Shirley B. Suskind v. North American Life & Casualty Company, 607 F.2d 76, 3rd Cir. (1979)
Shirley B. Suskind v. North American Life & Casualty Company, 607 F.2d 76, 3rd Cir. (1979)
2d 76
Shirley B. SUSKIND
v.
NORTH AMERICAN LIFE & CASUALTY COMPANY,
Appellant.
No. 78-2591.
In April, 1973, Suskind first became aware that he had cancer of the pancreas.
Inquiry was made of at least eight insurance companies regarding the issuance
of an individual or group life insurance policy insuring Walter Suskind's life.
Although the record is unclear when the inquiries were made or whether
applications were actually made to all eight companies, it is undisputed that
between June, 1973 and July, 1973 at least three group policies were issued
covering some or all of the employees of Walter B. Suskind and Associates,
including in each instance Walter Suskind. None of these policies required
evidence of the medical condition of the individuals covered, and Suskind did
not inform the companies that he had cancer.
The application for the group policy involved in this appeal was enclosed in a
letter by Walter Suskind dated June 14, 1973,1 which requested a June 1
effective date. Because the carrier always used an effective date on the 15th of
a month, the policy when approved was issued by North American with an
effective date of June 15, 1973. Walter Suskind died of cancer on April 28,
1974, following periods of hospitalization and treatment.
Plaintiff filed suit against North American on January 27, 1976, for $50,000
plus an assessment of punitive damages and attorney's fees, claiming that
defendant willfully and without reasonable justification or excuse refused to
pay her benefits due under the policy. North American's Answer to the
Complaint, filed March 4, 1976, denied liability alleging the policy "is null,
void and of no effect" because of the misrepresentation of Suskind and others
as to the number of eligible employees actually at work and because "Walter B.
Suskind was not an eligible employee working on a full-time basis, having
contracted an inoperable metastatic carcinoma sometime before he made said
statements and misrepresentations."
On June 17, 1977, following discovery, defendant filed a motion for summary
judgment, contending that plaintiff should be barred from recovery under the
policy for two reasons: first, it argued that Walter Suskind was not an eligible
employee under the policy, because he was not in "active service"2 on the
effective date of the policy, since he was admittedly hospitalized on June 15,
1973, and that he did not thereafter become eligible because he did not
complete the waiting period of 21 consecutive working days required by the
policy.3 Second, North American argued that whether or not Suskind was an
eligible employee under the policy, his misstatements, omissions and
concealments concerning his health and his status at work breached various
duties that he owed to the defendant so that his coverage under the policy
should be declared void. Plaintiff resisted summary judgment by a different
construction of the policy and facts. Plaintiff conceded that Suskind was not in
"active service" on June 15, 1973 but argued that he returned to "active service"
on June 18, 1973, that no waiting period was required for Suskind because he
had been in "active service" "before the Policy Effective Date" (see note 3), and
that under the provision of the policy that "an individual's effective date is the
15th of the month, coinciding with, or next following the date of his eligibility
if in ACTIVE SERVICE on that date, or otherwise 'upon his return to ACTIVE
SERVICE',"4 he was covered by the policy as of July 15, 1973.
7
Plaintiff countered the alleged breach of duty by emphasizing that there was no
physical examination, medical questionnaire or evidence of insurability
required to be furnished by Suskind or any other group member as a
precondition to issuance of the policy and coverage in question.
On December 20, 1977 the court denied defendant's motion for summary
judgment because "the Court finds the facts in these cases might cause
reasonable men to draw inconsistent inferences and conclusions. Such
inferences should be drawn by the finder of facts after hearing the evidence
presented and not by the Court in disposing of a motion for summary
judgment."
Plaintiff then moved for summary judgment on the ground that defendant was
barred from raising the defenses asserted in its Answer because of the
incontestability provision in the policy. The applicable language of the North
American policy is:
10
INCONTESTABILITY:
The validity of the Policy will not be contested by the
Company after two years from the Effective Date except for non-payment of
premiums. No statement made by an Insured Person or Insured Dependent relating
to insurability will be used in contesting the validity of the Insurance with respect to
which the statement was made after the Insurance with respect to that individual has
been in force prior to contest for a period of two years during the individual's
lifetime nor will any such statement be used unless it is contained in a written
instrument signed by him.
