Parker v. Western Fidelity Insurance Co.

560 So. 2d 953, 1990 La. App. LEXIS 907, 1990 WL 47889
CourtLouisiana Court of Appeal
DecidedApril 18, 1990
DocketNo. 88-1271
StatusPublished

This text of 560 So. 2d 953 (Parker v. Western Fidelity Insurance 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
Parker v. Western Fidelity Insurance Co., 560 So. 2d 953, 1990 La. App. LEXIS 907, 1990 WL 47889 (La. Ct. App. 1990).

Opinion

YELVERTON, Judge.

An insured sued his health insurer for medical insurance benefits. A jury found that benefits were due, and that the insurer was arbitrary and capricious in failing to pay, invoking the statutory penalty (double the benefits) and an award of attorney’s fees. The insurer appeals the awards, and the insured answered the appeal seeking an [955]*955increase in attorney’s fees incurred on appeal. We affirm in all respects, and award additional attorney’s fees for this appeal.

On February 4, 1986, Larry Parker was issued a health insurance policy by Western Fidelity Insurance Company (Western Fidelity) after being solicited by one of its agents. In the application Parker stated that he had a gallbladder attack in 1979 and while hospitalized, he was diagnosed as having diabetes. He stated that he was on a diet and insulin for several months, and that no further treatment or medication “was needed or applied”. The policy excluded coverage for Parker’s diabetic condition. It did not exclude coverage for the gallbladder.

In July 1986 while visiting in Houston, Texas, Parker started having chest pains. He saw a doctor who thought he was having a heart attack and sent him to the hospital. Three days later Parker was diagnosed as having acute cholecystitis (blocked bile ducts) which caused gangrene in the gallbladder. Dr. Edward Rensimer of Houston removed the gallbladder. As a result of this surgery, Parker incurred $37,334.40 in medical expenses.

In August 1986 he filed an application for medical benefits. Western Fidelity denied benefits taking the position that Parker’s gallbladder condition was preexistent under the terms of .the policy.

After a trial a jury returned a verdict finding Western Fidelity liable for medical benefits, penalties and attorney’s fees. Pursuant to a stipulation, the trial judge determined the amount of medical benefits and assessed the amount of the award of attorney’s fees. The trial judge calculated the medical benefits to be $33,987.60 after subtracting the $1,000 deductible under the policy and the expenses relating solely to Parker’s excluded diabetes. He awarded $8,457.50 as attorney’s fees.

Western Fidelity’s appeal raises five specifications of error. The issues relate to coverage under the policy, instructions to the jury, the arbitrariness of the insurer’s conduct, admission of certain evidence, and calculation of benefits. We will discuss these issues under their appropriate headings.

COVERAGE

Western Fidelity’s initial reason for denying coverage was that the medical expenses were for a preexistent condition. If the gallbladder operation was for a preexis-tent condition as defined by the policy, the insurer would not be liable.

The policy defined a preexisting condition as follows:

Pre-existing [sic] condition means the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a five year period prior to the effective date of the policy; or a condition for which medical advice or treatment was recommended by or received from a physician within a five year period prior to the effective date of the policy.

Where an insurer denies coverage based on a policy exclusion, it bears the burden of proving facts which place the claim within the exclusion. Richard v. Old Southern Life Ins. Co., 502 So.2d 1168 (La.App. 3rd Cir.1987).

There were five witnesses to the facts. Parker and his wife testified in the presence of the jury. The testimony of three doctors was presented to the jury by videotaped depositions.

There was no evidence that Parker ever went to a doctor within five years before February 4, 1986. He and his wife testified that during that five years he might have had an upset stomach, back pain or other aches — Parker aged from 59 to 64 during that five years — , but they declared that nothing occurred of sufficient concern to send him to a doctor. He had no illness which he could attribute to his gallbladder.

Dr. Jack Cappel, Parker’s treating physician for the gallbladder attack in 1979, testifying without his notes, stated that he probably recommended that Parker stay on a low fat diet, which had already been prescribed by another doctor due to Parker’s diabetic condition. He agreed that he probably told Parker that sooner or later [956]*956he should get the gallbladder removed. He also testified that Parker could well not have had any gallbladder symptoms between the 1979 attack and the 1986 attack.

Dr. Edward Rensimer, Parker’s treating physician for the 1986 gallbladder attack, testified that in his initial consultation he noted that Parker had been a mainly diet-controlled diabetic prior to the 1986 gallbladder episode. He also testified that it was possible that no gallbladder symptoms manifested between 1979 and 1986, although he thought this would be unusual. He testified, however, that gallbladder symptoms can be quite subtle, and not be such as to require the patient to seek treatment.

Dr. Alberto Roca, a pathologist in Houston, Texas, testified that gallstones don’t always cause symptoms that would cause a person to seek treatment. He testified that a person could have a gallstone all his life and never know it.

There was no other testimony on the subject of the preexisting condition. This testimony, along with the application for insurance, constituted the evidence that went to the jury. The jury was instructed that the policy’s definition of preexisting condition was the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a five year period prior to the date of the policy, or a condition for which medical advice or treatment was recommended by or received within a five year period prior to the date of the policy. With this evidence and this instruction before it, the jury returned a general verdict answering yes to the question whether Western Fidelity was liable to the plaintiff for his medical expenses.

Our review of this finding of fact is regulated by the manifest error rule. Dear v. Blue Cross of Louisiana, 511 So.2d 73 (La.App. 3rd Cir.1987). The.jury’s finding that Parker’s gallbladder condition was not preexisting according to the terms of the policy is supported by all of the testimony.

Although it was not raised initially as a basis for denying coverage, Western Fidelity at the trial raised the additional defense that Parker intentionally made a material misrepresentation to it by not disclosing on the February 4, 1986, application, that Dr. Cappel placed him on a low fat diet and recommended surgery. It is the insurer’s contention that this material misrepresentation voided the policy.

For an insurer to avoid liability under its policy, it must prove that the insured intentionally made a material misrepresentation. To determine whether there has been an intent to deceive, courts look to the surrounding circumstances indicating the insured’s knowledge of the falsity of the representation made in the application and his recognition of the materiality of misrepresentation, or from circumstances which create a reasonable assumption that the insured recognized the materiality. Cousin v. Page, 372 So.2d 1231 (La.1979); Jamshidi v. Shelter Mut. Ins. Co., 471 So.2d 1141 (La.App. 3rd Cir.1985). In the present case Dr.

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Related

Lucito v. Louisiana Hospital Service, Inc.
392 So. 2d 700 (Louisiana Court of Appeal, 1980)
Cousin v. Page
372 So. 2d 1231 (Supreme Court of Louisiana, 1979)
Dear v. Blue Cross of Louisiana
511 So. 2d 73 (Louisiana Court of Appeal, 1987)
Jamshidi v. Shelter Mut. Ins. Co.
471 So. 2d 1141 (Louisiana Court of Appeal, 1985)
Slay v. Old Southern Life Insurance Co.
498 So. 2d 1129 (Louisiana Court of Appeal, 1986)
Richard v. Old Southern Life Insurance Co.
502 So. 2d 1168 (Louisiana Court of Appeal, 1987)

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Bluebook (online)
560 So. 2d 953, 1990 La. App. LEXIS 907, 1990 WL 47889, Counsel Stack Legal Research, https://law.counselstack.com/opinion/parker-v-western-fidelity-insurance-co-lactapp-1990.