Pinell v. Patterson Services, Inc.
| Decision Date | 23 June 1986 |
| Docket Number | No. 85-C-0954,85-C-0954 |
| Citation | 491 So.2d 637 |
| Parties | Erroll PINELL v. PATTERSON SERVICES, INC. and Pan-American Life Insurance Company. |
| Court | Louisiana Supreme Court |
Joseph Weigand, Jr., Wiegand, Weigand & Meyer, for plaintiff-applicant.
Darryl Foster, Lemle, Kelleher, et al, for defendant-respondent.
Pan American Life Insurance Company (PALIC) issued a group accident and sickness policy to Patterson Services, Inc. for the benefit of Patterson's employees. The Schedule of Insurance provides the following benefits:
EMPLOYEE MAXIMUM BENEFITS
Occupational and Non-
occupational Accident
and Sickness--Weekly
Benefit .............................. 60% of Basic
Payable 1st day of Weekly Income
accident. to maximum of
8th day of sickness. $200 per week
Maximum 52 weeks
Twenty-four hour Accident and Sickness Weekly benefit
is to be Integrated with Workmen's Compensation. 1
1 This clause shall hereafter be referred to as the Integration Clause
Accident and Sickness Weekly Benefit reduces one-half after 26 weeks of Benefits have paid.
Furthermore, the General Limitations Clause provides:
Unless otherwise specified in the Policy no benefits shall be payable for or on account of: (1) any bodily injury or sickness for which the person on whom claim is presented has or had a right to compensation under any Workmen's Compensation or occupational disease law, or; (2) any bodily injury or sickness which arises from or is sustained in the course of any occupation or employment for compensation, profit or gain ....
Erroll Pinell, an employee of Patterson, was injured on June 4, 1977 during the course and scope of his employment while on a Mallard Drilling Company rig located in navigable waters. He filed for benefits under both the PALIC policy and the Longshoreman's and Harbor Workers' Compensation Act (LHWCA). 33 U.S.C.A. 901 et seq. (West 1986). As a result, Pinell received LHWCA benefits from Patterson of $282 per week. Pinell received those benefits from June 4, 1977 until October 1, 1978, and again from June 1, 1979 until March 1, 1981. The payment of LHWCA benefits terminated when Pinell settled a tort suit against CRC Mallard, Inc. and Texas Gas Transmission Corporation for $210,000. From this settlement Patterson received $39,500 as reimbursement for the benefits paid to Pinell and was given a credit against any future LHWCA benefits for which it might be liable, up to the entire amount of the settlement. 33 U.S.C.A. § 933(c)(1) (West 1986).
During the period of time Pinell was receiving compensation benefits, PALIC did not pay benefits under the group accident and sickness policy. Pinell concedes in his petition he was not entitled to benefits during that period of time, because his compensation payments exceeded $200 per week. In other words, benefits are payable under the Integration Clause of the policy only when the weekly compensation benefits are less than $200 per week. In that event the amount of the weekly benefits under the PALIC policy is the difference between the weekly compensation benefits and $200. 2
After Patterson was reimbursed the benefits which it had paid to Pinell, it was alleged by Pinell he was entitled to maximum benefits under the PALIC policy since the reimbursement had negated all compensation which he received. PALIC refused to pay any benefits arguing the General Limitations Clause excluded coverage. After trial on the merits, the trial court rendered judgment in favor of the plaintiff for $7,800, the maximum amount recoverable under the policy. The First Circuit reversed concluding the reimbursement did not establish a right to benefits. Pinell v. Patterson Services, Inc., 468 So.2d 762 (La.App. 1st Cir.1985). We affirm.
Only one issue is presented by this case: Does the General Limitations Clause operate to bar the plaintiff's claim for benefits under the policy issued by Pan American Life Insurance Company?
What is the nature of the Integration Clause?
As discussed earlier, the General Limitations Clause precludes the recovery of accident and sickness weekly benefits when any amount of workmen's compensation is available "unless otherwise specified in the policy." The plaintiff argues that since the Integration Clause allows the recovery of PALIC benefits when compensation benefits are less than $200 per week, the "unless otherwise specified" phrase of the General Limitations Clause precludes its applicability. That argument lacks merit.
In order to determine the intention of the parties when they amended the insurance contract to include the Integration Clause, we must look to the standard provisions of the policy. When an amendment has been made to the provisions of a standard policy, the substance of the amendment is evidence of the intention of the contractual parties. In construing the provisions of the policy, we must take into account the possible reasons for making the amendment. The terms and provisions of the policy, including any amendments thereto, must be construed together in order to ascertain the true intent of the parties when the policy was issued. Benton Casing Service, Inc. v. Avemco Ins. Co., 379 So.2d 225 (La.1979); Martin v. Phillips, 356 So.2d 1016 (La.App. 1st Cir.1977).
The General Limitations Clause provides in essence that unless otherwise specified in the policy no benefits shall be payable when the claimant has or had a right to compensation under any Workmen's Compensation law; or when the bodily injury or sickness is sustained in the course of any occupation or employment for compensation. Under this provision, disability benefits are never available as long as the injured employee "has or had a right to workmen's compensation," regardless of the amount the employee is eligible to receive. In fact, it appears benefits are never available under the General Limitations Clause when the employee is injured during the course and scope of his employment. This was apparently unacceptable to Patterson Services, Inc. As a result, the Integration Clause was incorporated into the policy for the purpose of using...
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...of the jurisprudence regarding disability (or health and accident) policies confirms our holding. UNUM relies upon Pinell v. Patterson Services, Inc., 491 So.2d 637 (La.1986), in support of its position. In Pinell, the Supreme Court held that an injured employee who had received benefits un......
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