Rhodes v. Aetna Life Ins. Co.

• Decision Date: 17 September 1984
• Docket Number: Docket No. 71537
• Citation: 135 Mich.App. 735,356 N.W.2d 247
• Parties: Valda RHODES, Plaintiff-Appellant, v. AETNA LIFE INSURANCE COMPANY, Defendant-Appellee.
• Court: Court of Appeal of Michigan — District of US

Page 247

356 N.W.2d 247

135 Mich.App. 735

Valda RHODES, Plaintiff-Appellant, v. AETNA LIFE INSURANCE COMPANY, Defendant-Appellee.

Docket No. 71537.

Court of Appeals of Michigan.

Submitted April 9, 1984.

Decided June 28, 1984.

Released for Publication Oct. 19, 1984.

Rehearing Denied Sept. 17, 1984.

Posner, Posner & Posner by Samuel Posner and Gerald F. Posner, Detroit, for plaintiff-appellant.

Dickinson, Wright, Moon, Van Dusen & Freeman by Susan Bieke Neilson, Robert P. Young, Jr., and Arthur S. Meyers, Jr., Detroit, for defendant-appellee.

Before HOOD, P.J., and KELLY and LIVO ^*, JJ.

KELLY, Judge.

Plaintiff filed this action in circuit court for the payment of group disability insurance benefits. Defendant responded with a motion for summary judgment, which the trial court treated as a motion for accelerated judgment under GCR 1963, 116.1(5), seeking dismissal of plaintiff's complaint for failure to exhaust her contractual remedies. The trial court granted accelerated judgment and denied plaintiff's motion for summary judgment brought under GCR 1963, 117.2(3). Plaintiff appeals from both orders and we remand for further proceedings consistent with this opinion.

The following facts are not in dispute. Plaintiff has been employed by Chrysler Corporation as an inspector at the Warren Truck Plant since 1953. As a member of the United Auto Workers Union (UAW) she is entitled to group disability benefits under an insurance plan collectively bargained for between the UAW and Chrysler. Employee disability benefits are provided by Chrysler through a policy underwritten by the defendant.

On October 6, 1978, plaintiff sustained serious back injuries when she was involved in an automobile accident. Through her group policy with the defendant, plaintiff applied for and received sickness and accident benefits as well as extended disability benefits until August 22, 1979. In March of 1979, plaintiff was examined by two different doctors pursuant to an "independent medical opinion" (IMO) format developed as part of the labor negotiations between Chrysler and the UAW. The first doctor, an internist, found that plaintiff was able to return to work. The second doctor, an orthopedist, found that plaintiff was able to return to work only under restricted conditions and recommended that she not be required to lift more than ten pounds or engage in repeated bending. Chrysler agreed to consider plaintiff for restricted work only and defendant continued to pay plaintiff disability benefits.

According to plaintiff, she would have enthusiastically accepted restricted employment had it been offered to her but Chrysler never informed her that such work was available. According to the defendant, information was received from Chrysler revealing that plaintiff had been offered and had rejected employment consistent with her restrictions. In any event, defendant terminated plaintiff's benefits on August 22, 1979.

Pursuant to letter agreements entered into between Chrysler and the UAW in 1976 and 1979, supplementing the master collective bargaining agreement, an employee's right to disability benefits became subject to two procedures. The IMO plan was implemented in 1976 and requires an employee to submit to physical examination by an independent physician in order to determine whether that employee is able to return to work. The 1979 supplemental letter agreement between Chrysler and the UAW created a procedure for review of denied or terminated benefits. Where an employee disputes the denial or termination of benefits, he or she may seek review of that decision as follows:

"To afford employees a means by which they can seek review and possible reconsideration of a denied claim, internal procedures of Chrysler Corporation and the Aetna Life Insurance Company will provide a procedure along the following lines:

"(1) The formal notification letter from the plant group insurance representative by which the employee is advised that his claim is denied will inform the employee that if he has any questions regarding the denial they may be referred to the plant group insurance office.

"(2) Upon request, the plant group insurance office will advise what if anything the employee can do to support his claim for payment benefits.

"(3) The employee may request a Union representative to discuss insurance matters with local management to obtain this information.

"(4) Upon request, a representative of local management will review the employee's case with the Union representative. At this meeting, there will be furnished to the Union representative all the material pertinent to the claim including any detailed explanation of the reasons for the denial of the claim.

"(5) If, after discussion with the representative of local management, the Local Union representative contests the position of management, he can refer the case to the International Union for review with the Corporation in Detroit. At such time he should advise local management of his intention.

"(6) The Corporation and the International Union will review the case, as at present, and if they are unable to resolve their differences the Corporation at the request of the Union will request a review by Aetna and will incorporate in such request the Union's position. Such review will be conducted by a committee of three employees of Aetna, at least one of whom shall be an officer of Aetna.

"(7) Aetna will report to the International Union and to the Corporation its action as the result of such review."

Defendant alleges that plaintiff never utilized these procedures and never sought internal review of the defendant's decision to terminate her benefits and is thus precluded from instituting judicial proceedings to obtain benefits.

Plaintiff responds that because her cause of action is under the insurance contract and not under the collective bargaining agreement, and because the insurance contract does not provide for or require any petition for internal review prior to instituting civil proceedings, she need not exhaust any remedies provided under the collective bargaining agreement before filing a judicial action to recover benefits. We disagree.

Plaintiff is not a primary party to the insurance contract under which sh...