11
12
The district court granted plaintiff's motion for summary judgment. The court
held that the incontestability clause barred the defendant's assertion of both the
ineligibility defense and the fraud defense. 458 F.Supp. 680.
13
To reach this result, the court read the first sentence of the incontestability
provision as applicable to both the group policy and the individual insurance
issued under it; both became incontestable when the period specified in that
sentence had expired. The court read the second sentence "as an exception
which allows an ongoing right to contest the individual insurance, when the
insured dies prior to the expiration of the contestability period and the contest is
based on written statements by the insured relating to his health or physical
condition." 458 F.Supp. at 685. The court classified the defense based on
eligibility as one contesting the "validity" of the decedent's insurance, and
therefore within the terms of the first, and not the second, sentence of the
incontestability provision. Since the term "contest" is generally interpreted to
mean some action taken in a judicial proceeding to cancel the policy or prevent
its enforcement, see Travelers Insurance Co. v. Caravasilis, 21 Del.Ch. 164,
182 A. 412 (1936), and North American's first such action took place when it
filed its Answer to the Complaint in this case more than two years after the
policy was issued, the court held that the defense based on eligibility was
barred by the incontestability provision.
14
Further, the court held that the defense based on fraud was likewise barred
because it did not fall within the exception provided by the second sentence
which is limited to statements relating to "insurability". Although defendant had
argued that Suskind's written statement on his enrollment card regarding his
"full-time" status or "eligibility" were statements relating to his "insurability",
thereby within the exception provided by the second sentence of the
incontestability provision, the Court concluded that such a construction would
contravene the intent of the Delaware legislature which elsewhere had
distinguished between the concepts of eligibility and insurability.6
15
16
I.
18
Central to the district court's disposition of this matter was its conclusion that
the first sentence of the provision ("The validity of the Policy will not be
contested by the Company after two years from the Effective Date except for
non-payment of premiums") encompasses both the group policy and the
individual insurance issued under it. If this were so, then the failure of the
company to contest within two years of its effective date, June 15, 1973 (its
first judicial action being the filing of an Answer denying liability on March 4,
1976), would have barred suit under the incontestability clause, assuming that
the defenses raised, ineligibility and fraud, fall within the concept of "validity
of the policy."
19
There are several reasons why we believe the first sentence of the
incontestability clause relates only to the group policy. First, the language of
the sentence itself refutes its application to the individual's insurance. Under
group insurance, the only "Policy" that is issued is the master policy covering
the group. The individual group member receives a Certificate of Insurance, not
a "Policy", and that certificate refers to the provisions and conditions set forth
in the master "Policy." 1 Appleman, Insurance Law and Practice 46, at 46-47
(1965). A certificate issued to an employee is part of the insurance contract
under a group policy. 19 Couch on Insurance 82.7 (2d ed. 1968). The
distinction is carefully observed throughout the language of the master policy
in issue which by its express terms provided the Certificate did not constitute a
part of the Policy:
20
CERTIFICATES:
The Company will issue to the Policyholder for delivery to each
Insured Person, an Individual Certificate summarizing the benefits for which the
Insured Person is insured by the Policy including any changes in the amount of
Insurance because of a change in classification and the rights to which such Insured
Person is entitled in case of termination of Insurance or termination of the Policy.
Such Certificate will not constitute a part of the Policy nor will it change, modify or
invalidate any of the terms and conditions of the Policy.
21
Second, the court's construction strains the language of the second sentence of
the incontestability provision. If the first sentence covers both the group policy
and the individual's insurance, the court was obliged to find some explanation
for the second sentence. This was done by reading it as an exception,
notwithstanding that the language does not read as an exception. A reading of
the provision more in keeping with its syntax and choice of language is that the
first sentence refers to the group policy and provides that two years after the
issue date, the validity of the policy can no longer be challenged; the second
sentence contributes incontestability for the individual insurance covered by
the Certificate and bars the company from contesting payment on the basis of
written statements made by the insured relating to his/her insurability after the
insurance has been in force for two years during the lifetime of the insured.
22
There is nothing in the legislative history upon which the court relied that
would conflict with this construction. The court noted that the Delaware
legislature revised the statute in accordance with language recommended by the
National Association of Insurance Commissioners (NAIC) for the purpose of
providing incontestability for individuals insured under group life insurance
after two years.7 Even if this is believed also to have been the Delaware
legislature's purpose, the construction we place on the statute is entirely
consistent with this legislative goal, since it interprets the second sentence as
one providing an incontestability provision on behalf of individuals insured
under the group policy.
