Coots v. United Employers Federation, 1:93CV79SNL.

• Decision Date: 04 October 1994
• Docket Number: No. 1:93CV79SNL.,1:93CV79SNL.
• Citation: 865 F. Supp. 596
• Parties: Irma J. COOTS, Plaintiff, v. UNITED EMPLOYERS FEDERATION and Durham Life Insurance Company, Defendants.
• Court: U.S. District Court — Eastern District of Missouri

865 F. Supp. 596

Irma J. COOTS, Plaintiff, v. UNITED EMPLOYERS FEDERATION and Durham Life Insurance Company, Defendants.

No. 1:93CV79SNL.

United States District Court, E.D. Missouri, Southeastern Division.

October 4, 1994.

Donald Rhodes, Bloomfield, MO, for plaintiff.

Mike W. Bartolacci, Thompson & Mitchell, St. Louis, MO, for defendants.

MEMORANDUM

LIMBAUGH, District Judge.

Plaintiff seeks medical benefits allegedly due pursuant to a group medical insurance policy provided by defendant United Employers Federation and issued by defendant Durham Life Insurance Co. This matter is before the Court on the defendants' motion for summary judgment (as regards the plaintiff's second amended complaint and the defendants' amended counterclaim for declaratory judgment) (# 22), filed August 15, 1994. This case is set for trial on the Court's trial docket of October 3, 1994.

Courts have repeatedly recognized that summary judgment is a harsh remedy that should be granted only when the moving party has established his right to judgment with such clarity as not to give rise to controversy. New England Mut. Life Ins. Co. v. Null, 554 F.2d 896, 901 (8th Cir.1977). Summary judgment motions, however, "can be a tool of great utility in removing factually insubstantial cases from crowded dockets, freeing courts' trial time for those that really do raise genuine issues of material fact." Mt. Pleasant v. Associated Elec. Coop. Inc., 838 F.2d 268, 273 (8th Cir.1988).

Pursuant to Fed.R.Civ.P. 56(c), a district court may grant a motion for summary judgment if all of the information before the court demonstrates that "there is no genuine issue as to material fact and the moving party is entitled to judgment as a matter of law." Poller v. Columbia Broadcasting System, Inc., 368 U.S. 464, 467, 82 S.Ct. 486, 488, 7 L.Ed.2d 458 (1962). The burden is on the moving party. Mt. Pleasant, 838 F.2d at 273. After the moving party discharges this burden, the nonmoving party must do more than show that there is some doubt as to the facts. Matsushita Elec. Industrial Co. v. Zenith Radio Corp., 475 U.S. 574, 586, 106 S.Ct. 1348, 1356, 89 L.Ed.2d 538 (1986). Instead, the nonmoving party bears the burden of setting forth specific facts showing that there is sufficient evidence in its favor to allow a jury to return a verdict for it. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249, 106 S.Ct. 2505, 2510-11, 91 L.Ed.2d 202 (1986); Celotex Corp. v. Catrett, 477 U.S. 317, 324, 106 S.Ct. 2548, 2553, 91 L.Ed.2d 265 (1986).

In passing on a motion for summary judgment, the court must review the facts in a light most favorable to the party opposing the motion and give that party the benefit of any inferences that logically can be drawn from those facts. Buller v. Buechler, 706 F.2d 844, 846 (8th Cir.1983). The court is required to resolve all conflicts of evidence in favor of the nonmoving party. Robert Johnson Grain Co. v. Chem. Interchange Co., 541 F.2d 207, 210 (8th Cir.1976). With these principles in mind, the Court turns to an examination of the facts.

Plaintiff's husband, Lan Coots, owns and operates a farm supplies business known as Lanco, Inc. The only employees of Lanco, Inc. (other than Lan Coots) were Mark and Michael Coots, the sons of the plaintiff and her husband.

The Coots were desirous of obtaining medical insurance for themselves and their families. In order to obtain group medical insurance, Lanco, Inc. applied for membership in the defendant United Employers Federation (UEF) as an employer. UEF administers a plan which offers a group medical insurance policy underwritten by defendant Durham Life Insurance Co. The Coots family, including the plaintiff, applied for and obtained medical insurance coverage.

Prior to obtaining insurance coverage, Mr. Coots (as the member employer) was required to fill out an application form on behalf of himself and the plaintiff. Affidavit of Nancy Patton. The application seeks a variety of medical information about the applicant(s). Defendants' Exhibit 2. It states in pertinent part:

10. To the best of your knowledge or belief, has any proposed covered person ever had sought or received advice for, or been treated for any of the following? (If yes, give details below) (Circle Condition).

a. Thyroid disorder, diabetes, albumin, sugar in urine, kidney, or urinary tract disorder?

b. Allergies, asthma, tuberculosis, disorder of the eyes, ears, nose, throat, or respiratory system?

c. Heart disease, chest pain, heart murmur, rheumatic fever, stroke, high blood pressure, anemia or disorder of the blood?

d. Arthritis, gout, rheumatism or disorder of the back, spine, bones, muscles, or joints?

e. Liver, stomach, intestine, or rectal disorder?

f. Cyst, tumor, cancer, or growth of any kind?

g. Any disorder of the reproductive organs or breasts?

h. Mental or nervous disorder, drug addiction, or alcoholism, or arrested for driving under the influence of drugs or alcohol?

