Wasserman v. Life General Security Insurance Co.

656 So. 2d 762, 94 La.App. 5 Cir. 588, 1995 La. App. LEXIS 1465, 1995 WL 320602
CourtLouisiana Court of Appeal
DecidedMay 30, 1995
DocketNo. 94-CA-588
StatusPublished

This text of 656 So. 2d 762 (Wasserman v. Life General Security Insurance 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
Wasserman v. Life General Security Insurance Co., 656 So. 2d 762, 94 La.App. 5 Cir. 588, 1995 La. App. LEXIS 1465, 1995 WL 320602 (La. Ct. App. 1995).

Opinions

| iBOWES, Judge.

This appeal is taken from a motion granting summary judgment in favor of the defendant, Life General Security Insurance Company (“LGS”). For the following reasons we annul and set aside the judgment and remand for further proceedings.

FACTS AND PROCEDURAL HISTORY

William “Billy” Graham (“Graham”) Benefit Services of Louisiana Inc. (“Benefit”) are agents/brokers for various insurance companies. For purposes of this action, Graham has stipulated that he and Benefit are one and the same. Graham (Benefit) were requested to assist C & W in ^purchasing health insurance in 1988; at that time, Graham helped C & W to obtain coverage under the Western Pacific Employers Trust. Their rates rose, prompting C & W to find another carrier. On behalf of C & W, Graham sought another health insurer. In November 1989, Graham became a licensed agent of Life General Security (LGS). Subsequently, Graham was notified by LGS that it had accepted the health insurance application submitted by C & W, and would issue a health insurance policy for their employees effective January 1, 1990. Diana Wasser-man, an employee/owner of C & W, was a potential insured, and her husband Martin Wasserman (also one of the owners of the company) would also be covered through the policy.

LGS received signed enrollment cards from C & W employees, but the evidence of insurability questionnaire and portions of the cards, involving information concerning preexisting medical conditions, were blank. Eventually, the forms were completed and returned to LGS.

The only form relevant to this appeal is the form concerning Diana Wasserman, the secretary for C & W, who requested coverage for herself and her husband, Martin.

The LGS underwriting division reviewed the enrollment cards and evidence of insura-bility forms which it received and, on January 19,1990, wrote to Graham that the group had been approved for coverage under | ijgroup policy #409129 effective January 1, 1990. The letter reiterated “Evidence of In-surability will be required always.”

On January 23, 1990, LGS mailed to Graham individual certificates for coverage for distribution to C & W employees, as well as administrative information.

On February 7, 1990, Martin Wasserman was admitted to East Jefferson General Hospital as an Emergency Room patient, and was subsequently hospitalized and treated for an ischemic coronary heart disease. By[764]*764pass surgery was performed on February 12, 1990.

In March and April 1990, LGS received claims for medical benefits relative to cardiac bypass surgery performed on Martin Was-serman in February 1990. Because these claims were submitted within the contestable period of the policy, LGS began an investigation into his medical history.

Based on its investigation, on August 31, 1990, LGS wrote to Mrs. Wasserman and informed her that it was rescinding coverage on her and her dependent effective January 1, 1990. LGS had discovered that Mr. Was-serman had been diagnosed with severe hypertension and had incurred medical expenses in excess of $5,000.00 within 24 months of the application date. These facts, had they been known to LGS, would have precluded coverage under the policy and the policy would never have been issued to Mr. Wasserman. LGS refunded all premiums that C & W had paid on the Wasserman’s behalf. Mrs. Wasserman was advised that, with | ¿respect to the evidence of insurability forms, certain material facts were omitted and that, had LGS known those facts at the time it requested the statement, it would not have issued coverage on her husband.

The Wassermans sued LGS for benefits due under the group insurance policy. In their petition, they brought claims against Benefit Services of Louisiana, Inc., Billy Graham, and LGS. It was alleged that Graham had submitted false information on the evidence of insurability forms, without the Was-serman’s knowledge, causing LGS to deny the claim for Mr. Wasserman’s bypass surgery. The Wassermans further alleged LGS was bound by the actions of its purported agent, Graham, to pay the benefits claimed.

LGS filed a cross-claim against Graham alleging he did not comply with their requests to obtain information necessary to process applications of C & W employees for coverage under the policy and that Graham failed to provide full and complete information to LGS about the health of plaintiffs in order that LGS could determine whether they were eligible for coverage under the policy.

Prior to trial, a settlement was reached between the Wassermans and LGS. According to the terms of the settlement agreement, LGS reimbursed the Wassermans for their out-of-pocket expenses and paid what was owed to the healthcare provider. LGS paid out a total of $67,715.00. In connection | gwith the settlement, the Wassermans assigned any rights, claims and causes of action which they might have against Graham to LGS.

LGS moved for summary judgment on its cross-claim in order to recover the losses it incurred in settling the matter. Following a hearing, the trial court granted summary judgment in favor of LGS and against Graham on the cross-claim, in the full amount paid by LGS to the Wassermans, $67,715.12. Graham appeals.

Graham avers on appeal that the trial court erred in determining there were no genuine issues of material fact and that the mover was entitled to judgment as a matter of law.

ANALYSIS

Our Supreme Court has recently summed up the applicable jurisprudence with regard to summary judgments in Smith v. Our Lady of the Lake Hosp., Inc., 93-2512 (La. 7/5/94), 639 So.2d 730, as follows:

Summary judgments are reviewed on appeal de novo. An appellate court thus asks the same questions as does the trial court in determining whether summary judgment is appropriate: whether there is any genuine issue of material fact, and whether the mover-appellant is entitled to judgment as a matter of law. ‘Stated conversely, [summary judgment] should be denied if there is (1) a genuine issue of fact and (2) it is material to the case.’
A ‘genuine issue’ is a ‘triable issue.’ More precisely, ‘[a]n issue is genuine if reasonable persons could disagree. If on the state of the evidence, reasonable persons could reach only one conclusion, there is no need for a trial on that issue. Summary | {judgment is the means for disposing of such meretricious disputes.’ In determining whether an issue is ‘genuine,’ courts cannot consider the merits, make [765]*765credibility determinations, evaluate testimony or weigh evidence. ‘Formal allegations without substance should be closely scrutinized to determine if they truly do reveal genuine issues of fact.’
A fact is ‘material’ when its existence or nonexistence may be essential to plaintiffs cause of action under the applicable theory of recovery. ‘[F]acts are material if they potentially insure or preclude recovery, affect a litigant’s ultimate success, or determine the outcome of the legal dispute.’ Simply put, a ‘material’ fact is one that would matter on the trial on the merits. Any doubt as to a dispute regarding a material issue of fact must be resolved against granting the motion and in favor of a trial on the merits.
Because the summary judgment device deprives a party of a trial on the merits, Louisiana courts ‘cautiously and sparingly1 employ it.

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427 So. 2d 470 (Louisiana Court of Appeal, 1983)
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550 So. 2d 577 (Supreme Court of Louisiana, 1989)
Richard v. AM. FEDERATION OF UNIONS, ETC.
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Smith v. Our Lady of the Lake Hospital, Inc.
639 So. 2d 730 (Supreme Court of Louisiana, 1994)

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Bluebook (online)
656 So. 2d 762, 94 La.App. 5 Cir. 588, 1995 La. App. LEXIS 1465, 1995 WL 320602, Counsel Stack Legal Research, https://law.counselstack.com/opinion/wasserman-v-life-general-security-insurance-co-lactapp-1995.