Waldrip v. CONNECTICUT NAT. LIFE INS. CO.

573 So. 2d 1172, 1991 WL 6521
CourtLouisiana Court of Appeal
DecidedJanuary 16, 1991
Docket90-CA-491
StatusPublished
Cited by1 cases

This text of 573 So. 2d 1172 (Waldrip v. CONNECTICUT NAT. LIFE INS. CO.) 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
Waldrip v. CONNECTICUT NAT. LIFE INS. CO., 573 So. 2d 1172, 1991 WL 6521 (La. Ct. App. 1991).

Opinion

573 So.2d 1172 (1991)

John B. WALDRIP
v.
CONNECTICUT NATIONAL LIFE INSURANCE COMPANY, Delta Health Network, Inc., Delta Care Group Trust, Trustees of Delta Care Group Trust.

No. 90-CA-491.

Court of Appeal of Louisiana, Fifth Circuit.

January 16, 1991.
Rehearing Denied February 19, 1991.

*1173 Charles K. Reasonover, Duris L. Holmes, Deutsch, Kerrigan & Stiles, New Orleans, for defendants/appellants.

Clement P. Donelon, Metairie, for plaintiff/appellee.

Before GAUDIN, GRISBAUM and WICKER, JJ.

WICKER, Judge.

Connecticut National Life Insurance Company; Delta Health Network, Inc.; and Delta Care Group Trust, the defendants in this suit to enforce payment of benefits under a medical insurance policy, appeal a judgment in favor of the plaintiff insured, John B. Waldrip. The judgment in question, one of several rendered in this proceeding, required these insurers to provide continuing coverage to Waldrip under a terminated policy for his liver ailment. It also awarded penalties and attorney's fees, awarded benefits for medical care unconnected with his liver disease which were incurred prior to the termination of his policy as well as penalties on these unpaid benefits, and awarded interest and costs. The judgment denied Waldrip's claim for a lump sum award representing future medical expenses. The judge deferred a determination of the amount of attorney's fees until a hearing could be held on this issue, and the judgment as a result of that hearing is pending on a separate appeal. We amend and, as amended, affirm.

This is the second appeal in this case. The previous judgment in Waldrip's favor awarded him the medical expenses incurred in connection with his liver transplant, approximately $160,000.00. We affirmed the judgment against CNL, but we remanded for a determination of whether or not Delta Care and Delta Health were "insurers." The facts of the case are outlined in that opinion, 566 So.2d 434 (La.App.1990). The judge has not yet made a ruling on the liability of Delta Care and Delta Health, so they remain parties to this instant appeal.

The issues are whether CNL, Delta Health, and Delta Care were unjust and unreasonable in denying coverage under their "experimental" care exclusion either before or after the policy was cancelled and whether they are liable for expenses incurred after cancellation of the policy for a disease which manifested itself prior to the cancellation.

*1174 CONTINUING COVERAGE

Waldrip had group health coverage through his law firm beginning January of 1987. That coverage was in effect when he developed terminal liver dysfunction which resulted in a successful liver transplant on March 3, 1988. On June 29, 1988, Delta Health cancelled the law firm's policy effective September 1, 1988, because the coverage was no longer profitable. It agreed to "pay all valid claims incurred" prior to the cancellation date. We have already held that all claims submitted prior to termination were covered so those amounts are no longer at issue.

The judge ruled that CNL, Delta Care, and Delta Health were liable to Waldrip for claims related to his liver ailment although they were incurred after cancellation of the policy.

La.R.S. 22:215A(1)(d) provides that modification, amendment, or cancellation shall be without prejudice to any claim for benefits accrued, or for expenses incurred for services rendered, prior to such modification, amendment, or cancellation. Benefits and expenses incurred shall be as defined and limited by the terms of the policy.

The policy defines expenses incurred: "We will deem an expense as incurred: 1) on the date the care or treatment, for which a charge is made, is received; or 2) on the date the supplies are obtained." The policy does not define "benefits accrued." The judge found that the phrases "benefits accrued" and "expenses incurred" had different meanings, and he proceeded to determine what "benefits accrued" meant with regard to the fact of this case. Citing Soniat v. Travelers Insurance Co., 538 So.2d 210 (La.1989), he ruled that "benefits accrued" means "services related to the condition of which the insurer was aware before it cancelled the policy." Soniat at 215. He concluded:

The amendments [to La.R.S. 22:215A(1)(d) ] allow the insurer to define "benefits accrued" and "expenses incurred." Here, the insurer defined only "expenses incurred." Also, the policy refers to itself as a "Comprehensive Medical Expense Benefit" policy. Because this phrase is ambiguous, this Court finds that "benefits accrued" under this policy refers to services related to plaintiff's liver ailment which arose during the policy term.

We hold that the judge's interpretation of the term "benefits accrued" as used in La.R.S. 22:215A(1)(d) is not erroneous as a matter of law and decline to reverse his ruling that CNL, Delta Health, and Delta Care are liable for continuing expenses for Waldrip's liver condition.

PENALTIES AND ATTORNEY'S FEES

When Waldrip was admitted to Ochsner Foundation Hospital for a liver transplant, both he and Ochsner tried to confirm coverage for this procedure. CNL advised Delta Health that liver transplantation was considered experimental and not covered by the policy. Delta Health did not advise Waldrip of the alleged non-coverage until months later.

La.R.S. 22:657A provides:

All claims arising under the terms of health and accident contracts issued in this state, except as provided in Subsection B, shall be paid not more than thirty days from the date upon which written notice and proof of claim, in the form required by the terms of the policy, are furnished to the insurer unless just and reasonable grounds, such as would put a reasonable and prudent business man on his guard, exist.... Failure to comply with the provisions of this Section shall subject the insurer to a penalty payable to the insured of double the amount of the health and accident benefits due under the terms of the policy or contract during the period of delay, together with attorney's fees to be determined by the court....

Subsection B deals with matters which are not germane.

The claims submitted by Waldrip were not paid timely because of CNL's interpretation of its policy provisions to exclude liability for liver transplants. That provision excludes coverage for *1175 Care, treatment, services or supplies not approved or accepted as essential to the treatment of injury or sickness by any of the following:

(1) the American Medical Association;
(2) the United States Surgeon General;
(3) the United States Department of Public Health; or
(4) the National Institutes of Health....

We previously upheld the judge's ruling that this provision was in violation of the entire contract statute, La.R.S. 22:628, and affirmed his decree that Waldrip's liver transplant was a covered expense.

While this appeal has been pending, however, CNL has filed an exception of no cause of action for the first time, contending that Waldrip's claims under La. R.S. 22:657 are preempted by 29 U.S.C. Sec. 1132 (ERISA). ERISA is a comprehensive federal system which regulates employee welfare benefit plans and preempts the application of some state law. Cramer v. Association Life Ins. Co., 569 So.2d 533 (La.1990); Soniat, supra.

This court may consider CNL's exception for the first time on appeal "if proof of the ground of the exception appears of record."

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Bluebook (online)
573 So. 2d 1172, 1991 WL 6521, Counsel Stack Legal Research, https://law.counselstack.com/opinion/waldrip-v-connecticut-nat-life-ins-co-lactapp-1991.