Silva v. Aetna Life Insurance Co.

805 S.W.2d 820, 1991 Tex. App. LEXIS 193, 1991 WL 5088
CourtCourt of Appeals of Texas
DecidedJanuary 24, 1991
DocketNo. 13-90-147-CV
StatusPublished

This text of 805 S.W.2d 820 (Silva v. Aetna Life Insurance Co.) 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
Silva v. Aetna Life Insurance Co., 805 S.W.2d 820, 1991 Tex. App. LEXIS 193, 1991 WL 5088 (Tex. Ct. App. 1991).

Opinion

OPINION

NYE, Chief Justice.

This is an appeal from a summary judgment. Appellant, Noe J. Silva, sued appel-lee, Aetna Life Insurance Company, for wrongfully refusing to pay his medical bills. Silva alleges that Aetna violated sections 1104(a) and 1109 of the Employee Retirement Income Security Act (ERISA)1 and article 21.21 of the Texas Insurance Code. The trial court granted summary judgment favorable to Aetna. By two points of error, Silva complains that the trial court erred in holding that Aetna had not acted arbitrarily and capriciously and that ERISA pre-empted his state law claims. We affirm the trial court’s judgment.

Silva’s suit alleges that Aetna issued a health insurance policy to Baker Marine Corporation. On or about August 1, 1983, he injured his foot while at work for Baker Marine. He required medical attention which was payable pursuant to the policy’s terms. Aetna, however, has refused to pay his medical bills. Silva asserts that Aetna “failed to provide benefits with the care, skill, prudence and diligence that a prudent man acting in like capacity would have done in the same or similar circumstances” in violation of ERISA. He also alleges that Aetna failed “to timely and properly pay benefits and representing [sic] that an insurance agreement confers rights and remedies which it does not” in violation of the Texas Insurance Code.

Aetna’s summary judgment motion alleges that Aetna did not act arbitrarily and capriciously in denying Silva benefits. It also alleges that section 1144(a) of ERISA pre-empts Silva’s state law claims. Further, Silva has no standing to sue under section 1109 of ERISA because this section only inures to the benefit of the plan as an entity and not to the individual beneficiary. As a separate ground for summary judgment, Aetna alleges that the evidence shows that Silva’s alleged injury occurred in the course and scope of his employment. The Aetna insurance plan does not provide coverage for occupational injuries.

[822]*822Aetna’s summary judgment proof includes Jerry Yon Tungeln’s affidavit, the insurance policy between Aetna and Baker Marine (the Aetna plan), a “MEMORANDUM FOR THE RECORD,” and an “EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL ILLNESS.” Tun-geln, Baker Marine’s vice-president, declares that on August 1, 1988, Baker Marine employed Silva as a “yard hourly employee.” On August 9,1983, Silva reported to Baker Marine that on August 1,1983, he injured his left foot while climbing a ladder at Baker Marine during regular working hours. Prior to August 1, 1983, Aetna issued a group insurance policy to Baker Marine which provided accident and health benefits to its employees for non-occupational injuries and diseases. Baker Marine administrated this policy plan.

The Aetna insurance policy states, in pertinent part, that unless otherwise specified, the accident and health coverage provided is non-occupational. The policy also says that “[a]n injury is considered non-occupational only if it is an accidental bodily injury and does not arise out of (or in the course of) any work for pay or profit nor, in any way, results from an injury which does.”

The “MEMORANDUM FOR THE RECORD” states that on August 9, 1983, Silva told Joe E. Carrales, III, at Baker Marine’s safety department that he had a non-occupational injury to his left foot. He said that as a result of his work at Baker Marine, he had aggravated the injury.

The “EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL ILLNESS” indicates that Silva reported his injury under the Longshoremen’s and Harbor Workers’ Compensation Act. The report shows that Silva, while at work for Baker Marine, aggravated a non-occupational injury to his left foot. According to this report, Silva injured his foot over three years prior to the date of the report. The report is dated August 9, 1983.

Silva’s response states that ERISA does not pre-empt his state law claims under the Texas Insurance Code. He maintains that section 1144(b) of ERISA exempts his state law claims from the pre-emption provision. Additionally, Silva states that the evidence shows that his injury was not job related. Thus, Silva claims, there is a fact issue whether the Aetna plan covers his medical expenses.

Silva’s summary judgment proof includes the Honorable James B. Ragan’s affidavit, an “APPLICATION FOR APPROVAL OF AGREED SETTLEMENT” and a letter signed by Thomas L. York, M.D. Ragan declares that he represented Silva in his claim for longshoremen’s benefits. According to Ragan, attachments to his (Ra-gan’s) affidavit show that during the course of the longshoremen’s claim, evidence was discovered proving that no cause or relationship existed between any work activity and Silva’s surgery need. Ragan states that “[a]s a result of this evidence, the case in question was settled for a nominal amount with the agreement between Plaintiff [Silva] and employer [Baker Marine] that due to the fact that the injuries were not work related it would then be covered by the employer’s group health insurance.”

The “APPLICATION FOR APPROVAL OF AGREED SETTLEMENT” includes an “AGREED STATEMENT OF FACT.” This agreed statement indicates that Silva “was climbing a ladder which aggravated an old injury to his foot.”

Dr. York states that he examined Silva on March 4, 1984, regarding an injury to his left foot. He found a severe lesion on the sole of Silva’s left foot. Silva told Dr. York that he injured this foot when, as a boy, he stepped on a broken fruit jar. Dr. York says that Silva “had this prior to going to Baker Marine and admits to trouble prior to that time.”

The trial court granted Aetna’s summary judgment motion and ordered that Silva take nothing against Aetna. In reviewing a summary judgment record, this court must determine whether a disputed material fact issue exists that would preclude a summary judgment. Gonzales v. Mission America Insurance Co., 33 Tex.Sup.Ct.J. 697-98 (Sept. 6, 1990); Bayouth v. Lion Oil Co., 671 S.W.2d 867, 868 [823]*823(Tex.1984). Every reasonable inference must be indulged in the non-movants’ favor, and any doubt resolved in their favor. Wilcox v. St. Mary’s University, 531 S.W.2d 589, 593 (Tex.1975). The question on appeal is not whether the summary judgment proof raises a fact issue with reference to the essential elements of the plaintiff’s cause of action, but whether the summary judgment proof establishes that the movant is entitled to summary judgment as a matter of law. Gibbs v. General Motors Corp., 450 S.W.2d 827, 828 (Tex. 1970); Tucker v. Atlantic Richfield Co., 787 S.W.2d 555, 557 (Tex.App.—Corpus Christi 1990, writ denied).

By point two, appellant complains that the trial court erred in holding that ERISA pre-empts his state law claims under the Texas Insurance Code. ERISA contains a broadly worded pre-emption provision found in 29 U.S.C. § 1144(a) (1985)2 This section provides, in relevant part:

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Cite This Page — Counsel Stack

Bluebook (online)
805 S.W.2d 820, 1991 Tex. App. LEXIS 193, 1991 WL 5088, Counsel Stack Legal Research, https://law.counselstack.com/opinion/silva-v-aetna-life-insurance-co-texapp-1991.