Ward v. Dixie National Life Insurance

257 F. App'x 620
CourtCourt of Appeals for the Fourth Circuit
DecidedOctober 5, 2007
Docket06-2022, 06-2054
StatusUnpublished
Cited by17 cases

This text of 257 F. App'x 620 (Ward v. Dixie National Life Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fourth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Ward v. Dixie National Life Insurance, 257 F. App'x 620 (4th Cir. 2007).

Opinion

ON REHEARING

PER CURIAM:

Plaintiff Martha Ward sued National Foundation Life Insurance Company (National) and Dixie National Life Insurance Company (Dixie), asserting that National refused to pay the full amount of benefits owed under supplemental cancer insurance policies that were issued by Dixie and later assigned to National. The district court certified a statewide (South Carolina) plaintiff class rather than the multistate class Ward sought to represent, and the court later granted summary judgment in favor of National on the breach of contract claims. Ward appealed and National cross-appealed. In a prior opinion, we concluded that although the district court properly limited the plaintiff class to South Carolina residents, the court improperly granted summary judgment on the breach of contract claims, and we remanded for further proceedings on those claims. We dismissed National’s cross-appeal without prejudice. See Ward v. Dixie Nat’l Life Ins. Co., — Fed.App. -, 2007 WL 2914954 (4th Cir.2007).

Ward filed a petition for rehearing, and National, supported by various amici, filed a petition for rehearing and rehearing en banc. We granted Ward’s petition for panel rehearing and denied National’s petition for rehearing, thus vacating our pri- or opinion. 2 See Fourth Circuit I.O.P. 40.2. Dispensing with further briefing and argument, we now vacate the district court’s decision granting summary judgment in favor of National, and we remand with instructions for the district court to instead enter judgment in favor of Ward on the breach of contract claims. In light of our remand, we conclude that it would be premature for us to consider the class certification issue. We therefore dismiss without prejudice National’s cross-appeal.

I.

In August 1990 Ward purchased a cancer treatment benefit policy from Dixie covering both herself and her husband. *623 Ward’s policy is a type of supplemental insurance under which direct payments are made to the policyholder when an insured patient undergoes covered cancer treatments. Benefits under this kind of policy are paid regardless of whether the patient has other insurance sufficient to cover all medical expenses. When the patient has other insurance covering cancer treatments, the policyholder is able to retain the money received as a result of the supplemental coverage.

Benefits under Ward’s policy vary as to the procedure performed. In some sections the policy provides clear caps as to the maximum benefit to be paid. For example, the policy provides a “Schedule of Operations” listing the maximum amount to be paid—ranging from $150 for skin excisions to $3000 for removal of an intracardiac tumor—for a variety of operations. In many other sections of the policy no dollar amounts are provided, and benefits are calculated in relation to the “actual charges” for the covered procedures. Section (F) of the policy, titled “X-ray Therapy, Radium Therapy, Radiation Therapy, and Chemotherapy Benefit,” provides an example of this language:

We will pay the actual charges for teleradiotherapy, using either natural or artificially propagated radiation, when used for the purpose of modification or destruction of tissue invaded by cancer. We will also pay the actual charges made for plaques or molds or the administration internally, interstitially, or intracavitarially of radium or radioisotopes in sealed sources for the purpose of modification or destruction of tissue invaded by cancer. We will also pay the actual charges for cancericidal chemical substances and the administration thereof for the purpose of the modification or destruction of tissue invaded by cancer.

J.A. 221. Although the phrase is used repeatedly throughout the policy, no definition for “actual charges” is provided.

Dixie assigned Ward’s policy to National in 1994. In 2001 Ward began filing claims under the policy after her husband, James Ward (James), was diagnosed with prostate cancer and started receiving treatment. Shortly thereafter, a dispute between Ward and National arose over how benefits paid in the amount of the “actual charges” are calculated.

For a number of years after the assignment, National appears to have calculated benefits in the same manner that Dixie had previously done. Specifically, when the benefit owed was based on the “actual charges,” Dixie paid the benefit based on the amounts billed to patients by then-medical providers. Dixie paid such amounts even though providers often have agreements with certain insurers to accept as payment-in-full an amount less than that reflected on the patient’s bill. In this case, for example, James’s primary health insurance is provided through a plan administered by Blue Cross and Blue Shield of South Carolina (BCBS). Regardless of the amounts billed to James, his medical providers have an agreement with BCBS that requires them to accept a discounted amount as payment-in-full for services rendered to BCBS insureds. This agreement prohibits providers from attempting to collect an amount in excess of the pre-negotiated, discounted fee from BCBS insureds such as James.

Toward the end of the year in 2001, National changed its benefit payment practice. When Ward submitted claims for James’s treatments in 2002, she was told that she would have to submit an explanation of benefits (EOB) statement. By viewing the EOB, National would be able to determine what the pre-negotiated discount rate was for James’s treatments *624 and calculate benefits in light of this reduced amount. Ward refused to provide National with the EOB statements because she contended that under the terms of her policy, the “actual charge” was reflected in the non-discounted bill that she received rather than in the EOB.

On March 7, 2003, after Ward was unable to resolve the dispute, she filed an action in the Court of Common Pleas for Richland County, South Carolina, against both Dixie and National. The defendants removed the action to federal court on October 10, 2003. On September 15, 2004, Ward moved to certify a plaintiff class consisting of

all persons insured under cancer policies from Defendant Dixie National Life Insurance Company where Dixie promised to pay to the insured the “actual charges” incurred for certain medical services, but instead paid not the actual charges but rather the (lesser) amount that the insured’s primary health insurer negotiated with the healthcare provider to pay for the medical procedure!)]

S.A. 7. On May 5, 2005, the district court certified a class of South Carolina residents. The court limited the class to South Carolina residents based on its understanding of South Carolina’s door-closing statute, S.C.Code Ann. § 15-5-150. Ward, with permission of the court, filed a third amended complaint on September 27, 2005, asserting claims for (1) breach of contract against both Dixie and National; (2) bad faith refusal to pay against National; and (3) breach of contract accompanied by a fraudulent Act against National. Ward later abandoned the bad faith claim. Cross-motions for summary judgment followed. In addition, National filed a motion, joined by Dixie, to decertify the statewide class.

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Bluebook (online)
257 F. App'x 620, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ward-v-dixie-national-life-insurance-ca4-2007.