23
The district court was concerned that the protection afforded would be too
limited for the individual because it relates only to statements as to
"insurability", equated by the court with the insured's health, which may not be
required in the group policy context. Even if the court's restrictive definition of
"insurability" is correct,8 there are instances in which individuals insured under
a group policy have been required to make statements regarding their medical
history, medical condition, and recent hospitalization. See, e. g., George
Washington Life Insurance Co. v. Adams, 514 S.W.2d 205 (Ky.1974); Wright
v. Minnesota Mutual Life Insurance Co., 271 S.C. 211, 246 S.E.2d 866 (1978);
General American Life Insurance Co. v. Wojciechowski, 314 Mich. 275, 22
N.W.2d 371 (1946); Continental Assur. Co. v. Henson, 297 Ky. 764, 181
S.W.2d 431 (1944). Moreover, the insurance policy in issue in this case
required submission of evidence of insurability for late applicants and persons
whose insurance had previously terminated, (see note 4 Supra ), further
demonstrating that the second sentence provides a measure of meaningful
protection.9
24
II.
25
Plaintiff argues that defendant failed to contest the policy within the time period
required by its "incontestability" provision, referring to the "overwhelming
weight of authority" defining contest to mean some affirmative or defensive
action taken in court to cancel the policy or prevent its enforcement. Although
plaintiff's proposition as to the meaning of "contest" has ample support, See, e.
g., Franklin Life Insurance Co. v. Bieniek, 312 F.2d 365, 368 (3rd Cir. 1962), it
can only operate to bar contests relating to the validity of the policy under the
first sentence of the incontestability clause at issue.
26
The language of the second sentence differs considerably from that in the
provisions involved in the cases cited by plaintiff. In this policy, the
incontestability period begins only "after the insurance with respect to the
individual has been in force prior to contest for a period of two years During the
individual's lifetime " (emphasis added). This use of the words "during the
individual's lifetime" is significant.
27
In Mutual Insurance Company v. Hurni Co., 263 U.S. 167, 44 S.Ct. 90, 68
L.Ed. 235 (1923), the Court held that the death of the insured within the twoyear period provided by the incontestability clause did not suspend the running
of the period of contestability. The incontestability clause in that case did not
have language tying the period to the "individual's lifetime."10 See also
Monahan v. Metropolitan Life Insurance Co., 283 Ill. 136, 119 N.E. 68 (1918).
In order to overturn this construction, the insurance companies prevailed upon
the state legislatures to amend the statutory language mandated for the
incontestability clause to permit insertion of the phrase making the policy
incontestable after being in force "during the lifetime of the insured" for a
specified period. See Villaronga, Supra at 34. This language was adopted by
the National Association of Insurance Commissioners, whose suggested
provision served as the model for the Delaware statute. As noted in Carpentieri
v. Metropolitan Life Insurance Co., 138 Pa.Super. 1, 7, 10 A.2d 37, 39 (1939) "
(O)ne of the objects sought to be attained by the insertion of the clause ("during
the lifetime of the insured") was the protection of the company from imposition
by persons who might procure insurance by concealing ill health of such a
serious nature as to cause death within a year."
28
The Fourth Circuit decision in Taylor serves once again as precedent. There,
the court also held: "It follows that the certificate was not incontestable since
Mr. Taylor did not live for two years after its date of issuance." 448 F.2d at
1378. Accord, Reliance Life Insurance Co. v. Everglades Discount Co., 204
F.2d 937, 942 (5th Cir. 1953); Greenbaum v. Columbian National Life
Insurance Co. of Boston, 62 F.2d 56, 58 (2d Cir. 1932); George Washington
Life Insurance Co. v. Adams, 514 S.W.2d 205, 206 (Ky.1972). Whether or not
the insurance ever became effective as to Suskind, a matter that the defendant
contests and upon which we express no view, his death in 1974 means that he
failed to satisfy the two-year requirement that is a precondition to operation of
the second sentence of the incontestability clause. Thus, the death of Walter
Suskind prior to the expiration of the period after the insurance allegedly
became effective as to him suspended the operation of the incontestability
clause as to his individual insurance coverage, and neither of the defenses
alleged is barred.
