Horvath v. Globe Life & Accident Ins. Co.

• Decision Date: 26 August 2019
• Docket Number: Case No. 3:18-cv-84
• Parties: TAMMY HORVATH, Plaintiff, v. GLOBE LIFE AND ACCIDENT INSURANCE COMPANY, Defendant.
• Court: U.S. District Court — Western District of Pennsylvania

TAMMY HORVATH, Plaintiff, v. GLOBE LIFE AND ACCIDENT INSURANCE COMPANY, Defendant.

Case No. 3:18-cv-84

UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA

August 26, 2019

JUDGE KIM R. GIBSON

MEMORANDUM OPINION

I. Introduction

Before the Court is Defendant Globe Life and Accident Insurance Company's ("Defendant") Motion for Partial Summary Judgment (ECF No. 20). The Motion is fully briefed (ECF Nos. 21, 22, 23, 24, 25, 26, 35, 36, 40, 41) and is ripe for disposition. For the reasons that follow, Defendant's Motion is GRANTED IN PART and DENIED IN PART.

II. Subject-Matter Jurisdiction & Venue

The Court has diversity jurisdiction over this case pursuant to 28 U.S.C. § 1332(a)(1) because Plaintiff Tammy Horvath ("Plaintiff") is a citizen of a different state than Defendant and the amount in controversy exceeds $75,000. (ECF No. 1 ¶¶ 1-3.)

Venue is proper in the Western District of Pennsylvania under 28 U.S.C. § 1391(b)(2), as a substantial portion of the events and omissions giving rise to Plaintiff's claims occurred in this District.

III. Background

A. Factual History¹

1. The Applications and Policies

On January 26, 2016, Plaintiff applied for a life-insurance policy for her son, Luke Yuzwa, in the amount of $30,000. (ECF No. 22 ¶ 1; ECF No. 23 ¶ 1.) The application asked the following question about Mr. Yuzwa's health ("Question 4(a)"):

(a)Within the past 3 years, have any of the Proposed Insured(s) had any chronic illness or condition which requires periodic medical care?

(ECF No. 22 ¶ 2; ECF No. 23 ¶ 2; ECF No. 23-2 ¶ 1; ECF No. 25 ¶ 1.)² The application did not define the terms "chronic illness" or "condition," nor did it provide a list of medical conditions which would qualify as either a "chronic illness" or "condition." (ECF No. 23-2 ¶¶ 2, 4; ECF No. 25 ¶¶ 2, 4.) The application also did not define "periodic medical care" or otherwise indicate what length or frequency of visits qualifies as "periodic medical care." (ECF No. 23-2 ¶¶ 3, 5; ECF No. 25 ¶¶ 3, 5.) The application failed to ask any specific questions regarding the use of alcohol, marijuana, or other drugs, or about dependency on or addiction to alcohol or drugs. (ECF No. 23-2 ¶¶ 35-36; ECF No. 25 ¶¶ 35-36.)

Plaintiff answered Question 4(a) in the negative. (ECF No. 22 ¶ 3; ECF No. 23 ¶ 3.) Defendant approved the application and issued Policy 008F85062. (ECF No. 22 ¶ 4; ECF No. 23¶ 4.)

On February 22, 2016, Plaintiff applied for a second life-insurance policy for Mr. Yuzwa in the amount of $25,000. (ECF No. 22 ¶ 7; ECF No. 23 ¶ 7.) The application again asked Question 4(a) about Mr. Yuzwa's health. (ECF No. 22 ¶ 8; ECF No. 23 ¶ 8; ECF No. 23-2 ¶ 1; ECF No. 25 ¶ 1.) The application did not define the terms used in Question 4(a). (ECF No. 23-2 ¶¶ 2-3, 6-7; ECF No. 25 ¶¶ 2-3, 6-7.)

Plaintiff answered Question 4(a) in the negative. (ECF No. 22 ¶ 9; ECF No. 23 ¶ 9.) Defendant approved the application and issued Policy 008G98329. (ECF No. 22 ¶ 11; ECF No. 23 ¶ 11.)

