Tingle v. Pacific Mut. Ins. Co.
| Decision Date | 23 July 1993 |
| Docket Number | No. 92-4413,92-4413 |
| Parties | , 17 Employee Benefits Cas. 1052, Pens. Plan Guide P 23883W James M. TINGLE, Sr. and Yvette Cecile Tingle, Plaintiffs-Appellees, and Lafayette General Medical Center, Intervenor-Plaintiff-Appellee, Cross-Appellant, v. PACIFIC MUTUAL INSURANCE CO., Defendant-Appellant, Cross-Appellee. |
| Court | U.S. Court of Appeals — Fifth Circuit |
Nicholas F. LaRocca, Jr., Lippman, Mahfouz, Martin & LaRocca, Morgan City, LA, for defendant-appellant.
Edward M. Leonard, Jr., Leonard & Hayes, Morgan City, LA, for Tingle.
Jayne L. Friedland, Stephanie M. Lawrence, McGlinchey, Stafford & Lang, New Orleans, LA, for Lafayette General.
Appeals from the United States District Court for the Western District of Louisiana.
Before WISDOM and DUHE, Circuit Judges, and DOHERTY 1, District Judge.
In this case, the plaintiffs/appellees, James M. Tingle, Sr. and his wife, Yvette Cecile Tingle, sued to recover medical expenses under a health insurance policy provided through Tingle's employer. When Tingle's wife suffered injuries to her back, Tingle filed a claim for her medical expenses with his insurance company, Pacific Mutual Insurance Company ("Pacific"), the defendant/appellant. Pacific responded by notifying Tingle that his policy had been retroactively cancelled based on its discovery that he had misrepresented his wife's medical history on his insurance application. Tingle filed suit in state court to recover under his insurance policy. Pacific removed the case to the Western District of Louisiana where the case was tried to the court. At trial, the district court applied Louisiana law and concluded that Tingle was entitled to recover under the policy. We hold that the Employee Retirement Income Security Act ("ERISA") 2 preempts state law in this case. Therefore, we reverse and remand with instructions to the district court to apply federal law instead of Louisiana law.
In September 1987, Tingle was employed by Coastal Tubular Services ("Coastal"). Coastal maintained a group health care policy for its employees and their families. When Coastal failed to pay its insurance premiums, causing its policy to lapse, Pacific supplied the replacement policy. Coastal informed its employees that there would be no lapse in their coverage.
On September 3, 1987, Coastal summoned all of its employees from their jobs to meet with Coastal's insurance agent. 3 The agent gave each of the employees a Pacific enrollment form to complete and waited about fifteen minutes to collect the forms. The form required the employees to answer questions regarding their medical histories and their covered family members' medical histories. Pacific agreed to provide health insurance to Tingle and his wife based on this application.
In April 1988, Mrs. Tingle injured her back while attempting to pull on her girdle. When she saw her doctor three days later, he admitted her to Lakewood Hospital. Because the hospital was unable to treat her, it transferred her to Lafayette General Medical Center ("Lafayette General"). There she was found to have a herniated disc, not brought on by her previous back condition. She was operated on to correct this condition. Mrs. Tingle was hospitalized again on two separate occasions because of complications arising from the surgery. Pacific pre-approved each separate treatment. The total cost of Mrs. Tingle's treatments amounted to $71,300. Tingle filed a claim for these costs with Pacific.
When Pacific received Tingle's claim for these expenses, it investigated Mrs. Tingle's medical history and discovered several discrepancies between her medical history and the information Tingle had provided on his enrollment form. Pacific denied Tingle's claim and retroactively cancelled his policy based this discovery. Tingle filed suit in state court to recover under his policy. Pacific removed the case to the Western District of Louisiana under 29 U.S.C. § 1132(e) and (f) (ERISA) and 28 U.S.C. § 1331. The Tingles executed an assignment of health care benefits in favor of Lafayette General, which intervened at trial.
