Taboada A. v. AmFirst Insurance Company

CourtDistrict Court, S.D. Mississippi
DecidedJuly 24, 2020
Docket3:18-cv-00883
StatusUnknown

This text of Taboada A. v. AmFirst Insurance Company (Taboada A. v. AmFirst Insurance Company) is published on Counsel Stack Legal Research, covering District Court, S.D. Mississippi primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Taboada A. v. AmFirst Insurance Company, (S.D. Miss. 2020).

Opinion

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF MISSISSIPPI NORTHERN DIVISION

JOSE EVENOR TABOADA A. PETITIONER

VS. CIVIL ACTION NO. 3:18-CV-883-TSL-RHW

AMFIRST INSURANCE COMPANY RESPONDENT

MEMORANDUM OPINION AND ORDER Before the court are the motion of petitioner Jose Evenor Taboada to vacate arbitrator’s award pursuant to § 10 of the Federal Arbitration Act (FAA), 9 U.S.C. § 10, and the motion of respondent AmFirst Insurance Company (AmFirst USA) to confirm arbitrator’s award pursuant to § 9.1 The court, having reviewed and considered the motions, concludes that the motion to vacate should be denied and the motion to confirm arbitrator’s award should be granted. Previous Litigation In December 2018, petitioner Taboada, pursuant to FAA § 4, filed in this court a complaint to compel arbitration against AmFirst USA under the terms of a policy of health insurance

1 The motion to confirm arbitrator’s award is presented as having been filed by “AmFirst Insurance Company (“AmFirst”) and AmFirst Insurance Company Ltd., as assignee and successor-in- interest to AmFirst (“AmFirst Bermuda”).” However, AmFirst Bermuda is not a party to this action. Nevertheless, for reasons made clear herein, AmFirst Bermuda is a necessary party to this action, and the court thus interprets the motion to confirm as including a request to join AmFirst Bermuda as a necessary party, which request is granted. originally issued by AmFirst USA to petitioner in May 2004 and allegedly renewed annually in each succeeding year, through 2018. Petitioner alleged that when his wife was diagnosed with liver cirrhosis in June 2017 and subsequently underwent a liver transplant in August 2017, AmFirst wrongly denied coverage, citing policy provisions excluding coverage for alcohol-related

illness and for organ transplants. Petitioner alleged that his AmFirst policy, as issued in 2004 and as modified from time to time, contained no such exclusions and, in fact, expressly provided coverage of up to $150,000 for organ transplants. Petitioner alleged that AmFirst USA had refused his demand for arbitration under the terms of his 2004 policy, taking the position that it was no longer his insurer as the policy it originally issued to him in 2004 had been assigned in 2005 to AmFirst, Ltd. (AmFirst Bermuda), an affiliated but separate company, and that AmFirst Bermuda, and not AmFirst USA, had issued each of petitioner’s subsequent policies, including the

2017 policy that excluded coverage for organ transplants and treatment for alcohol-related illness. AmFirst USA thus asserted that petitioner was demanding arbitration against the wrong party under the wrong policy. In answer to petitioner’s complaint herein, AmFirst USA maintained that same position. On March 8, 2019, petitioner filed a motion to compel arbitration. Therein, he insisted that the 2004 policy was the operative policy at all times, including when his wife underwent treatment in 2017, because there was no valid assignment of the 2004 original policy to AmFirst Bermuda or replacement of that 2004 policy with a new policy between him and AmFirst Bermuda with substantially different terms/exclusions than his 2004 policy. He argued that the purported assignment was invalid,

both because AmFirst USA did not comply with policy requirements for effectuating a valid assignment and because it failed to provide him with notice of the assignment; and he claimed that he was never given notice of any amendments to his coverage. By order entered August 6, 2019, the court granted petitioner’s motion to compel arbitration, finding that although AmFirst USA claimed the arbitration provision in the 2004 policy was no longer valid as the policy no longer existed, there was nevertheless “no dispute that in 2004, a contract was formed between these parties that contained an arbitration agreement which plaintiff now seeks to enforce.” Jose Evenor Taboada A.

v. AmFirst Ins. Co., No. 3:18CV883TSL-RHW, 2019 WL 3604613, at *4 (S.D. Miss. Aug. 6, 2019). Arbitrator’s Findings The case proceeded to arbitration. Following a final hearing, the arbitrator made the following findings and conclusions: Petitioner was issued a policy by Respondent in 2004. The policy provided coverage for organ (liver) transplants for at least $150,000.

Subsequent policies deleted this coverage and also excluded coverage for alcohol-related illnesses.

Each renewal policy with a schedule of benefits was delivered to petitioner’s agents, and hence was constructively delivered to petitioner himself.

Petitioner’s denial that he received and/or read these policies, and specifically the policy in effect in 2017, was not credible.

Since petitioner received the policies and had an opportunity to read them, whether he did so or not is irrelevant since under the law, he is presumed to know and understand their terms.

Petitioner’s wife became seriously ill in 2017 with liver failure, cirrhosis, requiring hospitalization.

Requests for verification/precertification for treatment by Georgetown Hospital and Johns Hopkins University Hospital were denied by Respondent on the basis that the policy in effect contained an exclusion for alcohol-related illness.

Petitioner’s wife underwent a liver transplant in August 2017 at a Miami, Florida hospital.

Petitioner never submitted a proof of claim for any of this treatment and no claim was ever denied under either the original 2004 policy or the 2017 policy in effect at the time of treatment.

Absent waiver, a proof of claim is a condition precedent to coverage under both the 2004 policy and 2017 policy.

There was no proof of any waiver. On the basis of these findings, the arbitrator denied petitioner’s claim for payment of medical expenses. Standard of Review The FAA reflects a strong policy favoring arbitration. See Hall St. Assocs., L.L.C. v. Mattel, Inc., 552 U.S. 576, 586-590, 128 S. Ct. 1396, 170 L. Ed. 2d 254 (2008). In light of this, “judicial review of an arbitration award is extraordinarily narrow” and “exceedingly deferential.” Cooper v. WestEnd

Capital Mgmt., L.L.C., 832 F.3d 534, 543–44 (5th Cir. 2016) (citations omitted); Pfeifle v. Chemoil Corp., 73 F. App'x 720, 723 (5th Cir. 2003) (judicial review of arbitration awards is “among the narrowest known to the law”). “Courts ... do not sit to hear claims of factual or legal error by an arbitrator as an appellate court does in reviewing decisions of lower courts.” United Paperworkers Int'l Union v. Misco, Inc., 484 U.S. 29, 38, 108 S. Ct. 364, 98 L. Ed. 2d 286 (1987). Rather, the FAA provides for “just the limited review needed to maintain arbitration's essential virtue of resolving disputes straightaway.” Hall St. Assocs., 552 U.S. at 588, 128 S. Ct.

1396. Thus, a party seeking vacatur of an arbitration award “must clear a high hurdle.” Stolt-Nielsen S.A. v. AnimalFeeds Int'l Corp., 559 U.S. 662, 671, 130 S. Ct. 1758, 1767, 176 L. Ed. 2d 605 (2010) (stating that “[i]t is not enough for [a party seeking vacatur] to show that the [arbitration] panel committed an error—or even a serious error.”); see also Antwine v. Prudential Bache Sec., Inc., 899 F.2d 410, 413 (5th Cir.

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Taboada A. v. AmFirst Insurance Company, Counsel Stack Legal Research, https://law.counselstack.com/opinion/taboada-a-v-amfirst-insurance-company-mssd-2020.