On April 12, 2016, Plaintiff completed online applications seeking to increase coverage on Policy 008F85062 and Policy 008G8329 (the "Policies") by $5,000 each, and, in doing so, certified that Mr. Yuzwa was in good health. (ECF No. 22 ¶¶ 5, 13; ECF No. 23 ¶¶ 5, 13.) Defendant approved the applications and issued a $5,000 Term Life Insurance Rider on each of the Policies. (ECF No. 22 ¶¶ 6, 14; ECF No. 23 ¶¶ 6, 14.)

On July 7, 2016, Plaintiff signed an application seeking to increase coverage on Policy 008G98329 by $5,000, and, in doing so, certified that Mr. Yuzwa was in good health. (ECF No. 22 ¶ 15; ECF No. 23 ¶ 15.) Defendant approved the application, and, on July 23, 2016, Defendant issued a $5,000 Term Life Insurance Rider on Policy 008G98329. (ECF No. 22 ¶ 16; ECF No. 23 ¶ 16.)

On August 2, 2017, Mr. Yuzwa died due to a gunshot wound to the head. (ECF No. 22 ¶ 17; ECF No. 23 ¶ 17.) On August 14, 2017, Defendant received a Proof of Death - Claimant's Statement from Plaintiff. (ECF No. 22 ¶ 18; ECF No. 23 ¶ 18.)

The Policies both contained incontestability provisions providing that: "We cannot contest this policy after it has been in force during the Insured's lifetime for 2 years from the Policy Effective Date." (ECF No. 22 ¶ 19; ECF No. 23 ¶ 19.) Mr. Yuzwa died within the contestability period set forth in the Policies, and Defendant was allowed to contest the Policies. (ECF No. 22 ¶ 20; ECF No. 23 ¶ 20.)

2. Defendant's Investigation

Defendant initiated an investigation, and, on August 7, 2017, Defendant sent a letter to Plaintiff requesting various documents, including an AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPPA. (ECF No. 22 ¶ 21; ECF No. 23 ¶ 21.) On August 25, 2017, Defendant sent a letter to Plaintiff notifying her that "IT WILL BE NECESSARY FOR US TO REQUEST SOME INFORMATION FROM MEDICAL PROVIDERS THAT PROVIDED TREATMENT TO THE INSURED OVER THE PAST FEW YEARS." (ECF No. 22 ¶ 22; ECF No. 23 ¶ 22.) On September 14, 2017, Defendant again wrote to Plaintiff to notify her that "ALL OR PART OF THE REQUESTED INFORMATION HAS NOT BEEN RECEIVED." (ECF No. 22 ¶ 23; ECF No. 23 ¶ 23.)

a. Records from Laurel Pediatric Associates

As part of its investigation, Defendant obtained Mr. Yuzwa's medical records from Laurel Pediatric Associates. (ECF No. 22 ¶ 24; ECF No. 23 ¶ 24.) The records detail Mr. Yuzwa's medical treatment from April 8, 2013, through April 7, 2015, in part as follows:

a. April 8, 2013 Chief Complaint—Possible Influenza. Assessment—cough, nausea alone, viral illness and contact or exposure to other viral disease. No medication prescribed.

b. April 17, 2013 Chief Complaint—Possible Allergies. Assessment—allergic rhinitis cause uns, abdominal pain other site, headache. Prescribed cetirizine.c. May 23, 2014 Chief Complaint—Stomach ache x 2 days. Assessment—gastro[]enteritis,³ abdominal pain epigastric, nausea with vomiting. Advised to take OTC Pepto Bism[o]l and OTC Probiotics. No medication, diagnostic testing, or follow-up treatment prescribed.

d. November 22, 2014 Chief Complaint—Stomach cramps x "years." Assessment—abdominal tenderness LLQ, Irritable Bowl Syndrome.⁴ "[D]iscussed that diet is likely causing a great deal of his pain and discomfort." "Foods containing glut[]en (wheat products) and dairy products can cause stomach issues." No medication, diagnostic testing, or follow-up treatment prescribed.

e. January 28, 2015 Chief Complaint—Fever and achiness since last night. Assessment—viral illness, nasal congestion, myalgia.

f. February 17, 2015 Chief Complaint—Feeling achy today. Assessment—abdominal pain generalized, nausea alone, cough, headache. Advised he could take Tums or Aspirin-free Alka Seltzer and Tylenol if needed.

g. March 31, 2015 Chief Complaint—School excuse needed. Was vomiting this morning, but is now resolved. Assessment—acute gastroenteritis, vomiting alone. No medication, diagnostic testing, or follow-up treatment prescribed.

h. April 7, 2015 Chief Complaint—"My joints." Assessment—pain in joints other sites. "Recommended to take OTC anti-inflammatory medicines for pain. May take up to 600 mg of ibuprofen." No medication, diagnostic testing, or follow-up treatment prescribed.

