Jones v. Golden Rule Ins. Co.

• Decision Date: 02 August 2017
• Docket Number: 1:16–cv–3678–WSD
• Citation: 275 F.Supp.3d 1361
• Parties: Dawn M. JONES, Plaintiff, v. GOLDEN RULE INSURANCE COMPANY, Defendant.
• Court: U.S. District Court — Northern District of Georgia

275 F.Supp.3d 1361

Dawn M. JONES, Plaintiff,

v.GOLDEN RULE INSURANCE COMPANY, Defendant.

1:16–cv–3678–WSD

United States District Court, N.D. Georgia, Atlanta Division.

Signed August 2, 2017

Jennifer Auer Jordan, Joshua Forrest Silk, Shamp Speed Jordan Woodward, LLC, Atlanta, GA, for Plaintiff.

Cavender C. Kimble, Balch & Bingham, Birmingham, AL, Brooke Walker Gram, Balch & Bingham LLP, Atlanta, GA, for Defendant.

OPINION AND ORDER

WILLIAM S. DUFFEY, JR., UNITED STATES DISTRICT JUDGE

This matter is before the Court on Defendant Golden Rule Insurance Company's ("Defendant") Motion for Summary Judgment [9].

I. BACKGROUND

A. Facts

On April 16, 2014, Plaintiff Dawn M. Jones ("Plaintiff") had a routine mammogram as part of her annual physical. (Deposition of Dawn Michele Jones (Mar. 22, 2017) [38.3] ("Pl. Dep.") at 97–100; [9.7] ). Plaintiff had received annual mammograms for the past "several years," and neither Plaintiff nor her physician was aware of any signs of cancer in Plaintiff's breasts. (Deposition of Michael DuBois, M.D. (Mar. 29, 2017) [38.2] ("DuBois Dep.") at 101; [9.7] ).

On May 13, 2014, the radiologist reviewed the mammogram results and issued the following written report ("May Report"):

FINDINGS: The breast tissue is heterogeneously dense (BI–RADS Type III Density). The breast has more areas of fibrous and glandular tissue (from 51 to 75%) that are found throughout the breast. This can make it hard to see small masses (cysts or tumors). Linearly distributed calcifications are noted in the right axillary tail posteriorly. No dominant masses, calcifications, or indirect signs of malignancy are identified in the left breast.

IMPRESSION:

1. Incomplete: Need additional evaluation (BIRADS 0)

RECOMMENDATION: Spot magnification views in the right XCCL and right ML should be performed.¹ Additionally, possible right breast ultrasound should be performed.

( [9.7] at 2). Plaintiff's mammogram results were "abnormal" in view of the "[l]inearly distributed calcifications" found in her right breast. (DuBois Dep. at 102, 110, 118–120; Pl. Dep. at 169). The calcifications were "suggestive of possible cancer," although "you can find micro-calcifications in normal breasts." (DuBois Dep. at 105, 116, 122–123, 172).

On June 25, 2014, Plaintiff submitted an application to Defendant for short-term health insurance coverage. (Defendant's Statement of Undisputed Material Facts in Support of its Motion for Summary Judgment [9.2] ("DSMF") ¶ 1). Plaintiff certified, on the application form, that she understood "no benefits will be paid for a health condition that existed within the last 5 years prior to the date insurance takes effect." ( [9.4] ). Plaintiff's application was accepted on June 25, 2014, and the insurance policy ("Policy") was issued providing coverage from June 26, 2014, through December 25, 2014. (Pl. Dep. at 140–142; DSMF ¶ 3; [9.5] at 23). The Policy reiterated what was disclosed on Plaintiff's application form, specifically, that "Preexisting conditions will not be covered under this policy. " (DSMF ¶ 9). The Policy defined the term "preexisting condition:"

‘Preexisting Condition’ means a condition:

(A) For which medical advice, diagnosis, care, or treatment was recommended or received within the 60 months immediately preceding the date the covered person became insured under this policy ;

(B) That, in the opinion of a qualified doctor :

1) Began prior to the date the covered person became insured under this policy ; or

2) Manifested symptoms that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment within the 60 months immediately preceding the date the covered person became insured under this policy ; or

(C) A pregnancy existing on the effective date of coverage.

(DSMF ¶ 9).

On July 14, 2014, Plaintiff received a copy of the May Report. (Pl. Dep. at 155). She had a follow-up mammogram later that day, which revealed a "mass with calcifications span[ning] 3 cm in the right axillary tail." ( [36.3] ). The radiologist's report noted that "[t]he calcifications are pleomorphic and the mass is irregular." ( [36.3] ). The radiologist found the results "suspicious (BIRADS 4)" and recommended an "ultrasound-guided biopsy of the mass." ( [36.3] ). After undergoing a biopsy on August 4, 2014, Plaintiff was diagnosed with invasive ductal carcinoma, a form of breast cancer. ( [9.8] at 3; DuBois Dep. at 93–94; [36.5] at 3). On September 29, 2014, cancer surgery was performed. ( [9.8] at 3; [36.6] at 6). On December 19, 2014, Defendant told Plaintiff that the treatment she received for her breast cancer was excluded under the Policy. (DSMF ¶ 19).

