Thibodeaux v. Lmrma
| Decision Date | 13 October 1999 |
| Docket Number | No. 99-241.,99-241. |
| Citation | 745 So.2d 109 |
| Parties | Raymond THIBODEAUX, Plaintiff-Appellee, v. LOUISIANA MUNICIPAL RISK MANAGEMENT AGENCY, II, Defendant-Appellant. |
| Court | Court of Appeal of Louisiana — District of US |
Michael Voorhies Matt, Eunice, for Raymond Thibodeaux.
Bradley Charles Myers, Lana D. Crump, Baton Rouge, for Louisiana Municipal Risk Management Agency, II.
BEFORE: COOKS, SAUNDERS and DECUIR, Judges.
This is a dispute concerning the denial of benefits on an accident and health indemnity contract. The insurer appeals the trial court's grant of summary judgment finding there was coverage. For the following reasons, we affirm.
On June 24, 1995, Raymond Thibodeaux was seriously injured when he fell from a ladder while washing a house. At the time of the injury, Raymond Thibodeaux had been employed by the City of Opelousas for eighteen years. Thibodeaux occasionally would wash houses to make some extra money. The record revealed Thibodeaux earned anywhere from $300 to $1,000 annually washing houses. It was not connected to his work for the City of Opelousas.
After the accident, Thibodeaux sought payment of his medical bills through Louisiana Municipal Risk Management Agency (LMRMA), the health care benefits provider for the City of Opelousas. LMRMA denied benefits based on an exclusion in the contract between it and the City of Opelousas. Both LMRMA and Thibodeaux filed motions for summary judgment grounded on the coverage issue. After a hearing and the submission of post-argument briefs, the trial court took the matter under advisement. Judgment was issued by the trial court denying LMRMA's motion and granting Thibodeaux's motion finding the policy did not exclude coverage. This appeal followed.
The City of Opelousas provides health and accident indemnification to its employees and their dependants through an "Accident and Health Contract" maintained through LMRMA. The Accident and Health Contract contains an exclusion that provides:
Section VII. Exclusions and Limitations.
Coverage under this contract is subject to the following exclusions and limitations for which no benefits shall be paid:
* * *
5. Services for any occupational condition, sickness, or injury arising out of or in the course and scope of employment for wage or profit, or services which are furnished to a participant under the laws of the United States or any state or political subdivision thereof, or for services which the participant is entitled to benefits under any workers compensation or occupational disease law; for which the participant shall have no right under this contract, even though he elects to waive his right to such benefits or services.
In Ledbetter v. Concord General Corp., 95-809 (La.1/6/96); 665 So.2d 1166, the Louisiana Supreme Court addressed the interpretation of insurance policies. The court stated:
An insurance policy is an agreement between the parties and should be interpreted by using ordinary contract principles. Smith v. Matthews, 611 So.2d 1377, 1379 (La.1993). The parties' intent, as reflected by the words of the policy, determine the extent of coverage. Such intent is to be determined in accordance with the general, ordinary, plain and popular meaning of the words used in the policy, unless the words have acquired a technical meaning. La.Civ. Code art. 2047; Louisiana Insurance Guaranty Association v. Interstate Fire & Casualty Co., 93-0911 (La.1/14/94); 630 So.2d 759, 763. If the policy wording at issue is clear and expresses the intent of the parties, the agreement must be enforced as written. Pareti v. Sentry Indemnity Co., 536 So.2d 417, 420 (La.1988).
Exclusionary provisions in insurance contracts are strictly construed against the insurer, and any ambiguity is construed in favor of the insured. Garcia v. St. Bernard Parish School Board, 576 So.2d 975, 976 (La.1991). However, the rule of strict construction does not "authorize a perversion of language, or the exercise of inventive powers for the purpose of creating an ambiguity where none exists." Muse v. Metropolitan Life Ins. Co., 193 La. 605, 192 So. 72, 75 (1939). Insurance companies have the right to limit coverage in any manner they desire, so long as the limitations do not conflict with statutory provisions or public policy. Reynolds v. Select Properties, Ltd., 93-1480 (La.4/11/94); 634 So.2d 1180, 1183.
Id. at pp. 3-4; 665 So.2d at 1169.
It was undisputed that in addition to his work for the City of Opelousas, Thibodeaux, "on the side" during the summer months, washed houses to earn extra money. It was estimated that Thibodeaux earned between $300 and $1,000 per year by washing houses.
The trial court found, although the policy in question was "described as an accident and health contract, for all practical purposes, it is a health insurance policy." We agree, and note regardless of its classification, it is still subject to the general rules of interpretation of contracts.
The trial court, after setting out the law as to interpretation of contracts, gave the following well-articulated reasons for denying the exclusion, which we adopt as our own:
If defendant is going to provide a "health plan" (health insurance policy) for City of Opelousas employees such as plaintiff herein, it must be clear and unambiguous. It is not. Furthermore, considering how essential health insurance is in our society, it is shocking to the conscious to deny health insurance coverage to a city employee who is trying to make a little extra money on the side with a part-time, self-employed summer job, without said employee having actual notice of the exclusion of coverage, if he is injured while doing any other side-line work. How would the employee know this until he is injured such as what occurred in the case at bar? This would qualify as an "absurd conclusion" as set forth in the LIGA v. Interstate Fire [630 So.2d 759 (La. 1994)] case supra.
Plaintiff in this case is an everyday hard-working "blue collar" employee serving the City of Opelousas. All along (for 18 years) he was led to believe and thought he had health insurance with the City. He gets hurt in an accident ("fall") totally unrelated to his true occupation. He applies for benefits. Defendant locates and asserts an exclusion denying coverage in the accident and health contract. Plaintiff is "bare" and ruined financially. Plaintiff, like any other worker in that situation, was justified in thinking and believing he had health insurance coverage. Certainly, if plaintiff, at the time of his accident, was working as an employee for someone else, with other health insurance or workers compensation benefits available, that would be an entirely different story. That would be the situation which would justify and trigger such an exclusion. But that was not the case here. Plaintiff has nothing to fall back on. If the exclusion is inapplicable, at least the defendant would have subrogation rights under the contract against a negligent party other than its insured, if the insured gets hurt working part-time.
When considering the facts in this case, to uphold this exclusion, or make it applicable, would require that the plaintiff be given actual notice of said exclusion by having him sign a waiver of coverage if hurt while working...
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