(ECF No. 23-2 ¶ 14 (citations omitted); ECF No. 25 ¶ 14.)

The records obtained from Laurel Pediatric Associates further indicate that, on April 17, 2013, Mr. Yuzwa was diagnosed with abdominal pain and admitted to "on/off lower-middle abdominal pain x 1 year." (ECF No. 22 ¶ 25; ECF No. 23 ¶ 25.) During the April 17, 2013, office visit, the records indicate that Mr. Yuzwa stated that the "pains are 'sort of achy' & they tend to occur 'a couple of times a week.'" (ECF No. 22 ¶ 26; ECF No. 23 ¶ 26.) According to his records,Mr. Yuzwa also admitted to "occasionally feeling nauseated." (ECF No. 22 ¶ 27; ECF No. 23 ¶ 27.) The records indicate that Plaintiff accompanied Mr. Yuzwa to his appointment. (ECF No. 22 ¶ 28; ECF No. 23 ¶ 28.) The records indicate that Plaintiff stated, "He has told me that he has trouble moving his bowels, then he will have diarrhea at other times," although Mr. Yuzwa apparently stated that his bowels "were normal." (ECF No. 22 ¶ 29; ECF No. 23 ¶ 29.)

The records also show that on May 23, 2014, Mr. Yuzwa complained of a "stomachache and nausea," reported "diffuse abdominal pain," and was diagnosed with gastroenteritis. (ECF No. 22 ¶ 30; ECF No. 23 ¶ 30.) The records indicate that Plaintiff accompanied Mr. Yuzwa to his appointment. (ECF No. 22 ¶ 31; ECF No. 23 ¶ 31.)

According to the records, on November 22, 2014, Mr. Yuzwa complained of abdominal pain and was diagnosed with irritable bowel syndrome ("IBS"). (ECF No. 22 ¶ 32; ECF No. 23 ¶ 32.) His records indicate that he was "diagnosed with IBS in the past and took probiotics." (ECF No. 22 ¶ 33; ECF No. 23 ¶ 33.) Again, the records indicate that Plaintiff accompanied Mr. Yuzwa to his appointment. (ECF No. 22 ¶ 34; ECF No. 23 ¶ 34.)

Then, on February 17, 2015, Mr. Yuzwa, while accompanied by Plaintiff, sought treatment and stated that his "stomach hurts as well as he feels nauseated." (ECF No. 22 ¶ 35; ECF No. 23 ¶ 35.)

On February 24, 2015, Mr. Yuzwa once again sought treatment for a "stomach ache" and was diagnosed with gastroenteritis. (ECF No. 22 ¶ 36; ECF No. 23 ¶ 36.) Mr. Yuzwa was accompanied by Plaintiff, his mother. (ECF No. 22 ¶ 37; ECF No. 23 ¶ 37.)

On March 31, 2015, Mr. Yuzwa sought treatment, while accompanied by Plaintiff, and was diagnosed with gastroenteritis for the third time in less than a year. (ECF No. 22 ¶ 38; ECF No. 23 ¶ 38.)

The records also indicate that, on April 7, 2015, Mr. Yuzwa again sought treatment while accompanied by Plaintiff and complained that "his joints have been hurting him for years and he thinks he has arthritis." (ECF No. 22 ¶ 39; ECF No. 23 ¶ 39.)

From March 31, 2015, until the date of his death on August 2, 2017, Mr. Yuzwa did not visit Laurel Pediatric Associates for any stomach conditions. (ECF No. 23-2 ¶ 22; ECF No. 25 ¶ 22.)

b....