Simmons v. Congress Life Insurance

791 So. 2d 371, 2000 Ala. LEXIS 343
CourtSupreme Court of Alabama
DecidedAugust 11, 2000
Docket1980570
StatusPublished
Cited by8 cases

This text of 791 So. 2d 371 (Simmons v. Congress Life Insurance) is published on Counsel Stack Legal Research, covering Supreme Court of Alabama primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Simmons v. Congress Life Insurance, 791 So. 2d 371, 2000 Ala. LEXIS 343 (Ala. 2000).

Opinions

LYONS, Justice.

The plaintiff Laura A. Simmons appealed to this Court from summary judgments in favor of Congress Life Insurance Company (“Congress”) and Insurers Administrative Corporation (“IAC”) on her claims alleging bad-faith refusal to pay, or to investigate, certain health-insurance claims. She also appealed from a partial summary judgment in favor of Congress and IAC on her claim alleging breach of the insurance contract. Congress and IAC cross-appealed from the trial court’s denial of their motion to “reform” the insurance contract. We transferred the appeals to the Court of Civil Appeals, pursuant to § 12-2-7(6), Ala.Code 1975. The Court of Civil Appeals affirmed the judg[373]*373ments of the trial court; see Simmons v. Congress Life Ins. Co., 791 So.2d 360 (Ala.Civ.App.1998). We granted Simmons’s petition for certiorari review.1 We affirm the judgment of the Court of Civil Appeals in part, reverse it in part, vacate it in part, and remand.

I. Factual Background

On May 6, 1994, Simmons applied for group health-insurance coverage with Congress. The application for insurance with Congress asked several questions about the applicant’s medical history during the preceding five years. One question specifically asked whether the applicant had “[b]een diagnosed or treated for ... back disorder.” Simmons checked the “no” box next to this question. From August 1992 until September 1993, however, Simmons had been treated by a chiropractor for chronic back pain.2 She later was diagnosed as having scoliosis (curvature of the spine), which was thought to be the source of her pain.

Congress offers coverage for two different groups under two different insurance plans. The “Insight plan” is designed to insure individuals whose employers procure group health insurance for them and pay premiums to Congress for their employees’ health insurance. Persons insured under the Insight plan are covered under a policy issued to the Multiple Unit Security Trust I (“MUST I”). The “Insight Answer plan” is designed to insure individuals whose employers do not procure group health insurance for them and who pay premiums themselves to Congress for their health insurance. Persons insured under the Insight Answer plan are covered under a policy issued to the Multiple Unit Security Trust II (“MUST II”). The two policies define “pre-existing medical condition” differently. Under the MUST I policy, “pre-existing condition” is defined as “any ... sickness for which the individual received any medical care or treatment within the six (6) month period immediately prior to the effective date of the Major Medical Expense Benefits with respect to the individual.” Under the MUST II policy, “pre-existing condition” is far more broadly defined as “any ... sickness, or any complications therefrom, for which medical treatment, ... advice or consultation was rendered to the Insured, or which produced distinct symptoms in the Insured which would have caused an ordinary prudent person to seek medical diagnosis or treatment within the twelve (12) months preceding the Insured’s effective date.”

Because her employer did not provide health insurance, Simmons applied to Congress for coverage under the MUST II policy. Congress issued Simmons a certificate of insurance with an effective date of May 31, 1994, “if [the insured was] then at active, full-time work,” under a group policy issued to the “Multiple Unit Security Trust [no Roman numeral]” as the policyholder. The certificate sent to Simmons contained the definition of “pre-existing condition” found in MUST I policies. The front of the certificate stated that the certificate itself “summarizes the provisions of the Policy as they may affect you” and that the certificate is “merely evidence of insurance under the Policy.”

Shortly after the effective date of her coverage, Simmons’s primary-care physician referred her to Dr. Richard Sawyer, a neurologist, for consultation in identifying the cause of medical problems Sim[374]*374mons was then experiencing. Dr. Sawyer’s notes reflect that Simmons reported that she was experiencing pain and numbness in various parts of her body. Dr. Sawyer ordered a battery of tests and recommended to Simmons that she also consult an orthopedic surgeon. Simmons’s medical providers submitted five claims to Congress for payment of medical services rendered to her during this period, designated as claims 996006, 995865, 995854, 995276, and 995519. These claims contained diagnostic codes that identified the condition giving rise to the medical services as “lumbago/pain low back,” “backache, unspecified,” “pain in joint,” “migraine, unspecified,” “pain in neck/cervicalgia,” “congenital musculoskel-etal deformity of spine (postural: lordosis scoliosis),” and “disturbance of skin sensation.” Dr. Sawyer’s office notes concerning his treatment of Simmons were also submitted with the claims. In these notes, Dr. Sawyer stated on June 22, 1994, that Simmons had been “referred for a variety of aches and pains of at least several months[’] duration. [She] reports a constellation of symptoms which probably began about 6 mo. ago.... She saw a chiropractor during this time and he diagnosed mild scoliosis and left sciatica.” (See the opinion of the Court of Civil Appeals for the text of Dr. Sawyer’s notes, 791 So.2d at 863). On June 30, Dr. Sawyer’s notes reflected that he thought Simmons’s problems might be caused by multiple sclerosis. Simmons continued to undergo diagnostic testing and treatment by Dr. Sawyer and other medical-service providers during the next three months.

IAC is the third-party that administers claims submitted to Congress under the MUST policies. Upon receiving Simmons’s first five claims and Dr. Sawyer’s June 22 office notes, an IAC benefits analyst recommended that Simmons’s claims be denied as related to a preexisting condition, under the “prudent person” standard of the MUST II policy. IAC’s records indicated that Simmons was insured under the MUST II policy, and its employees did not know at that time that she had actually received a certificate of insurance referring only to a “MUST” policy and containing the definition of “pre-existing condition” applicable to the MUST I policy. In September 1994, IAC informed Simmons that it had denied her claims because, it said, she had incurred medical services for a preexisting condition.

When Simmons telephoned IAC to inquire about the denial of her claims, an IAC employee told her that she had the right to appeal if she did not agree with the manner in which the claims had been processed, and that she would need documentation from a physician stating why her condition was not a “pre-existing” one. In December 1994, Simmons sent IAC a handwritten letter requesting that it reconsider her claims. That letter states:

“Enclosed is a statement from my previous doctor that is treating me for my multiple sclerosis, also are the copies of my records you requested from the chiropractor I saw in the past. I would hope you would consider my situation. I’m very sick and I cannot handle the stress from this.
“I have to continue to see my doctor, but cannot afford cash payment. I would like for you to review my file and your denial of claims.”

Simmons sent with her letter records from her chiropractor regarding her treatment through May 1993 and a letter from Dr.

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791 So. 2d 371, 2000 Ala. LEXIS 343, Counsel Stack Legal Research, https://law.counselstack.com/opinion/simmons-v-congress-life-insurance-ala-2000.