The district court found that Tingle had misrepresented his wife's medical history on his enrollment form. Mrs. Tingle was a borderline diabetic and had continuing back problems. Yet, when asked whether or not Tingle or his wife suffered from any form of diabetes or back or spine disorder, Tingle answered in the negative to both of these questions. In addition, he failed to mention that his wife suffered from obesity. At trial, Tingle testified that he thought his wife was taking medication to avoid becoming a diabetic; thus, he did not believe she was diabetic. Further, he stated that he thought her previous back problems had been merely the result of pulled muscles; hence, he did not believe that they constituted a "disorder". Tingle also testified that he overheard Coastal's insurance agent telling another Coastal employee to report only major surgeries and illnesses. Based on this testimony, the district court found that Tingle did not have the actual intent to deceive Pacific when he made the misrepresentations.
The district court held that ERISA did not preempt the applicable state law. Consequently, interpreting La.R.S. 22:619 to require an actual intent to deceive in order to bar recovery, the district court concluded that Pacific was liable on the policy in spite of Tingle's misrepresentations. The district court entered judgment in favor of the Tingles and Lafayette General for the $71,300 in medical expenses and for reasonable costs but not attorneys' fees.
Pacific appeals the court's award allowing recovery under the policy and Lafayette cross appeals the court's decision to deny attorneys' fees.
Pacific argues that ERISA preempts the otherwise applicable Louisiana law in this case. We agree. As a general rule, ERISA preempts any state law that relates to an employee benefit plan. 4 However, ERISA's "insurance saving clause" expressly exempts state laws that regulate insurance from preemption. 5 The district court held that La.R.S. 22:619 is exempt from ERISA preemption because it falls within the insurance savings clause. We disagree.
In Metropolitan Life Insurance Co. v. Massachusetts, 6 the Supreme Court enumerated the requirements a statute must meet to fall within the ERISA insurance savings clause. The Court took a two-pronged approach. First, the court determined whether the statute in question fitted the common sense definition of insurance regulation. Second, it looked at three factors: (1) Whether the practice (the statute) has the effect of spreading the policyholders' risk; (2) whether the practice is an integral part of the policy relationship between the insurer and the insured; and (3) whether the practice is limited to entities within the insurance industry. 7 If the statute fitted the common sense definition of insurance regulation and the court answered "yes" to each of the questions in the three part test, then the statute fell within the savings clause exempting it from ERISA preemption. 8
In Metropolitan Life, the Court considered a Massachusetts statute that mandated insurers to include minimal mental health care benefits in all policies issued to Massachusetts residents. 9 The Court held that ERISA did not preempt this statute because the statute fell within the insurance savings clause. The Court found that the statute was directed solely to the insurance industry; it spread the risk of mental health care costs among all policyholders in the state; and it formed an integral part of the insurer-insured relationship. Specifically in reference to the risk factor, the Court reasoned that because the statute caused the cost of mental health care to be shared by all policyholders in the state, it met the risk spreading factor. 10 In contrast, in Pilot Life, the Supreme Court held that ERISA preempted the state law at issue (the Mississippi common law of bad faith and tortious breach of contract) in part because it did not serve to spread the risk. 11 The Court stated that "[u]nlike the mandated-benefits law at issue in Metropolitan Life, the Mississippi common law of bad faith does not effect a spreading of policyholder risk". 12
The statute at issue in the instant case, La.R.S. 22:619(B), provides:
In any application for life or health insurance made in writing by the insured, all statements therein made by the insured shall, in the absence of fraud, be deemed representations and not warranties. The falsity or any such statement shall not bar the right to recovery under the contract unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer.
Pacific contends that this statute does not act to spread policyholder risk. Thus, it argues, the statute is preempted by ERISA. We agree. Unlike the mandated benefits statute in Metropolitan Life, the instant statute does not spread the cost of health care among the policyholders in the state. Although the statute does shift the burden of innocent misrepresentations (the legal risks) onto the insurer, it does not spread the risk of insurance (health) coverage for which the parties contracted. 13 Thus, the statute is more akin to the Mississippi law at issue in Pilot Life, which defined the criteria necessary for an insured to collect punitive damages from an insurer. Although the statute fits the common sense definition of insurance regulation, it fails to satisfy at least one prong of the three part Metropolitan Life test 14. Thus, the statute does not fall within the ERISA insurance savings clause and is, therefore, preempted by ERISA.
Tingle argues that because there is little or no federal common law developed in this area and ERISA is silent concerning misrepresentation, this type of state law is what the ERISA preemption exception was...
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