King v. National Foundation Life Ins. Co.

CourtSupreme Court of Alabama
Citation541 So.2d 502
PartiesGeraldine KING and John R. King v. NATIONAL FOUNDATION LIFE INSURANCE COMPANY. 87-1074.
Decision Date31 March 1989

Page 502

541 So.2d 502
Geraldine KING and John R. King
Supreme Court of Alabama.
March 31, 1989.

Page 503

Lawrence B. Clark and Sally S. Reilly of Lange, Simpson, Robinson & Somerville, Birmingham, for appellants.

Cathy S. Wright and James M. Proctor II of Maynard, Cooper, Frierson & Gale, Birmingham, for appellee.

MADDOX, Justice.

The issue in this case is whether the trial court erred in entering summary judgment for National Foundation Life Insurance Company ("National") on the plaintiffs' claims for breach of contract, fraud, and bad faith.

This appeal involves a medical insurance policy. The evidence before the trial court tended to show the following: On March 24, 1983, the Kings applied to National for a policy of major medical health insurance through National's agent, Christopher R. Farrow. On the application, the Kings indicated that Geraldine King had received medical treatment for a prior pregnancy, but the Kings responded in the negative to a question about whether they had received any "other medical or surgical advice or treatment or operation." National issued a policy to the Kings, effective March 24, 1983. The policy provided as follows:

"Subject to all provisions, waiting periods, exclusions, exceptions and limitations contained herein, the Company will pay the benefits provided hereunder for loss by reason of certain hospital confinement expenses or other specified expenses incurred by an Insured Person which commences while this policy is in force for such person and which is a result of Injury (see page 2 definitions) or Sickness (see page 2 definitions)."

On page 2 of the policy, sickness is defined as "illness or disease of any Insured which first manifests itself thirty (30) days after the Effective Date of Insurance and while the policy is in force."

In September 1983, Geraldine had surgery to remove some cysts on her breast and face. On September 30, 1983, National received a claims submission from Geraldine's treating physician; on the claim form, the doctor had answered "no" to the question whether the patient had ever had the same or similar symptoms. National also received other documents related to the claim, including a discharge summary prepared by Geraldine's treating physician on September 21, 1983. This document stated "HISTORY OF PRESENT ILLNESS: The patient is a 30 year old female with six month history of cystic masses of the left breast and left nipple. She also has had chronic problems with cystic lesions of the face." Based upon this information

Page 504

indicating that the cysts had appeared before the end of the 30-day exclusion period of the policy, National denied coverage for this claim.

On January 9, 1984, Geraldine wrote National and told them that the cyst condition had not been a preexisting condition. National responded by stating that the claim was still denied, but National did invite Geraldine to submit additional information from her physician. The Kings denied receiving this letter. Apparently, this letter from National was incorrectly addressed and was not received by the Kings. The Kings and National had further communications, and in April 1984, Geraldine's physician sent National a letter stating that the breast cysts did not appear until July or August 1983. Based upon this letter, National decided to reopen the claim to review it further; National informed the Kings of this action in June 1984.

In addition to the treatment regarding the cysts, Geraldine was hospitalized in January 1984 for a miscarriage. The Kings filed a claim for this hospitalization, and National requested additional information, which arrived in April and May 1984. Before National could complete its review of the cyst and pregnancy claims, the Kings filed suit on both claims on June 20, 1984.

All benefits for both claims were paid by National in October 1984. The Kings introduced evidence of National's internal procedures and how National had not consistently followed these procedures in handling their claims. National introduced evidence that it had been in the process of moving its corporate headquarters from November 1983 until mid-1984 and that as a result of this move it had been required to hire an almost entirely new claims staff. National claimed that this change had created a backlog of claims and thus that those claims were not processed as quickly as they would have been under normal conditions.


Because this suit was filed prior to June 11, 1987, the...

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36 cases
  • McCullough v. Golden Rule Ins. Co., 88-193
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    ...form the focus of this tort. The Alabama court substitutes the word "arguable" for debatable. King v. National Foundation Life Ins. Co., 541 So.2d 502 (Ala.1989). The logical premise of the debatable (or arguable) standard is that if a realistic question of liability does exist, the insuran......
  • State Farm Fire & Cas. Co. v. Owen, 1961950.
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    • 21 de agosto de 1998 support such a finding. See Hardy v. Blue Cross & Blue Shield, 585 So.2d 29 (Ala.1991); King v. National Foundation Life Ins. Co., 541 So.2d 502 (Ala. 1989). Thus, the imposition of a duty of disclosure could have been justified only if this case presented "special circumstances" manda......
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