Fraker v. Sentry Life Ins. Co

In Fraker v. Sentry Life Ins. Co. (1993) 19 Cal. App. 4th 276, the plaintiff, an independent building contractor, obtained group health insurance in 1978. (Id. at p. 279.) In 1983, while the Plan was in force, the plaintiff injured and subsequently lost his right eye. (Id. at p. 280.) At the time the injury occurred, the Plan provided for a "maximum" or "aggregate" benefit of $ 1 million. (Id. at p. 283.) For five years, the plaintiff received insurance benefits totaling nearly $ 50,000 for his medical expenses related to the eye injury. (Id. at p. 280.) In 1988, the underwriter, Sentry, gave notice that it would not be renewing the group plan and gave plaintiff the option of converting to an individual plan. (Ibid.) The plaintiff declined to exercise this option. The group plan was terminated. The plaintiff then sued Sentry, alleging among other things that his right to reimbursement for medical expenses under the plan was effective throughout his lifetime up to the maximum liability of $ 1 million. (Id. at p. 280.) Fraker defined the question as "whether upon modification or termination of a health insurance policy the insurer may still be held liable for the insured's medical expenses for a particular illness or condition which was covered under the former policy." (Fraker, supra, 19 Cal. App. 4th at p. 281.) Fraker observed: "Other states' treatment of this issue of vesting of medical insurance coverage has depended principally on the precise wording of the policy in question rather than the particular manner in which the insurance coverage was eliminated. 'Thus, the insurer's liability for all expenses relating to a particular illness or condition has been held to have become fixed upon the inception of the illness or disease, where the policy in question provided benefits for an illness contracted during the life of the contract. . . . But where the policy provided insurance against the insured's incurring expenses or charges as a result of a disease or condition having its inception during the policy term, the termination of the policy has been held to mark the end of the insurer's liability thereunder.' " (Fraker, supra, 19 Cal. App. 4th at p. 281.) Fraker said: "We look first at what event was insured according to the language of the instant policy. If the relevant event was the inception of a disease or condition by appellant during the life of the policy, this may give rise to respondent's posttermination liability. If appellant's incurrence of medical expenses during the policy period was the relevant event, then this creates only pretermination liability for respondent. " (Fraker, supra, 19 Cal. App. 4th at p. 282.) Fraker stated there was no language in the policy or certificate of insurance specifying or suggesting that it was the occurrence of a specific injury or illness that was the insured event. (Fraker, supra, 19 Cal. App. 4th at p. 282.) "To the contrary, the documents unambiguously stated that the insured was entitled to medical benefits for covered charges incurred during the life of the policy, that benefits were payable for covered charges only during the term of the policy, and that no benefits were payable for covered charges incurred after termination of insurance coverage. . . ." (Ibid.) "Also pertinent to the issue of vesting is the presence of certain provisions in health insurance policies. For example, if the subject Plan expressly provides for termination of coverage, for no posttermination coverage, or for posttermination benefits under strictly limited conditions, no vesting of benefits has been found. (Sonneman v. Blue Cross, Etc., of Minn. (Minn.Ct.App. 1987) 403 N.W.2d 701; Tabb v. Louisiana Health Services & Indem. Co. (La.Ct.App. 1977) 352 So.2d 771.)" (Fraker, supra, 19 Cal. App. 4th at p. 282.) In Fraker, the plaintiff sought to rely on a sales brochure which specified the maximum was " 'payable for the lifetime of the insured.' " (Fraker, supra, 19 Cal. App. 4th at p. 283.) In addition to finding the reliance misplaced because of the brochure's disclaimer that it was for information only and not a substitute for the Plan, Fraker stated: "Also, the aforementioned 'lifetime' statement was qualified by the brochure itself which stated, 'provided the insured remains insured in the plan.' This language is reasonably interpreted as meaning that 'lifetime' benefits were provided only while there was insurance coverage." (Id. at pp. 283-284.)