11. Are you (or any eligible dependent) taking, or has any physician or other practitioner recommended that you take medication of any kind?

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15. Has any proposed covered person been sick, injured, received treatment, had medical tests, taken medication, consulted a doctor, or other practitioner, or been hospitalized within the past five years for any condition not already listed?

16. Is there any reason to believe that any proposed covered person is not in good health, mentally or physically, and free from any impairment, deformity, or infirmity?

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Mr. Coots, on behalf of himself and the plaintiff, answered No to all of the above-cited questions, except to Question 10(a) wherein Mr. Coots noted that he had been treated recently for kidney stones. Defendants' Exhibit 2.

At the beginning of the questionaire/application, it states: "Please complete ALL of the following questions. Failure to divulge complete facts will result in ALL COVERAGE BEING CANCELLED AS OF THE ORIGINAL ISSUE DATE." At the end of the questionaire/application, it states:

"This is to certify that I have received the summary of benefits, Form No. G3465, and I understand the benefits and exceptions, including pre-existing general limitations and coordination of benefits. The statements and answers in this application are complete and true to the best of my knowledge and belief, and I understand that the answers to the above questions shall be the basis of any coverage issued; and that any incorrect answers may operate to void this insurance. I UNDERSTAND THAT NO INSURANCE WILL BE IN FORCE UNTIL APPROVED BY THE INSURANCE COMPANY."

Both the plaintiff and her husband signed the insurance application form, dated October 2, 1991. Defendants' Exhibit 2.

On December 27, 1991 UEF Vice-President Amy Pryor wrote to the plaintiff's husband requesting that he review the insurance application form for accuracy. In her letter she states:

"Since our actions are based upon the information submitted on the application we ask that you check your answers to the questions carefully to assure that all health questions have been answered accurately and completely ... Incorrect, omitted, or incomplete information that materially effects underwriting may cause a claim to be denied and/or coverage to be voided."

Defendants' Exhibit 3.

On June 23, 1992, plaintiff was taken to the emergency room at Doctors Regional Medical Center in Poplar Bluff, Missouri suffering from acute gastrointestinal bleeding and hypovolence shock. Following efforts to stabilize her, she was admitted to the hospital. Defendants' Exhibit 4. According to the consultation report of Dr. Mark Bauman, dated June 23, 1992, plaintiff's family had informed him that the plaintiff "has had some bleeding episodes and ulcers in the past.". Furthermore, "she'd been treated with Tagamet in the past with good result but hasn't been taking it recently." As to her medication, Dr. Bauman was informed that "she takes a lot of Tums, takes a cholesterol pill but she doesn't know what it is, takes a lot of Tylenol # 3, and some sort of sleeping pill." Finally, Dr. Bauman relates that the plaintiff's son "counseled me in private that she probably does a fair amount of mind bending drugs but doesn't know what they are." Defendants' Exhibit 4.

As to her medical treatment history, Dr. Bauman's consultation report states that "in terms of surgical procedures, she is status post appendectomy, total abdominal hysterectomy, ovaries are intact. She had a bladder tack × 2, breast biopsy because of fibrocystic disease ... she had a hemorrhoidectomy. She has chronic ongoing reflux with problems related to that." Defendants' Exhibit 4.

In his discharge summary report, dated June 26, 1992, Dr. Bauman states (in the section of the report entitled HISTORY OF PRESENT ILLNESS) that "past medical history has been pertinent for a history of peptic ulcer disease with episodes of previous bleeding and ulcers in the past." He further states that "she is status post hysterectomy and has had previous bleeds as noted. He notes that at the time of admission, she "apparently had not been taking any medicine"; however, with regard to the laboratory results, he notes that "she apparently had been taking Percocet which contains Phenobarbital and because of concern about that, she was put on a tapering dose of Phenobarbital." Defendants' Exhibit 6. Finally, in the section of his report entitled HOSPITAL COURSE, Dr. Bauman states that "she (referring to the plaintiff) has been treated with Tagamet in the past but hadn't been taking it prior to admission." He further notes that "she was scoped the morning following admission and was found to have a large peptic ulcer that was covered with clot." In his concluding remarks, he states that he wanted to keep her hospitalized longer but that the plaintiff and her family insisted that she be released. Her post-hospitalization follow-up care was to include a return visit to Dr. Bauman for blood...