Reagan Equipment Co. v. Pan American Life Insurance Co.

514 So. 2d 253, 1987 La. App. LEXIS 10470
CourtLouisiana Court of Appeal
DecidedOctober 14, 1987
DocketNo. 87-CA-292
StatusPublished
Cited by3 cases

This text of 514 So. 2d 253 (Reagan Equipment Co. v. Pan American Life 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
Reagan Equipment Co. v. Pan American Life Insurance Co., 514 So. 2d 253, 1987 La. App. LEXIS 10470 (La. Ct. App. 1987).

Opinion

KLIEBERT, Judge.

Plaintiff, Reagan Equipment Company, sued its former employees’ group medical insurer, New York Life Insurance Company (New York) and its subsequent replacement insurer, Pan American Life Insurance Company (Pan Am) for the recovery of $474,831.34 in medical expenses, the burden of which was borne by Reagan on behalf of an employee’s wife. In essence, Reagan contends either one or both of the major medical insurers are liable for the medical expenses because the Louisiana Insurance Code, LSA-R.S. Title 22:1 et seq., prohibits a gap in coverage when substituting one insurance carrier for another by imposing the liability on the initial carrier and/or its successor, depending upon the factual situation prevailing at the time.

Alternatively, Reagan sought recovery from Aetna Life and Casualty Company (Aetna) under a fiduciary responsibility policy. Reagan contends the policy does or should have provided coverage for Reagan’s breach of a fiduciary responsibility, i.e., the failure to obtain major medical insurance coverage for employees who were ill and incurring medical expenses at the time the insurer was replaced. In the further alternative, in the event the Aetna policy failed to provide such coverage, then Reagan contends St. Paul Fire and Marine Insurance Company (St. Paul), the errors and omissions carrier of the insurance agency which secured the Aetna policy for Reagan, is liable for failing to obtain such coverage.

From a judgment which dismissed, after trial on the merits, its suit against all defendants plaintiff brought this appeal. We affirm the judgment in all respects.

FACTS

Reagan Equipment Company has provided major medical insurance coverage for its employees for over thirty years. In September of 1979 Reagan submitted specifications for group hospitalization and life insurance programs to several carriers, including New York and Aetna. New York submitted the winning proposal and a one year policy issued by the company went into effect on January 1, 1980. The previous carrier’s (Blue Cross’) policy provided only limited extended benefits, i.e., a $100.00 maximum for individuals entitled to or drawing benefits as of the date the policy terminated. After negotiations with Reagan, New York agreed to provide transitional protection for employees and/or dependents confined to a hospital on the New York policy’s effective date of January 1, 1980. In exchange for transitional protection at the policy’s inception New York limited extended benefits upon termination of its policy (scheduled for renewal or termination on January 1,1981) to those available under the Blue Cross policy it replaced, i.e., the $100.00 maximum.

In the latter part of 1980 New York informed Reagan renewal premiums would be increased due to a high claims experience. Reagan immediately sought alternative coverage and, as the search continued into 1981, renewed the New York policy on a month-to-month basis at an average pre[255]*255mium of $40,000.00 per month. An employee benefits consultant retained by Reagan, Mr. Guibault, informed its personnel manager, Mr. Ed Cooper, that there were limited extended benefits under the New York policy for persons entitled to draw or drawing benefits on the termination date. Nevertheless, New York’s offer to accept a supplemental premium to assume responsibility for transitional coverage was rejected by Reagan. (The record does not reflect the premium cost for such coverage).

Effective July 1, 1981 Pan Am issued its policy and became the employees’ group major medical insurer under a minimum premium plan. Premiums, which represent actual claims experience plus administrative costs, subject to a maximum cap, were approximately $10,000.00 per month. The policy, however, did not provide transitional protection for persons disabled on its effective date and in fact excluded as ineligible for coverage dependents who were hospitalized on the policy’s effective date. By letter dated July 30,1981, Pan Am memorialized an agreement with Reagan whereby it would process and pay the claims of persons disabled at the termination of the New York policy and Reagan would reimburse Pan Am for the claims paid plus 7½% for administrative fees. However, Reagan later claimed it thought the cost-plus agreement pertained only to certain claims arising from pregnancies.

Mrs. Marion Gregoire, the wife of a Reagan employee, was hospitalized on May 18, 1981, prior to termination of the New York policy. She remained hospitalized until her death from cancer on March 17, 1982. New York paid $58,592.46 in claims submitted on her behalf prior to their policy’s termination date, plus $100.00 in extended benefits. Subsequent to termination of the New York policy Mrs. Gregoire incurred medical expenses totalling $474,831.34. These claims were processed by Pan Am pursuant to the cost-plus agreement detailed in the letter of July 30,1981. Thereafter, Reagan reimbursed Pan Am for its payments. When the size of the claims became known, Pan Am agreed to accept a flat administration fee of $2,500.00 rather than 772% of the costs. The claim of a Reagan employee, other than Mrs. Gre-goire, who was disabled due to a heart condition, was likewise handled on a cost-plus basis.

Despite the exercise of the cost-plus agreement encompassed in the July 30, 1981 letter, Reagan, who calculated its own premiums, paid a premium for Mrs. Gre-goire under the minimum premium plan from July through September of 1981. Pan Am discovered the payment and refunded the premium. In late February or early March of 1982 Mr. Guibault and Mr. Cooper met with a Pan Am representative, Dudley Brown, for the purpose of convincing him that Mrs. Gregoire’s claims should be covered under the minimum premium plan. According to Guibault, upon reviewing the cost-plus agreement, he believed the possibility of convincing Pan Am to pay the claims pursuant to the minimum premium plan was non-existent. (Cooper had not previously informed Guibault of the existence of the cost-plus agreement encompassed in the July 30, 1981 letter).

Notwithstanding Mrs. Gregoire’s death on March 17, 1982, on advice of counsel Reagan included in one of its monthly premiums to Pan Am a premium on her behalf from the date the minimum premium plan went into effect to about March of 1982. Pan Am became aware of this during its preparation for trial. Hence, it gave a credit for the premium on its reconventional demand for administrative fees.

On April 15, 1982 Reagan sent a letter to New York requesting it “confirm its liability” for expenses generated by the illness of Marion Gregoire “both prior to and subsequent to June 30, 1982.” New York ultimately denied liability for all expenses incurred subsequent to the policy termination date beyond the $100.00 maximum.

Reagan also sent a letter on April 15, 1982 to Aetna requesting written confirmation of coverage under Fiduciary Responsibility insurance policy No. 39FF305BCA (replacing policy No. 39FF988CA) for claims arising as a result of Reagan’s possible failure to provide for extended bene[256]*256fits upon the termination of the New York Life Policy.” Aetna denied coverage for the claim on the following basis:

“We direct your attention to the endorsement on your policy 39 FF 305 BCA which reads as follows:

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Related

Opinion Number
Louisiana Attorney General Reports, 1997
Freeman v. Mowdy
743 F. Supp. 475 (S.D. Mississippi, 1990)
Reagan Equipment Co. v. Pan American Life Insurance Co.
515 So. 2d 1113 (Supreme Court of Louisiana, 1987)

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Bluebook (online)
514 So. 2d 253, 1987 La. App. LEXIS 10470, Counsel Stack Legal Research, https://law.counselstack.com/opinion/reagan-equipment-co-v-pan-american-life-insurance-co-lactapp-1987.