United American Insurance Company, a Delaware Insurance Corporation v. Richard D. Wibracht and Hilda A. Wibracht

825 F.2d 1196, 1987 U.S. App. LEXIS 10650
CourtCourt of Appeals for the Seventh Circuit
DecidedAugust 5, 1987
Docket86-3109
StatusPublished
Cited by4 cases

This text of 825 F.2d 1196 (United American Insurance Company, a Delaware Insurance Corporation v. Richard D. Wibracht and Hilda A. Wibracht) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United American Insurance Company, a Delaware Insurance Corporation v. Richard D. Wibracht and Hilda A. Wibracht, 825 F.2d 1196, 1987 U.S. App. LEXIS 10650 (7th Cir. 1987).

Opinion

REYNOLDS, Senior District Judge.

Plaintiff-appellee United American Insurance Company (“United American”) commenced this action in the Western District of Wisconsin against defendants-appellants Hilda A. Wibracht (“Mrs. Wibracht”) and her son Richard D. Wibracht. United American sought a declaratory judgment that Mrs. Wibracht was not entitled to hospital and nursing home benefits under the terms of a policy United American had written. The parties filed cross-motions for summary judgment, and the district court ruled that, under the facts presented, United American was obligated to pay hospital benefits, but that Mrs. Wibracht was not entitled to nursing home benefits. The district judge denied the Wibrachts’ motion to reconsider his decision denying nursing home benefits, and the Wibrachts have appealed from that decision. The decision of the district court will be affirmed.

RELEVANT FACTS

United American Insurance Company is a Delaware corporation with its principle place of business in Dallas, Texas. Hilda A. Wibracht, a registered nurse, is now confined in a skilled nursing home in St. Charles, Minnesota, as a result of injuries she suffered in an auto accident. Her son Richard is a citizen of Janesville, Wisconsin, and has power of attorney for the administration of his mother’s assets.

On March 20, 1974, Mrs. Wibracht, who was then 64 years old, applied to purchase a United American Medicare Supplement Policy. Pursuant to Wisconsin law, a brochure was attached to the application. The brochure’s cover page stated in large, boldfaced letters, that it was a “MEDICARE *1198 COUNTERPART POLICY” with “Hospital and Nursing Home Benefits That Automatically Increase as Corresponding Medicare Coverage Decreases.” The second page of the brochure included a paragraph which stated the nursing home coverage as follows: “All nursing home charges in excess of Medicare’s daily allowances for confinement in extended care facility from the 21st through the 100th day.”

The second page of the brochure also stated:

“POLICY DOES NOT COVER”
Loss caused by or resulting from alcoholism, narcotic addiction, nervous or mental disorders, dental treatment, rest cure, or any period of hospital or nursing home confinement that daily allowances are not paid under Medicare or loss covered by any Workmen’s Compensation or Employers’ Liability Laws.

United American issued Mrs. Wibracht a Medicare Supplement Policy on April 16, 1974, with a first-year annual premium of $116. The relevant language of that policy is as follows:

BENEFIT PERIOD means a period which begins ... with the first day a Family Member is confined in a hospital as a resident bed patient as a result of such injury or such sickness and ends at the close of 60 consecutive days on each of which the member was not confined in a hospital or nursing home.
Part 1 HOSPITAL EXPENSE BENEFITS
If a Family Member is necessarily confined as a resident bed patient in a hospital during a Benefit Period for which daily hospital benefits are paid under Medicare, the Company will pay the following items of expense actually incurred during such confinement:
1. The Initial Deductible for the Benefit Period.
2. Hospital charges ... in excess of the daily benefits paid under Medicare during the Benefit Period.
Part 3 NURSING HOME EXPENSE BENEFIT
If a Family Member is necessarily confined as a resident patient in a Nursing Home during a Benefit Period for which daily nursing home benefits are paid under Medicare, the Company will pay the portion of the daily expense incurred in excess of the daily benefit paid under Medicare.
Part 9 LIMITATIONS AND EXCLUSIONS
3.Hospital confinement as a resident bed patient or confinement in a Nursing Home for which daily benefits are not paid under Medicare during a Benefit Period are not covered under this policy....
ENTIRE CONTRACT; CHANGES
This policy, including endorsements and the attached papers, if any, and the application, a copy of which is attached hereto and made a part hereof, constitute the entire contract of insurance.

The front and back pages of the policy state that “THIS POLICY PROVIDES LIMITED SUPPLEMENTAL BENEFITS IN ADDITION TO MEDICARE.”

Mrs. Wibracht became a paraplegic as the result of an August 5, 1983, automobile accident, and she was hospitalized for an extended period. She is now necessarily confined at a skilled nursing home in Minnesota and has not been out of the hospital or a nursing home for a period of 60 days since the date of the accident. Medicare made payments of daily hospital or nursing home benefits from August through December of 1983, in March, July, and August of 1984, and in June of 1985. On or about June 10, 1985, Medicare stopped making daily nursing home benefits because Medicare determined that she no longer qualified for such benefits. United American, in turn, began to deny hospital or nursing home payments to Mrs. Wi-bracht on any days for which payment of hospital or nursing home benefits had not been made by Medicare.

RESOLUTION IN THE TRIAL COURT

This lawsuit followed the denial of payment. United American sought a court *1199 declaration that “there is no coverage under the policy for charges incurred for any days of nursing home or hospital confinement for which daily benefits are not paid under Medicare.” The district court decided the parties’ cross-motions for summary judgment by ruling that United American was obligated to pay hospital benefits “where daily benefits have first been paid by the federal Medicare program at any time during the benefit period;” but that United American was not obligated to pay supplemental benefits “for nursing home confinement unless daily benefits are first paid by the federal Medicare program for each day of such confinement.”

The Wibrachts moved for reconsideration as to the question of nursing home benefits on the ground that they had recently learned that Mrs. Wibracht was receiving “Part B” benefits under Medicare on a daily basis, including enteral nutrition fluid; that these benefits nearly equalled the amounts previously paid by Medicare as a daily benefit under “Part A” of Medicare; and that Mrs. Wibracht was therefore receiving Medicare benefits each day and was entitled to payment under the policy. “Part A” Medicare benefits refer to payments made for daily charges such as room, board, and care. “Part B” benefits cover such things as the costs of physician’s services, surgery, treatment, and other medical services and supplies.

The district judge denied the Wibrachts’ motion to reconsider, finding that the Wi-brachts had known that Mrs. Wibracht was receiving “Part B” benefits well before his first decision.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
825 F.2d 1196, 1987 U.S. App. LEXIS 10650, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-american-insurance-company-a-delaware-insurance-corporation-v-ca7-1987.