Poling v. Wisconsin Physicians Service

357 N.W.2d 293, 120 Wis. 2d 603, 1984 Wisc. App. LEXIS 4340
CourtCourt of Appeals of Wisconsin
DecidedSeptember 18, 1984
Docket83-2389
StatusPublished
Cited by41 cases

This text of 357 N.W.2d 293 (Poling v. Wisconsin Physicians Service) is published on Counsel Stack Legal Research, covering Court of Appeals of Wisconsin primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Poling v. Wisconsin Physicians Service, 357 N.W.2d 293, 120 Wis. 2d 603, 1984 Wisc. App. LEXIS 4340 (Wis. Ct. App. 1984).

Opinion

NETTESHEIM, J.

Wisconsin Physicians Service, administrator of the state of Wisconsin’s employee group *606 health insurance policies, appeals from that portion of the judgment affirming a jury verdict finding bad faith by WPS in refusing to honor Howard and Nellie Poling’s claims for nursing home care rendered to Mrs. Poling. The jury awarded bad faith damages of $35,000 and punitive damages of $100,000 in favor of the Polings. The jury also awarded the Polings $33,000 damages for breach of contract damages representing nursing home charges incurred by Mrs. Poling. WPS does not appeal this breach of contract award, but does appeal the award of twelve percent prejudgment interest on said amount. WPS also appeals the award of prejudgment interest on the bad faith and punitive damage awards. We vacate the award of prejudgment interest on the bad faith and punitive damage awards. In all other respects, we affirm the judgment.

Mrs. Poling is a retired state employee. She was insured under a group health insurance policy issued by the state of Wisconsin and administered by WPS. She was admitted to a hospital on August 5, 1981, suffering from early senility (Alzheimer’s Syndrome) and Parkinson’s Disease. She was then directly admitted to the Kinnic Nursing Home on August 13, 1981. 1 In March 1982, Mr. Poling submitted a claim to WPS for reimbursement of the nursing home charges incurred by Mrs. Poling. After referring the claim to its medical advisors, WPS concluded that the care provided was custodial, not skilled, and therefore not covered under the policy. Mr. Poling then sought legal assistance. On May 18, 1982, the Po-lings’ attorney resubmitted the claim together with a letter from Dr. Roland Hammer, who had originally admitted Mrs. Poling to the hospital. Dr. Hammer, contend *607 ing that Mrs. Poling’s care was skilled, noted that she was being monitored to avoid the development of bed sores and that occupational therapy, nursing supervision, and medication were being provided. WPS submitted this further request and information to its medical advisors who again concluded that Mrs. Poling’s care was custodial. The claim was again denied. This lawsuit ensued.

Bad Faith

WPS contends that there was no evidence to support the finding of bad faith. The test for determining whether an insurance company has committed a tortious bad faith refusal to honor a claim of an insured is stated in Anderson v. Continental Insurance Co., 85 Wis. 2d 675, 691, 271 N.W.2d 368, 376 (1978), as follows:

To show a claim for bad faith, a plaintiff must show the absence of a reasonable basis for denying benefits of the policy and the defendant’s knowledge or reckless disregard of the lack of a reasonable basis for denying the claim.

WPS argues that Mrs. Poling’s claim was fairly debatable and that it gave honest and intelligent consideration to it with knowledge of her circumstances. Thus, WPS asserts it denied the claim in good faith.

However, at trial, WPS abandoned its claim that Mrs. Poling was receiving only custodial care and conceded that she was receiving skilled care. WPS contended, however, that because Mrs. Poling was not receiving habilitative care, which would not be covered by Medicare provisions, her claim still was not covered. WPS’s claims director and principal witness, William Toole, explained that WPS coverage was the same as that provided by Medicare coverage. However, Toole was seriously impeached when it was revealed that the Medicare provi *608 sions decreed that the patient’s need for skilled care, rather than the expectation of rehabilitation, was the controlling factor in determining coverage. Toole was further seriously impeached when he testified that WPS’s June 1982 denial of the Poling claim was based on Dr. Hammer’s report. The report, in fact, was not prepared until August 24, 1982.

On review of a jury verdict, we view the evidence in the light most favorable to the verdict and uphold it if there is any credible evidence to support it. Meurer v. ITT General Controls, 90 Wis. 2d 438, 450, 280 N.W.2d 156, 162 (1979). This is especially true where, as here, the verdict has the approval of the trial court. Id. Matters of weight and credibility are left to the jury’s judgment, and where more than one reasonable inference can be drawn from the evidence, this court must accept the inference drawn by the jury. Id. This court is obligated to search for credible evidence that will sustain the verdict, not for evidence that would sustain a verdict the jury could, but did not, reach. Id. at 450-51, 280 N.W.2d at 162-63.

While an insurance company may challenge claims that are “fairly debatable” and will be found liable in bad faith only where it has intentionally denied (or failed to process or pay) a claim without a reasonable basis, the test is whether a reasonable insurer under the particular facts and circumstances would have denied or delayed payment of the claim. Anderson, 85 Wis. 2d at 692, 271 N.W.2d at 377. It is the duty of an insurer to assess a claim as a result of an appropriate and careful investigation so that its conclusions should be the result of the weighing of probabilities in a fair and honest way. Id. at 688, 271 N.W.2d at 375; see also Hilker v. Western Automobile Insurance Co., 204 Wis. 1, 15, 231 N.W. 257, *609 235 N.W. 413, 415 (1931) (opinion on reconsideration). Such a decision, in order to be made in good faith, must be based upon a knowledge of the facts and circumstances upon which liability is predicated and the lack of reasonable diligence to determine the nature and extent of the liability evinces bad faith. Anderson, 85 Wis. 2d at 688, 271 N.W.2d at 375.

WPS’s retreat at trial from its previous position that Mrs. Poling’s care was custodial presents a sufficient basis for the jury to have concluded that WPS did not properly investigate the Poling claim with respect to its potential liability. The fact that the denial of the claim was based upon Mrs. Poling’s doctor’s report, when such report was not prepared until much later, further discredits WPS’s claim of reasonable action. Therefore, WPS had no basis upon which to conclude that the claim was fairly debatable, and thus there was no reasonable basis for denying the claim. Accordingly, the first prong of the Anderson test was met.

In addition, the presentation, for the first time at trial, of a new basis for denial of the claim, coupled with the revelation that even this new theory was inapplicable under the Medicare guidelines, not only supports the finding under the first Anderson prong but further supports the claim that WPS acted at least in wanton disregard of its duty to the Polings, thus meeting the second Anderson prong.

WPS next argues there was no evidence to sustain the award of bad faith damages. Anderson

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Bluebook (online)
357 N.W.2d 293, 120 Wis. 2d 603, 1984 Wisc. App. LEXIS 4340, Counsel Stack Legal Research, https://law.counselstack.com/opinion/poling-v-wisconsin-physicians-service-wisctapp-1984.