Reisen v. Blue Cross Blue Shield

839 P.2d 729, 115 Or. App. 396, 1992 Ore. App. LEXIS 1820
CourtCourt of Appeals of Oregon
DecidedOctober 7, 1992
DocketA9004-02480; CA A66211
StatusPublished

This text of 839 P.2d 729 (Reisen v. Blue Cross Blue Shield) is published on Counsel Stack Legal Research, covering Court of Appeals of Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Reisen v. Blue Cross Blue Shield, 839 P.2d 729, 115 Or. App. 396, 1992 Ore. App. LEXIS 1820 (Or. Ct. App. 1992).

Opinions

EDMONDS, J.

In this action to recover benefits under a health insurance policy, plaintiff appeals from a judgment on a directed verdict for defendant insurer. ORCP 60. Plaintiff contends that the materiality of plaintiffs decedent’s representations in his insurance application was a question of fact for the jury. A directed verdict is proper only if reasonable people could draw but one conclusion from the evidence. James v. Carnation Co., 278 Or 65, 69, 562 P2d 1192 (1977). In reviewing the directed verdict, we view the evidence in the light most favorable to the non-moving party as to whether the representations were material. City of Rogue River v. DeBoer, 288 Or 485, 488, 605 P2d 697 (1980). We affirm.

In June, 1989, decedent applied for, and was issued, a health insurance policy by defendant. The application provided that, if it contained material or fraudulent misstatements or omissions, defendant was entitled to rescind the contract. In response to specific questions on his application, decedent said that he had not had any medical conditions or treatments and had not taken any medication in the past five years.1 After decedent became ill in the summer and fall of 1989, he sought benefits under defendant’s policy. Defendant reviewed hospital records and rescinded the policy.

At trial, defendant offered evidence that decedent had failed to disclose:

(1) A1984 auto accident, within the 5 year period, resulting in a back injury for which decedent received medical [399]*399treatment and physical therapy, including 18 physician visits and 14 physical therapy treatments.

(2) Emergency and follow-up treatment for herpes zoster in 1985.

(3) Treatment in 1985 to remove a growth on his face.

(4) Emergency treatment in 1986 for an accident that injured his hand and back and chiropractic treatments for the back injury.

(5) Treatment and medication in January, 1989, for what decedent described as a dandruff problem, which was diagnosed as seborrheic dermatitis.

(6) Treatment and medication in January, 1989, for an oral yeast infection known as mondial glossitis.

(7) A hospital record dated September 31, 1989, showing that decedent had said that he had had a questionable positive HIV test in January, 1989.

(8) A hospital record dated September 31, 1989, showing that decedent had said that he had had a chronic cough since January, 1989.

Decedent’s evidence indicated that the first six conditions were minor and that he had fully recovered from them and had experienced no recurring problems. He testified that, in July, 1989, he had received two emergency treatments and one follow-up visit for a cough that he had had for approximately one month. He was diagnosed as having bronchitis. In late August, 1989, he became very ill and was treated for pneumonia, but the treatment was unsuccessful. He became concerned that he was suffering from AIDS-related pneumonia. In September, 1989, he went to a Portland hospital and told a doctor that he had had a questionable positive HIV test. He testified that he gave the report about the HIV test, which was false, because his friends had advised him that he needed immediate therapy and testing would require too much delay. A medical report from that hospital says that decedent said that he had been tested for HIV in January, 1989, and had had a chronic cough since January, 1989.

[400]*400The failure to disclose information to an insurer by a prospective insured may prevent recovery of insurance benefits if the information was “material.” ORS 742.013(1).2 The issue is whether decedent’s representations in his application for insurance were material, as a matter of law, to acceptance of the risk by defendant. Plaintiff argues that decedent’s AIDS condition had not been treated or diagnosed and there were no “direct symptoms” of AIDS before he applied for insurance. Plaintiff says that, “ [although [decedent] had some past medical problems, unrelated to AIDS, that were omitted from the application, the materiality of those omissions is a question of fact [for the jury].”

Relying on Knight v. Continental Casualty, 259 Or 46, 485 P2d 403 (1971), defendant argues that decedent’s misrepresentations were material as a matter of law.3 If decedent had disclosed the omitted information, defendant argues that it would not have insured him or would have issued a more restrictive policy. In Knight, the defendant insurer refused to pay the plaintiff benefits under its policy for an injury to her back because of her misrepresentations on the insurance application. The application asked whether the plaintiff had ever been treated medically for any ulcer of the [401]*401stomach or intestines, whether she had had any medical treatment in the last five years and whether she had suffered from any other physical impairment. The plaintiff answered, “No.” The evidence showed that she had been treated by a doctor for an ulcerous condition for about six months during the pertinent time.

The court noted the testimony of the defendant’s underwriter, who said that any disorder of the stomach or the duodenum would have resulted in qualifying endorsements to the policy. It held:

“We are of the opinion that the evidence in the present case requires a ruling that the answers were material as a matter of law. It is common knowledge that an insurance company will not issue a policy of insurance or will issue only a qualified policy if the company knows that the applicant has certain serious symptoms relevant to the type of coverage offered under the policy. * * * Some of the variations [in the degree of the seriousness of the applicant’s affliction] will be such that the court, drawing upon its knowledge of business practice, would be entitled to rule as a matter of law that the failure to reveal information in response to the question in the application is or is not material. When the court does not have such knowledge, the insurer must adduce evidence to establish the fact and the claimant may rebut it with other evidence.
“In the present case [the insurer] presented evidence on the issue of materiality, but plaintiff did not. The question is whether, under these circumstances, the issue of materiality should be submitted to the jury. We hold that it is not a jury question in this case.
CC* * * * *
“And the misrepresentation was material even though it did not relate to the injury for which the claim is made in this case. * * * If plaintiff had digestive difficulties and they were disclosed by her response to the questions in the application, defendant would have issued the policy only with qualifying endorsements thus protecting itself against the risk of loss resulting from plaintiffs digestive problems. If plaintiff misrepresented her condition, defendant would be subjected to the risk that the misrepresentátion might go undetected and claims relating to plaintiffs digestive tract might be paid.” 259 Or at 50. (Citation omitted; emphasis supplied.)

[402]*402Under ORS 742.013(1) and Knight,

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Related

Maine Bonding & Casualty Co. v. Centennial Insurance
693 P.2d 1296 (Oregon Supreme Court, 1985)
James v. Carnation Co.
562 P.2d 1192 (Oregon Supreme Court, 1977)
City of Rogue River v. DeBoer
605 P.2d 697 (Oregon Supreme Court, 1980)
Wiebe v. Seely
335 P.2d 379 (Oregon Supreme Court, 1959)
Rickard v. Ellis
368 P.2d 396 (Oregon Supreme Court, 1962)
Knight v. Continental Casualty Co.
485 P.2d 403 (Oregon Supreme Court, 1971)

Cite This Page — Counsel Stack

Bluebook (online)
839 P.2d 729, 115 Or. App. 396, 1992 Ore. App. LEXIS 1820, Counsel Stack Legal Research, https://law.counselstack.com/opinion/reisen-v-blue-cross-blue-shield-orctapp-1992.