Time Insurance v. Sams

692 F. Supp. 663, 1988 U.S. Dist. LEXIS 8247, 1988 WL 80430
CourtDistrict Court, N.D. Mississippi
DecidedJuly 20, 1988
DocketCiv. A. EC 87-137-D-D
StatusPublished
Cited by3 cases

This text of 692 F. Supp. 663 (Time Insurance v. Sams) is published on Counsel Stack Legal Research, covering District Court, N.D. Mississippi primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Time Insurance v. Sams, 692 F. Supp. 663, 1988 U.S. Dist. LEXIS 8247, 1988 WL 80430 (N.D. Miss. 1988).

Opinion

MEMORANDUM OPINION

DAVIDSON, District Judge.

This cause is presently before the court on the defendants’ motion to dismiss. Having reviewed the parties’ briefs and being otherwise fully advised in this matter, the court finds that the defendants’ motion should be sustained.

I.

FACTUAL BACKGROUND

This is a declaratory judgment action brought pursuant to the Declaratory Judgment Act, 28 U.S.C. §§ 2201 and 2202. The plaintiff, Time Insurance Company (“Time”), is an insurance company organized and existing under the laws of the State of Wisconsin, with its principal place of business located at Milwaukee, Wisconsin. Defendant James H. Sams, M.D. (“Sams”) is an adult resident citizen of Lowndes County, Mississippi. Defendant Columbus Anesthesia Affiliates, Inc. (“the Clinic”), is a corporation organized and existing under the laws of the State of Mississippi.

This action was commenced by Time, seeking a declaratory judgment and other relief from the court concerning the extent of its liability, if any, under a group insurance policy issued to Sams and the Clinic. Coverage under the policy was afforded both Sams and his dependents. Time seeks a judgment declaring: 1) whether or not Time is entitled to deduct any amount paid under a separate policy of insurance from the amount to be paid under the Time policy, or whether Time is precluded from doing so by Regulation No. 84-102, as promulgated by the Commissioner of Insurance of the State of Mississippi; and, 2) whether Sams’ coverage under the Time policy is voidable as a matter of public policy because public policy would not permit Sams to reap a profit as a result of overinsurance of medical expenses. Sams has answered with a counterclaim alleging bad faith delay by Time in the payment of *665 claims made under the policy of insurance Time issued to Sams.

Prior to June 20, 1986, the Clinic carried a health insurance plan for its employees and their dependents with Shelter Insurance Company (“the Shelter policies”). The Shelter policies were applied for individually and were issued on an individual basis to each of the employees of the Clinic. The Shelter policies provided comprehensive medical insurance which included basic medical benefits and major medical coverage. These policies provided for the reimbursement to the insureds of most, if not all, of the medical expenses incurred by the insured. The Shelter policies were not limited benefit policies nor “daily indemnity” type policies fixing a maximum amount to be paid for each day an insured is hospitalized. The Clinic paid the premiums on these Shelter policies.

Sometime in June 1986, the Clinic reviewed its medical insurance plan and determined that medical insurance benefits could be provided for its employees and their dependents at less expense to the Clinic if it took advantage of lower group insurance premiums as opposed to the higher rates of individual premiums. On June 20,1986, the Clinic applied to Time for coverage under a group insurance plan. The employees of the Clinic, including Sams and his wife, Lindsey 0. Sams, became insured under the Time group policy as of July 1, 1986.

The evidence before the court indicates that the Clinic apparently paid the premiums on the individual Shelter policies up through June 30, 1986. At that time, the Clinic apparently ceased paying the premiums on the Shelter policies and began to make payments on the Time group policy. The Shelter policies, however, provided for a grace period for the payment of premiums of at least 30 days after the premium due date. The premium due date for the individual Shelter policies was July 1, 1986. When the Clinic failed to pay the premiums on the individual policies on that date, having initiated coverage under the Time policy, the individual Shelter policies entered the 30-day grace period.

On July 23, 1986, Lindsey O. Sams was attacked and received severe injuries while vacationing in Florida. Sams allegedly telephoned the Clinic at that time and instructed an employee of the Clinic to pay the premium due on the individual Shelter policy which insured Sams and his wife. This employee of the Clinic apparently remitted the premium to Shelter within the grace period, thereby maintaining Sams’ individual policy in full force and effect. 1

The Time policy, like the Shelter individual policies, is a comprehensive medical insurance plan which is designed to reimburse the insured for most, if not all, of the insured’s medical expenses. Because both the Time policy and Sams’ individual Shelter policy were in force and effect at the time Lindsey O. Sams sustained her injuries, she was covered under both policies. Sams has submitted claims under both policies for his wife’s medical expenses. Sams asserts that he is entitled to collect the full amount of his wife’s medical expenses under both policies and that the insurance companies should not be permitted to coordinate benefits so that Sams will be reimbursed only once for these expenses.

Time asserts that Sams should not be permitted to collect amounts under both policies, the total of which would be approximately double the amount of medical expenses actually incurred by his wife. More than $250,000 in expenses were incurred in treating Mrs. Sams. If Sams is permitted to collect full benefits under both policies, Time argues that he will be unjustly and improperly enriched by at least $200,000 above and beyond the actual expenses incurred in the treatment of his *666 wife. 2

The defendants have filed a motion to dismiss the complaint, asserting that the plaintiff does not state a claim upon which relief may be granted. Insofar as matters outside the pleadings are presented with the motion, the court treats the motion as a motion for summary judgment in accordance with Rule 12(b) of the Federal Rules of Civil Procedure.

The following language from Time’s insurance contract with the Clinic is relevant to the court's ruling herein:

COORDINATION OF BENEFITS
Section B. Definitions
1. “Plan” means any plan providing benefits or services by reason of medical or dental care or treatment, which benefits or services are provided by (i) group or blanket insurance coverage, (ii) group Blue Cross, group Blue Shield, group practice, and other group prepayment coverage, (iii) any coverage under labor-management trusted plans, union welfare plans, employer organization plans, or employee benefit organization plans and (iv) auto no-fault coverage, if coordination of benefits with such coverage is allowed by law____
3. “Allowable Expense” means any necessary, reasonable and customary item of expense____
4. “Claim Determination Period” means a “calendar year.”
Section C. Effect on Benefits
1.

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Cite This Page — Counsel Stack

Bluebook (online)
692 F. Supp. 663, 1988 U.S. Dist. LEXIS 8247, 1988 WL 80430, Counsel Stack Legal Research, https://law.counselstack.com/opinion/time-insurance-v-sams-msnd-1988.