Swinea v. Humana Inc.

215 So. 3d 897, 2017 WL 603997, 2017 La. App. LEXIS 221
CourtLouisiana Court of Appeal
DecidedFebruary 15, 2017
DocketNo. 51,179-CA
StatusPublished
Cited by4 cases

This text of 215 So. 3d 897 (Swinea v. Humana Inc.) 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
Swinea v. Humana Inc., 215 So. 3d 897, 2017 WL 603997, 2017 La. App. LEXIS 221 (La. Ct. App. 2017).

Opinion

GARRETT, J.

It Humana, Inc., appeals from a trial court judgment denying its request to annul a default judgment rendered against it. The plaintiff, Michael Swinea, answers the appeal, seeking attorney fees for responding to Humana’s appeal. We affirm the trial court judgment and award the plaintiff additional attorney fees of $1,000.

FACTS

The plaintiff was employed at Graphic Packaging in West Monroe when he became disabled around April 1, 2012. He was covered by a disability insurance policy obtained through his employment from Kanawha Insurance Company (“Kana-wha”).1 He was paid disability benefits of $2,700 per month until November 15, 2013, when they were terminated.

The plaintiff received a letter from Hu-mana dated November 25, 2013, informing him of the termination decision and his appeal rights. The name “Humana” appears in large, bold letters in the top left-hand corner of this document, with the phone number, name and mailing address of Kanawha underneath it in much smaller, non-bold print. In pertinent part, the letter recited:

Your claim has been denied
Dear Michael Swinea:
We recently received your claim regarding your disability benefits. However after a thorough review, the claim is denied as the submitted services are not covered benefits on your policy.
Per your policy:
Total Disability—means, for the first 24 months of a disability that the Member is:
|¾* Unable to perform the substantial and material duties of His Regular Occupation;
• Not working in any other occupation; and
[899]*899• Under the care of a Physician for the disability.
After (24) months of Total Disability, Totally Disabled means that the Member is[:]
• Unable to perform the duties of Any Occupation; and
• Under the care of a Physician for the disability.
We will not require care of a Physician when it is no longer needed for the sound medical care of the condition causing Total Disability.
Information submitted did not warrant further disability beyond 11/15/13.
If you disagree with our claim determination, you do have the right to appeal the decision. Enclosed you will find your appeal rights and how to file an appeal with Humana.
We value you as a policyholder and appreciate the opportunity to be of service to you.

The accompanying document entitled “Your Appeal Rights” specified that appeals be sent to an address in Lancaster, South Carolina, for “Grievance and Appeals.” The last line in this document stated, “Insured by Kanawha Insurance Company, a Humana company.” Both this document and the letter contained a notation in the bottom left-hand corner which read:

Humana.com
InSystem

The plaintiff appealed the denial. In a letter dated January 3, 2014, the plaintiff was advised that the matter was being researched. The letter specifically stated:

Thank you for your inquiry we received on January 2, 2014. We are currently doing research and will send a decision letter within the required timeframe. Please be assured we’re committed to providing a full and fair review.
IsYou are covered by Kanawha Insurance Company, a subsidiary of KMG America, under a disability plan from April 1, 2012 to present, Humana, Inc. acquired KMG America on November 30,2007.

The letter instructed the plaintiff to send any other documents he wanted included in the review to “Humana Inc., Grievance and Appeal Department” at the same Lancaster, South Carolina post office box address provided in the previously sent appeal rights document. The letter was signed by a person who identified herself as a specialist for “Humana Grievance and Appeal Department.”

The plaintiff received another letter, which was dated January 27, 2014, and purported to be from a different specialist for “Humana Grievance and Appeal Department.” The letterhead on this document consisted solely of the word “Huma-na” in large, bold letters in the top left corner of the first page of the two-page letter. The letter stated:

We disapproved your request for disability benefits because from November 16, 2013, forward because [sic] the claim was processed correctly according to the terms of the plan.
You are covered by Kanawha Insurance Company, a subsidiary of KMG America, under a disability plan from April 1, 2012, through the present. Humana Inc. acquired KMG America on November 30, 2007.
This decision was based on review of your appeal request, the claim submission, medical records, and the disability plan. The information was reviewed by an independent external reviewer, a board certified orthopedic surgeon.
Disability benefits are limited as specified in the plan. The plan defines Totally Disabled as the inability of the employee [900]*900to perform their job duties, not working in any other occupation, and be under [sic] the care of a physician. The report from the external reviewer stated that the clinical notes do not support there is an indication for total disability from November 16, 2013, forward. The documentation supports you have some limitations, but these are not supported with any physical therapy (PT) notes or significant exam findings. Therefore, no additional benefits are payable.

| ¿The plan states on page 15:

Totally Disabled (Total Disability) means, for the first 24 months of a disability that You are:
• Unable to perform the substantial and material duties of Your Regular Occupation;
• Not working in any other occupation; and
• Under the care of a Physician for Your disability.
After 24 months of Total Disability, Totally Disabled means that You are:
• Unable to perform the duties of Any Occupation or employment for which You are qualified by reason of education, training, or experience and which provides You with substantially the same earning capacity as Your former earning capacity prior to the start of Your Disability; and
• Under the care of a Physician for Your disability.
We will not require care of a Physician when it is no longer needed for the sound medical care of the condition causing Total Disability!.]

The letter then informed the plaintiff that he could obtain a copy of “any guideline, criteria or clinical rationale” relied upon by the company by sending a written request to “Humana Inc., Grievance and Appeal Department” at the same Lancaster, South Carolina post office box address previously given in the company’s correspondence with him,2

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Cite This Page — Counsel Stack

Bluebook (online)
215 So. 3d 897, 2017 WL 603997, 2017 La. App. LEXIS 221, Counsel Stack Legal Research, https://law.counselstack.com/opinion/swinea-v-humana-inc-lactapp-2017.