823 F.3d 344 (5th Cir. 2016), 15-50559, Crose v. Humana Ins. Co.

Docket Nº:15-50559
Citation:823 F.3d 344
Opinion Judge:JAMES E. GRAVES, JR., Circuit Judge:
Party Name:ELEANOR CROSE, Individually and as Permanent Guardian of Ronald Crose, Plaintiff - Appellant v. HUMANA INSURANCE COMPANY, Defendant - Appellee
Attorney:For ELEANOR CROSE, Individually and as Permanent Guardian of Ronald Crose, Plaintiff - Appellant: Elizabeth Rose von Kreisler, George Brothers Kincaid & Horton, L.L.P., Austin, TX. For HUMANA INSURANCE COMPANY, Defendant - Appellee: Carlos Ramon Soltero, Ellen Burkholder Cochran, Rachael Kelly Pa...
Judge Panel:Before HIGGINBOTHAM, PRADO, and GRAVES, Circuit Judges.
Case Date:May 23, 2016
Court:United States Courts of Appeals, Court of Appeals for the Fifth Circuit
SUMMARY

Plaintiff filed suit against Humana, alleging claims for breach of contract and unfair insurance practices. The district court granted summary judgment to Humana. Plaintiff submitted a claim with Humana to cover the cost of her husband's medical services after he overdosed on ecstasy. At issue is the application of an exclusion under the policy that excluded loss due to being intoxicated or under ... (see full summary)

 
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823 F.3d 344 (5th Cir. 2016)

ELEANOR CROSE, Individually and as Permanent Guardian of Ronald Crose, Plaintiff - Appellant

v.

HUMANA INSURANCE COMPANY, Defendant - Appellee

No. 15-50559

United States Court of Appeals, Fifth Circuit

May 23, 2016

Page 345

          Appeal from the United States District Court for the Western District of Texas.

         For ELEANOR CROSE, Individually and as Permanent Guardian of Ronald Crose, Plaintiff - Appellant: Elizabeth Rose von Kreisler, George Brothers Kincaid & Horton, L.L.P., Austin, TX.

         For HUMANA INSURANCE COMPANY, Defendant - Appellee: Carlos Ramon Soltero, Ellen Burkholder Cochran, Rachael Kelly Padgett, McGinnis, Lochridge & Kilgore, L.L.P., Austin, TX.

         Before HIGGINBOTHAM, PRADO, and GRAVES, Circuit Judges.

          OPINION

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          JAMES E. GRAVES, JR., Circuit Judge:

         Eleanor Crose appeals the district court's summary judgment for Humana Insurance Company on her claims for breach of contract and unfair insurance practices. Because summary judgment was warranted, we AFFIRM.

         FACTS AND PROCEDURAL BACKGROUND

         On June 23, 2013, while Eleanor Crose attended a concert, her husband Ronald Crose ingested ecstasy. Ms. Crose rejoined her husband at around midnight at a friend's home. When she arrived, Mr. Crose told her that he was nauseated and suffering from diarrhea; he also stated that he had experienced a terrible headache earlier in the evening that felt like " his head was going to explode." Later that night, Mr. and Ms. Crose went on a walk, after which Ms. Crose went to bed and Mr. Crose went to play music. The next morning, Ms. Crose found her husband lying down in the backyard, non-responsive with his face covered in vomit. Ms. Crose called for an ambulance and

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told the operator that she believed that Mr. Crose had overdosed. Emergency services transported him to a nearby hospital.

         The emergency room doctor who initially treated Mr. Crose, Dr. Bogitch, provided an assessment, stating: This is [a] gentleman who unfortunately, with very little past medical history, used [ecstasy] last night and was found down today with a large intraparenchymal hemorrhage with an unusual subarachnoid component as well as an entrapped ventricle and early uncal herniation.

         Dr. Bogitch also ordered a urine drug screen, which came back positive for amphetamines (ecstasy), benzodiazepines (a prescription tranquilizer), and cannabinoids (marijuana).

         Another physician, Dr. Hinze, examined Mr. Crose; his report stated: I suspect that [Mr. Crose's stroke] is due to uncontrolled hypertension likely from his ecstasy ingestion . . . . [Ecstasy ingestion] would account for his diaphoresis, nausea, vomiting, diarrhea and could produce a hypertensive state, which would exacerbate if not initiate his [stroke].

         Dr. Hinze's report also noted that Mr. Crose rarely drinks alcohol and has a history of smoking marijuana and taking ecstasy, but using ecstasy was an " unusual event."

         At all times relevant to this appeal, Mr. Crose had an individual health insurance policy with Humana. Mr. Crose submitted a claim with Humana under the policy to cover the cost of medical services and treatments provided to Mr. Crose as a result of his stroke. Humana denied the claim, citing the following exclusion in the policy: " Causation Exclusions . .. Loss due to being intoxicated or under the influence of any narcotic unless administered on the advice of a health care practitioner."

         Ms. Crose filed suit claiming breach of contract, unfair insurance practices, and prompt payment violations under the Texas Insurance Code. Humana filed a motion for summary judgment, which the district court granted. Ms. Crose now appeals.

         DISCUSSION

          " We review a district court's summary judgment de novo." Health Care Serv. Corp. v. Methodist Hosps. of Dallas, 814 F.3d 242, 247 (5th Cir. 2016). We review the facts in a " light most favorable to the non-moving party." Cannon v. Jacobs Field Servs. N. Am., Inc., 813 F.3d 586, 590 (5th Cir. 2016). Summary judgment is appropriate if the moving party shows " that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Cass v. City of Abilene, 814 F.3d 721, 728 (5th Cir. 2016) (citing Fed.R.Civ.P. 56(a)). " A genuine issue of material fact exists when the evidence is such that a reasonable jury could return a verdict for the non-moving party." Crownover v. Mid-Continent Cas. Co., 772 F.3d 197, 201 (5th Cir. 2014).

         I.

         The parties agree that Texas law governs this case. Under Texas law, the elements of a breach of contract claim are: " (1) the existence of a valid contract; (2) performance or tendered performance by the plaintiff; (3) breach of the contract by the defendant; and (4) damages to the plaintiff resulting from that breach." Hunn v. Dan Wilson Homes, Inc., 789 F.3d 573, 579 (5th Cir. 2015) (citing Foley v. Daniel, 346 S.W.3d 687, 690 (Tex.App.--El Paso 2009, no pet.)), cert. denied, 136 S.Ct. 592, 193 L.Ed.2d 470 (2015).

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Generally, " for an insurance company to be liable for a breach of its duty to satisfy a claim presented by its insured, the insured...

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