Treasure Valley Transit v. Philadelphia Indemnity Insurance

88 P.3d 744, 139 Idaho 925, 2004 Ida. LEXIS 43
CourtIdaho Supreme Court
DecidedMarch 25, 2004
DocketNo. 28854
StatusPublished
Cited by1 cases

This text of 88 P.3d 744 (Treasure Valley Transit v. Philadelphia Indemnity Insurance) is published on Counsel Stack Legal Research, covering Idaho Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Treasure Valley Transit v. Philadelphia Indemnity Insurance, 88 P.3d 744, 139 Idaho 925, 2004 Ida. LEXIS 43 (Idaho 2004).

Opinion

TROUT, Chief Justice.

This is a dispute involving insurance coverage and a tender of defense. Appellant Treasure Valley Transit (“TVT”) appeals the decision of the district judge granting summary judgment to Respondent Philadelphia Indemnity Insurance Company (“PIIC”). TVT brought suit seeking damages it alleges were due to PIIC’s refusal to defend TVT [927]*927when the Idaho Department of Health and Welfare (“the Department”) began an investigation into alleged fraud committed by TVT in its Medicaid billing practices. We affirm the district judge.

I.

FACTUAL AND PROCEDURAL BACKGROUND

TVT is a non-profit corporation providing rural public transportation to Canyon County, particularly for elderly, disabled, and economically disadvantaged persons. TVT receives approximately one-fourth of its monthly income by providing transportation to Medicaid recipients, which transportation is paid for by the Department.

In January 1999, TVT was notified that it was being investigated by the Medicaid Fraud Unit of the Department and by the FBI for suspicion of excess billing of Medicaid. Specifically, TVT was suspected of billing services not performed, billing Medicaid more for transportation services than TVT charged to the general public for the same services, and billing for more transportation than was actually provided. The Department informed TVT that the Department might seek recovery of over $400,000 from TVT for improper billing over the past three years. The Department subsequently also notified TVT that it was suspending payment of all current and subsequently submitted billings from TVT pending the completion of the investigation, but that TVT could appeal this suspension of payments by filing a petition of appeal to prevent the suspension from becoming final. TVT appealed the suspension.

TVT then contacted its insurer, PIIC, requesting that it defend TVT’s interests in the appeal according to its directors and officers protection insurance policy. PIIC declined to defend, asserting that the Department’s action did not constitute a “claim” as defined by the insurance policy. TVT made additional requests to PIIC for its defense and was denied each time. PIIC then retained coverage counsel to determine if TVT’s claims for defense were valid. After reviewing the case, the coverage counsel advised PIIC that it had no duty to defend TVT.

In July 2000, TVT and the Department settled the administrative action with the Department agreeing that TVT did not engage in any fraudulent activity. The Department also agreed not to seek recovery of any additional funds from TVT; however, the parties agreed that the Department could withhold payment on the remaining billings as part of the settlement. TVT then filed suit against PIIC, alleging breach of contract and breach of duty of good faith and fair dealing and seeking approximately $34,000 in attorney fees and costs as well as over $65,000 for what it alleges was a loss encompassed in the withheld billings.

PIIC filed a motion for summary judgment and the district judge granted the motion, finding that the Department’s action was not a “claim” and the forfeited billings were not a “loss” as defined by the insurance policy. TVT now appeals that decision.

II.

STANDARD OF REVIEW

This Court’s review of a district judge’s decision on a motion for summary judgment is the same as that required of the district judge when originally ruling on the motion. Summary judgment must be granted when “the pleadings, depositions, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law.” I.R.C.P. 56(e). On review, as when the motion is initially considered by the district judge, this Court liberally construes the record in the light most favorable to the party opposing the motion, drawing all reasonable inferences and conclusions in that party’s favor. However, if the evidence reveals no disputed issues of material fact, only a question of law remains, and this Court exercises free review.

Construction Management Systems, Inc. v. Assurance Co. of America, 135 Idaho 680, 682, 23 P.3d 142, 144 (2001) (citations omitted).

[928]*928III.

THE DEPARTMENT’S INVESTIGATION DID NOT CONSTITUTE A CLAIM AS DEFINED BY THE INSURANCE POLICY

The key issue in this case is whether the investigation by the Department, accompanied by the suspension of payments, constituted a claim against TVT as defined by the insurance policy issued by PIIC. The policy, an officers and director’s protection policy, contains three definitions of a claim pertaining to a lawsuit, an administrative action, and a claim of wrongdoing by an insured. The pertinent definition here relates to an administrative action and defines a claim as: “Any proceeding before an administrative agency once it has concluded its investigative phase (if applicable).” The district judge found that the investigation by the Department was still ongoing at the time TVT attempted to tender its defense to PIIC and as a result, there was no claim under the policy because the investigative phase had not yet concluded.

TVT argues this definition of a claim is ambiguous in that the parenthetical phrase “if applicable” permits more than one reasonable interpretation of the definition. Specifically, TVT asserts that the “if applicable” language implies it is not necessary for an administrative agency to conclude its investigation before a claim exists. The district judge disagreed with this argument, finding that this definition of a claim was not susceptible to conflicting interpretations and under the plain and ordinary use of the language, there was no claim against TVT within the meaning of the policy.

We have held that “[wjhere the provisions of an insurance contract are not against public policy, the contract provisions control.” Howard v. Oregon Mut. Ins. Co., 137 Idaho 214, 217, 46 P.3d 510, 513 (2002). The directors and officers protection insurance policy obtained by TVT from PIIC provides an unambiguous definition of the term “claim” as used within the policy. It plainly provides that in an administrative action there is no claim requiring the insurer to defend the insured until the administrative agency has concluded its investigative phase. The “if applicable” parenthetical merely indicates that if the administrative agency does not conduct an investigation prior to commencing proceedings against an insured, then the requirement that there be a conclusion to such an investigation is inapplicable. TVT’s assertions that there are multiple possible interpretations to this definition does not establish ambiguity. We have previously held that “ambiguity is not established merely because the parties present differing interpretations to the court.” Payette River Property Otvners Ass’n v. Board of Com’rs of Valley County, 132 Idaho 551, 556, 976 P.2d 477, 483 (1999). Where there is no ambiguity in the definition in the insurance policy here, we need only determine if the Department’s action qualified as a claim pursuant to the definition of the policy.

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Related

Tvt v. Piic
88 P.3d 744 (Idaho Supreme Court, 2004)

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Bluebook (online)
88 P.3d 744, 139 Idaho 925, 2004 Ida. LEXIS 43, Counsel Stack Legal Research, https://law.counselstack.com/opinion/treasure-valley-transit-v-philadelphia-indemnity-insurance-idaho-2004.