Philadelphia American Life Insurance Co. v. Turner

131 S.W.3d 576, 2004 Tex. App. LEXIS 2048, 2004 WL 393155
CourtCourt of Appeals of Texas
DecidedMarch 4, 2004
Docket2-03-165-CV
StatusPublished
Cited by27 cases

This text of 131 S.W.3d 576 (Philadelphia American Life Insurance Co. v. Turner) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Philadelphia American Life Insurance Co. v. Turner, 131 S.W.3d 576, 2004 Tex. App. LEXIS 2048, 2004 WL 393155 (Tex. Ct. App. 2004).

Opinion

OPINION

DIXON W. HOLMAN, Justice.

In this interlocutory appeal, Appellant Philadelphia American Life Insurance Company (PALIC) appeals the trial court’s class certification order entered in favor of Appellee Billy “Rex” Turner. We reverse and remand.

I. Factual and PROCEDURAL BackgRound

Appellant is a company that sells group health insurance in at least eighteen states throughout the United States. Two of its group policies are at issue in this ease. The first is a major medical expense certificate of insurance policy, form H-0055P (“55P”). The second is a hospital medical-surgical expense certificate policy, form H-0070P (“70P”). Appellant sold both policies in Alabama, Arkansas, Arizona, Georgia, Illinois, Indiana, Missouri, Mississippi, Nevada, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

Appellee purchased the major medical insurance policy form 55P from Appellant in May 1999 through the Small Business Association of America and has been continuously covered under the policy through at least the day of his testimony at the class certification hearing on November 6, 2002. Appellant charged Appellee on a monthly basis, for a premium as well as an administrative fee. 1

On the first page of Appellee’s application for coverage under the 55P policy, there is a section that lists the types of fees with blanks left for the actual amount, if any, for the fees. The fee section on Appellee’s application lists the following fee descriptions and amounts:

*582 [[Image here]]

Appellee signed the application and executed an authorization allowing Appellant to electronically withdraw a premium in the amount of $173.16 directly from his bank account on a monthly basis. 2

Appellee received a certificate of coverage (Certificate) from Appellant, which states:

Entire Contract; Changes: The entire contract will consist of: 1. the Group Policy, the application of the Group Policyholder, which will be attached to the Group Policy; and 2. any enrollment applications of the proposed Insured individuals, including Your own.

The Certificate included a schedule of benefits, which provided that Appellant’s coverage encompassed a $500,000 maximum benefit for each injury or sickness and a $5,000,000 lifetime maximum benefit. In addition to the various coverage limits and copay requirements, the schedule lists the “initial premium” as $173.16 and indicates that it will be paid by a monthly bank draft.

The Certificate contains a non renewal provision, which states:

We can only terminate the Policy upon 90 days written notice if We offer the Policyholder coverage, on a guaranteed issue basis, under any policy which We are currently marketing or upon 180 days notice if We terminate all of Our policies in the state of delivery.

The Certificate states that if coverage terminates, the policyholder is entitled to conversion or continuation under the group policy as long as he was continuously insured under the group policy for at least three consecutive months prior to termination and the Certificate was not terminated involuntarily for cause, such as fraud or failure to pay the required premium. The Certificate offers two conversion options and one continuation option:

Option 1: A conversion policy providing similar coverage and benefits as provided under the Group Policy.
Option 2: A conversion policy with less[e]r coverage and benefits.
Option 3: Continuation of coverage under the Group Policy.

On December 31, 2001, Appellant sent all Texas 55P policyholders, including Ap-pellee, a notice terminating the group policy, effective on the first monthly premium *583 renewal date after April 5, 2002. The letter offered Texas 55P policyholders a certificate under the “only” available plan in Texas at the time. The plan provided limited benefit coverage with a $10,000 calendar year maximum benefit and a $50,000 lifetime maximum benefit. For more comprehensive coverage, the letter encouraged Texas 55P policyholders to contact an agent for assistance through another carrier.

Appellee filed suit on March 5, 2002, along with a request for class certification, alleging that Appellant breached the insurance contract by charging him, and other 55P and 70P policyholders, a monthly administrative fee not authorized by the insurance contract. 3 Although Appellee testified that he paid $173.16 a month and $173.16 was the amount of his premium, he argues that the $7.50 monthly administrative fee included in his payment was not authorized by the contract because he agreed to pay only a monthly premium, and not administrative fees. Appellee, seeking injunctive relief, additionally asserted that the non renewal of the 55P policy was not in compliance with his interpretation of the policy. Appellee claimed that Appellant’s attempt to cancel the Certificate constituted a breach of the terms of the insurance contract for two reasons. First, Appellee asserted that Appellant was required to provide a 180-day notice of cancellation because a 90-day notice was allowed under the contract only if Appellant offered alternative coverage under any policy that it currently marketed in Texas. Second, Appellee claimed that instead of offering a conversion policy with similar coverage and benefits as required by the contract, Appellant offered a “substantially inferior product” as the only replacement option.

On March 11, six days after Appellee filed suit, Appellant sent another letter to all Texas 55P policyholders offering an additional plan that covered eligible medical expenses after either a $5,000 or $10,000 calendar year deductible up to a lifetime maximum benefit of $1 million. With respect to Appellee’s request for in-junctive relief, the parties reached an agreement, and the trial court entered an “Agreed Order for Injunction” on April 5, 2002, enjoining Appellant from cancelling all Texas 55P certificates for a period of six months. Appellant then filed an application to withdraw from writing association coverage insurance with the Texas Department of Insurance (TDI) along with a withdrawal plan on May 24, 2002. Appellant’s withdrawal plan was approved by the TDI on June 27, 2002.

On July 1, 2002, Appellant sent another letter to the Texas 55P policyholders announcing that it was exiting the association group accident and health insurance market and therefore terminating coverage under 55P policies, effective January 1, 2003. The letter offered three conversion policies: a standard conversion policy, a basic conversion policy, and a $5,000 deductible conversion policy.

On October 24 and 25, 2002, the trial court held a hearing on Appellee’s request for a second injunction as well Appellant’s plea to the jurisdiction, motion to dismiss, and motion for summary judgment.

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Cite This Page — Counsel Stack

Bluebook (online)
131 S.W.3d 576, 2004 Tex. App. LEXIS 2048, 2004 WL 393155, Counsel Stack Legal Research, https://law.counselstack.com/opinion/philadelphia-american-life-insurance-co-v-turner-texapp-2004.