B. Procedural History

On September 30, 2016, Plaintiff filed her Complaint for Damages [1], asserting claims for breach of contract (Count 1), breach of the duty of good faith and fair dealing (Count 2), bad faith and attorney's fees (Count 3), and punitive damages (Count 4). The Complaint alleges that Defendant "breached its duties under the insurance contract by refusing to pay covered medical expenses." (Compl. ¶ 32). On November 21, 2016, Defendant filed its Motion for Summary Judgment on the grounds that Plaintiff's breast cancer was a preexisting condition not covered by the Policy.

II. LEGAL STANDARDS

A. Summary Judgment Standard

"Summary judgment is appropriate where the pleadings, the discovery and disclosure materials on file, and any affidavits show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Ahmed v. Air France–KLM, 165 F.Supp.3d 1302, 1309 (N.D. Ga. 2016) ; see Fed. R. Civ. P. 56. "An issue of fact is material if it ‘might affect the outcome of the suit under the governing law.’ " W. Grp. Nurseries, Inc. v. Ergas, 167 F.3d 1354, 1360 (11th Cir. 1999) (quoting Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986) ). "An issue of fact is genuine ‘if the evidence is such that a reasonable jury could return a verdict for the nonmoving party.’ " Id. at 1361 (quoting Anderson, 477 U.S. at 248, 106 S.Ct. 2505 ).

The party seeking summary judgment "bears the initial responsibility of informing the district court of the basis for its motion, and identifying [materials] which it believes demonstrate the absence of a genuine issue of material fact." Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). "The movant[ ] can meet this burden by presenting evidence showing there is no dispute of material fact, or by showing that the nonmoving party has failed to present evidence in support of some element of its case on which it bears the ultimate burden of proof." Graham v. State Farm Mut. Ins. Co., 193 F.3d 1274, 1281–82 (11th Cir. 1999). The moving party need not "support its motion with affidavits or other similar materials negating the opponent's claim." Celotex, 477 U.S. at 323, 106 S.Ct. 2548. Once the moving party has met its initial burden, the nonmoving party must demonstrate that summary judgment is inappropriate by designating specific facts showing a genuine issue for trial. Graham, 193 F.3d at 1282. The nonmoving party "need not present evidence in a form necessary for admission at trial; however, he may not merely rest on his pleadings." Id."[T]he mere existence of some alleged factual dispute between the parties will not defeat an otherwise properly supported motion for summary judgment; the requirement is that there be no genuine issue of material fact." Anderson, 477 U.S. at 247–48, 106 S.Ct. 2505.

"If the evidence presented by the non-moving party is merely colorable, or is not significantly probative, summary judgment may be granted." Apcoa, Inc. v. Fid. Nat. Bank, 906 F.2d 610, 611 (11th Cir. 1990) (internal quotation marks omitted) (quoting Anderson, 477 U.S. at 250, 106 S.Ct. 2505 ). The party opposing summary judgment "must do more than simply show that there is some metaphysical doubt as to the material facts .... Where the record taken as a whole could not lead a rational trier of fact to find for the nonmoving party, there is no genuine issue for trial." Scott v. Harris, 550 U.S. 372, 380, 127 S.Ct. 1769, 167 L.Ed.2d 686 (2007) (internal quotation marks omitted) (quoting Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 586–87, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986) ); cf. Miller v. Kenworth of Dothan, Inc., 277 F.3d 1269, 1275 (11th Cir. 2002) (a party is entitled to summary judgment if "the facts and inferences point overwhelmingly in favor of the moving party, such that reasonable people could not arrive at a contrary verdict" (quoting Combs v. Plantation Patterns, 106 F.3d 1519, 1526 (11th Cir. 1997) (internal quotation marks omitted))).

"At the summary judgment stage, facts must be viewed in the light most favorable to the nonmoving party only if there is a ‘genuine’ dispute as to those facts." Scott, 550 U.S. at 380, 127 S.Ct. 1769. "When opposing parties tell two different stories, one of which is blatantly contradicted by the record, so that no reasonable jury could believe it, a court should not adopt that version of the facts for purposes of ruling on a motion for summary judgment." Id."[C]redibility determinations, the weighing of evidence, and the drawing of inferences from the facts are the function of the jury." Graham, 193 F.3d at 1282. "The nonmovant need not be given the benefit of every inference but only of every reasonable inference." Id.

Rule 56(c) mandates the entry of summary judgment, after adequate time for discovery and upon motion, against a party who fails to make a showing sufficient to establish the existence of an element essential to that party's case, and on which that party will bear the burden of proof at trial. In such a situation, there can be "no genuine issue as to any material fact," since a complete failure of proof concerning an essential element of the nonmoving party's case necessarily renders all other facts immaterial.

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