Saturday, September 18, 2010

Northern California Judge grants judgment for diabetic woman against Mega Life & Health

On Wednesday Judge Chrales Breyer granted summary judgment for a woman's claim against her insurance company requiring the latter to pay for a "stump protector," a prosthetic lower leg, and a wheelchair.

The court has an excellent explanation of the case:
Plaintiff Rochelle Doble is diabetic, and as a result of her disease developed an infection in her foot that ultimately required amputation. Thereafter she was prescribed a “stump protector,” a prosthetic lower leg, and a wheelchair. She argues that defendant Mega [Life & Health Insurance Co.] was obligated to pay for those three items under the terms of her insurance contract. Mega disagrees.
According to court documents, Mrs. Doble claims Mega breached a medical insurance contract, in addition to tortious breach of the implied covenant of good faith and fair dealing, and violation of California Business and Professions Code § 17200. The debate centers around the diabetes treatment benefit in the insurance contract between the parties.  Mrs. Doble argues that it is ambiguous and should be read in her favor.  Mega counters that it is a provision mandated by statute and should be read strictly in view of its legislative history.

The policy covers, "the fees charged for equipment and supplies for the treatment and management of insulin using diabetes [] including [] podiatric devices to prevent or treat diabetes-related complications." (my emphasis).  The court noted that a legal fork in the road existed.  Under MacKinnon v. Truck Ins. Exchange (Cal. 2003), "insurance coverage is interpreted broadly so as to afford the greatest possible protection to the insured, whereas exclusionary clauses are interpreted narrowly against the insurer."  While National Auto. & Cas. Ins. Co. v. Underwood stated, "where the insurance policy language used is that of the Legislature, the language must be construed to implement the intent of the Legislature and should not be construed strictly against the insurer."  So the issue of contract language is dispositive of the issue presented in the cross-motions for summary judgment.

Judge Breyer noted that it was a close case but in order to have the policy construed as a statute the insurance company must "parrot" the statute exactly. Here it did not, using the word "including" as noted above, where the statute does not use that word.  That expands the reach of the policy into the MacKinnon realm which includes items that the insured could have reasonably foreseen needing.  Since diabetes can lead to loss of limbs it is reasonable to have "equipment and supplies" include a prosthetic, stump protectors and a wheelchair.

The Court granted partial summary judgment for the plaintiff.  The Case is Doble v. Mega Life & Health Ins. Co. No. C. 09-1611 and the opinion is below the jump.

Doble v. Mega Life Health

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