III.
29
The parties have briefed and argued the issue alluded to by the district court as
to whether the incontestability clause bars a contest to individual coverage
under a group policy based on the insured's ineligibility. In First Pennsylvania
Banking & Trust Co. v. United States Life Insurance Co., 421 F.2d 959 (3rd
Cir. 1969), this court held that Pennsylvania would follow the logic and
reasoning of the line of cases holding that the only defenses proscribed were
those going to the validity of the policy because of noncompliance with
conditions or the falsity of representations or warranties, and that the
incontestability clause could not be construed to enlarge the coverage of the
policy to compel an insurance company to insure lives it never intended to
cover. The clause interpreted in that case did not contain language comparable
to that in issue here which makes incontestable after two years' survival the
Defendant argues that there is no genuine issue of material fact and that the
district court erred in failing to grant it summary judgment. There is a threshold
question as to our jurisdiction to entertain defendant's claim, since ordinarily
the denial of summary judgment predicated on a determination that there are
genuine issues as to material facts which could be resolved only on a trial of the
action is interlocutory in nature and hence unappealable. Boeing Co. v.
International Union, 370 F.2d 969, 970 (3rd Cir. 1967). In Morgan Guaranty
Trust Company v. Martin, 466 F.2d 593, 599-600 (7th Cir. 1972) (per curiam),
the court suggested that Section 2106 of Title 28, U.S.C., gives the appellate
courts authority to direct the entry of summary judgment in an appropriate
case. 12 But see Hart v. Overseas National Airways, Inc., 541 F.2d 386, 394 n.
19 (3rd Cir. 1976). In Tabacalera Severiano Jorge S.A. v. Standard Cigar Co.,
392 F.2d 706, 716 (5th Cir.), Cert. denied, 393 U.S. 924, 89 S.Ct. 255, 21
L.Ed.2d 260 (1968), the court of appeals directed the entry of summary
judgment for the appellants because it was clear that there was no material
issue of any relevant fact under the law and the parties had ample time to
develop the factual issues. This is not such a case.
31
32
We, therefore, will reverse the entry of summary judgment and remand this
matter to the district court for further proceedings in accordance with this
opinion.
ACTIVE SERVICE;
(a) the date of completion of any applicable waiting period or if none, upon the
date of his eligibility if application is made on or before the date of eligibility,
or,
(b) the date of completion of any applicable waiting period or if none, upon the
date of written application if made within 120 days following date of eligibility
for units with 10 or more eligible Employees or; the date of completion of any
applicable waiting period or if none, upon the date of written application if
made within 31 days following date of eligibility for units with less than 10
eligible Employees, or,
(c) the date of approval of evidence of insurability by the Home Office of the
Company (such evidence to be furnished without expense to the Company) if
written application is made (1) more than 120 days after the date of eligibility
for units with 10 or more eligible Employees; or more than 31 days after the
date of eligibility for units with less than 10 eligible Employees, or (2)
following previous termination of insurance while the INSURED PERSON
remained eligible for insurance hereunder.
5
The court referred to the section of the Delaware Group Life Insurance Law
which requires inclusion of a provision in each group policy:
"setting forth the conditions, if any, under which the insurer reserves the right
to require a person Eligible for insurance to furnish evidence of individual
Insurability satisfactory to the insurer as a condition to part or all of his
coverage." (emphasis added by the district court). Del.Code Ann. tit. 18,
3115.
7
Delaware adopted the language proposed by the NAIC in 1946 for the revised
incontestability clause as part of a revision of its Insurance Code in 1968. 56
Del.Laws c. 380, 3113
Although eligibility for coverage under a group policy may not ordinarily be
dependent on the production of evidence of good health and past medical
history for those who come into the plan during designated enrollment periods,
late entrants and those seeking higher coverage than normally provided often
must make such a production. See Read, The Evolving Incontestability Clause
in Group Life Policies, 14 Association of Life Insurance Council Proceedings
797, 803 (1959)
10
The policy in Hurni stated: "This policy shall be incontestable, except for nonpayment of premiums, provided two years shall have elapsed from its date of
issue." 263 U.S. at 174, 44 S.Ct. at 90
11
With Crawford v. Equitable Life Assurance Society, 56 Ill.2d 41, 305 N.E.2d
144 (1973)
12