employed by the state as the claim administrator of the program. Plaintiff's initial claim was filed with the state on October 23, 1978. The form describes the nature of the sickness or injury as "heart attack—followed by surgery". The question "Did injury occur in the course of any employment?" is answered "yes". The question "Have you or do you intend to file this claim under workman's compensation?" is answered "no". The state paid several claims submitted by plaintiff.

Sometime in November it was recognized in the claims office that plaintiff might have a workman's compensation claim. The state group medical benefits plan excludes claims covered in whole or part by workman's compensation insurance. In early December plaintiff was advised by the claim administrator that his plan did not cover medical expense for injuries arising in the course of his employment which is covered in part or in full by the worker's compensation carrier and plaintiff was advised to contact his personnel office for instructions on filing for worker's compensation benefits.

A file was forwarded to the adjusters for the state's worker's compensation insurer. The adjusters conducted an investigation, including an interview with the plaintiff. Based on their investigation, including statements by the physicians who treated plaintiff contained in the claim forms previously submitted which stated that plaintiff's illness was not connected with his employment, the adjusters denied plaintiff's worker's compensation claim on January 11, 1979. The claims administrator of the group medical program was notified of this action and on February 6, 1979, paid all pending claims totaling $12,108.80. Plaintiff filed suit on February 8, 1979, alleging that benefits were unpaid and seeking benefits, penalties, and attorney fees from the state and Continental Casualty Company. The case was ultimately tried in November 1980 and judgment was rendered in June 1981.

Applicability of LSA-R.S. 22:657

After all of the operative facts giving rise to this litigation had occurred and while this suit was pending, LSA-R.S. 22:657 was amended by Act 240 of 1979, effective September 7, 1979, to make the provisions of the statute applicable to the state health and accident benefit program by the addition of Subsection C which reads as follows:

"Any person, partnership, corporation or other organization, or the State of Louisiana which provides or contracts to provide health and accident benefit coverage as a self-insurer for his or its employees, stockholders or any other persons, shall be subject to the provisions of this Section, including the provisions relating to penalties and attorney fees, without regard to whether the person or organization is a commercial insurer provided, however, this Section shall not apply to collectively bargained union welfare plans other than health and accident plans."

Prior to the amendment and at the time plaintiff's claims were filed and paid, the statute, which is a part of the Insurance Code, provided in pertinent part:

"A. All claims arising under the terms of health and accident contracts issued in this state, except as provided in Subsection B, shall be paid not more than 30 *703 days from the date upon which written notice and proof of loss ... are furnished to the insurer .... Failure to comply with the provisions of this Section shall subject the insurer to a penalty payable to the insured of double the amount of the health and accident benefits due under the terms of the policy or contract during the period of delay, together with attorney's fees to be determined by the court...." (emphasis supplied)

The definitions section of the Insurance Code, LSA-R.S. 22:5, contains the following applicable provisions:

(1) "`Insurance' is a contract whereby one undertakes to indemnify another or pay a specified amount upon determinable contingencies. It shall include any trust, plan or agreement, popularly known as employee benefit trusts, not specifically exempted from state regulation under Public Law 93-406, except collectively bargained union welfare plans, single employer plans or plans of the state or political subdivisions. ..." (emphasis supplied); and
(2) "`Insurer' includes every person engaged in the business of making contracts of insurance, other than fraternal benefits societies. A reciprocal, an inter-insurance exchange or a Lloyds organization is an `insurer.' Any person who provides an employee benefit trust as specified in R.S. 22:5(1) is an insurer."

It is clear that prior to the 1979 amendment the penalty and attorney fees provisions of LSA-R.S. 22:657 were applicable to insurers and insurance contracts and were not applicable to the state and its self-funded state medical benefit program for employees. Plans of the state or political subdivisions were specifically excluded from the definition of insurance contracts by LSA-R.S.

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