Simmons v. Congress Life Insurance

791 So. 2d 360, 1998 Ala. Civ. App. LEXIS 701, 1998 WL 737954
CourtCourt of Civil Appeals of Alabama
DecidedOctober 23, 1998
Docket2970564
StatusPublished
Cited by7 cases

This text of 791 So. 2d 360 (Simmons v. Congress Life Insurance) is published on Counsel Stack Legal Research, covering Court of Civil Appeals 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 360, 1998 Ala. Civ. App. LEXIS 701, 1998 WL 737954 (Ala. Ct. App. 1998).

Opinion

ROBERTSON, Presiding Judge.

Laura Simmons appeals from a summary judgment of the Mobile County Circuit Court in favor of Congress Life Insurance Company (“Congress”) and Insurers Administrative Corporation (“IAC”) on her claims of bad faith refusal to pay or to investigate certain health insurance claims. She also appeals from a partial summary judgment in favor of Congress and IAC on her claim of breach of an insurance contract. Congress and IAC cross-appeal from the trial court’s denial of their “motion to reform” the pertinent insurance contract. We affirm.

Facts

This case arises from a dispute concerning the refusal to pay five claims submitted by Simmons immediately following her acquisition of health insurance coverage from Congress in May 1994. Because the principal issue in this case is whether the trial court properly granted the summary judgment in favor of Congress and IAC, we will review the facts in a light most favorable to Simmons, the nonmovant. Thompson v. Mindis Metals, Inc., 692 So.2d 805, 806 (Ala.1997).

From August 1992 until September 1993, Simmons received chiropractic treatment for symptoms of chronic back pain. This pain was later diagnosed as resulting from scoliosis (i.e., curvature of the spine).

On May 6, 1994, Simmons executed an application for group health insurance from Congress through an insurance agency in Mobile. That application contained several questions (accompanied by ‘Tes” [362]*362and “No” check boxes) designed to elicit certain facts from Congress applicants concerning their medical history, including one that asked whether any individual applying for coverage had, during the preceding five years, “[b]een diagnosed or treated for ... back disorder.” The “No” check box was marked next to this question on Simmons’s application.

Congress affords group health insurance coverage to two distinct constituencies. Some persons receiving group health insurance coverage from Congress are covered under a group insurance policy issued to the “Multiple Unit Security Trust I” (“MUST I”) under a plan called the “Insight” plan. This plan is designed to insure persons whose employers enroll them in group health insurance coverage and pay premiums to Congress to maintain that coverage. Other persons, whose employers do not secure health insurance from Congress, may nevertheless obtain group health insurance from Congress under a group insurance policy issued to the “Multiple Unit Security Trust II” (“MUST II”), under a plan called the “Insight Answer” plan, by paying the premiums for group coverage themselves.

The principal difference between coverage under the MUST I plan and coverage under the MUST II plan that is pertinent to this litigation concerns Congress’s exclusion of coverage for “pre-existing” medical conditions. Under the MUST I/Insight plan, “pre-existing condition” means “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” (emphasis added). However, under the MUST II/Insight Answer plan, “pre-existing condition” is 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 ordinarily prudent person to seek medical diagnosis or treatment within the twelve (12) months preceding the Insured’s effective date” (emphasis added). Thus, Congress’s group policy issued to MUST II more rigidly defined “pre-existing conditions” that would not trigger coverage.

Simmons’s employer did not participate in the MUST I plan, and her application (which was captioned “Insight Answer”) requested insurance “under the provisions of the Master Policy issued to the Multiple Unit Security Trust II by Congress.” However, upon agreeing to insure Simmons, Congress issued Simmons a certificate of insurance that stated that Simmons would be covered as of May 31, 1994, “if you are then at active, full-time work,” under a group policy issued to the “Policyholder”; the certificate named the “Multiple Unit Security Trust” (without a Roman numeral) as the “Policyholder.” This certificate contained a “pre-existing condition” definition consistent with Congress’s MUST I policy rather than the MUST II policy. The front of the certificate states that it “summarizes the provisions of the Policy as they may affect you,” and that it is “merely evidence of insurance under the Policy.”

On June 10, 1994, just after the effective date of her coverage, Simmons was seen by a physician in Mobile, and she received treatment over several weeks from a number of other medical providers. During this period, Simmons submitted five claims for payment for medical services rendered to Simmons, designated as claim numbers 996006, 995855, 995854, 995276, and 995519. * These claims contain “diagnosis codes” identifying the condition prompting the services and treatments Simmons re[363]*363ceived as having been “lumbago/lower back pain,” “backache, unspecified,” “pain in neck/cervicalgia,” “migraine, unspecified,” “congenital musculoskeletal deformity of spine (posturaldordosis scoliosis),” and “disturbance of skin sensation.”

Among the medical records submitted in support of these claims were the June 22, 1994, office notes of Dr. Richard Sawyer, who noted:

“[Simmons] ... is 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. One day at work 6 mo. ago, she noted sudden onset of vertigo and her left arm felt numb and weak. Many of these symptoms resolved over that day but over the next 2 weeks she continued to feel off balance. This all subsequently improved. Over the next few months she began to develop a pinching sensation in her neck and lately she has noted that whenever she moves her neck the bottom half of her low back, feet and legs go to sleep. Her feet and legs feel numb much of the time and she notices that below her knees she can’t feel it when she shaves. Has also had severe pain in her left low back which runs down her leg and this started a month ago. Has noted numbness and tingling in her fingertips which comes and goes. The numbness and tingling in her legs below her knees has been present about a month. She denies any previous or recent viral illnesses, injuries, or immunizations. She saw a chiropractor during this time and he diagnosed mild [scoliosis] and left sciatica. Manipulations did not help and she reports that her neck symptoms seemed to get worse after [he] did some manipulations there.”

(Emphasis added.) On June 30, 1994, after a follow-up visit from Simmons, Dr. Sawyer would note his impression of her condition as “Possible] MS” (multiple sclerosis), extremity paresthesias, and left hip and leg pain. Simmons continued to undergo diagnostic and treatment procedures from Dr. Sawyer and other professionals during the following three months.

IAC, which is the third-party administrator that administers claims submitted to Congress under the policy issued to MUST II, received and reviewed Simmons’s five claims, as well as Dr. Sawyer’s office notes. An IAC benefits analyst recommended that Simmons’s claims be denied, stating as follows:

“Long [history] of numerous neuro-mus-cular [conditions]. ‘Could not remember’ name of chiro who treated in past. Pis.

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Related

Simmons v. Congress Life Insurance
791 So. 2d 371 (Supreme Court of Alabama, 2000)
Ex Parte Simmons
791 So. 2d 371 (Supreme Court of Alabama, 2000)

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Bluebook (online)
791 So. 2d 360, 1998 Ala. Civ. App. LEXIS 701, 1998 WL 737954, Counsel Stack Legal Research, https://law.counselstack.com/opinion/simmons-v-congress-life-insurance-alacivapp-1998.