Opinion
Civil Action No. 04-505, Section "L" (5).
November 2, 2004
ORDER REASONS
Before the Court is the Motion of the Defendant for Summary Judgment, taken under submission after oral argument. After considering the argument of counsel, the legal memoranda, and all of the evidence before it, the Court hereby DENIES the Defendant's Motion.
I. Facts
This case arises out of the Defendant's denial of disability benefits to the Plaintiff. Plaintiff was hired as an independent contractor truck driver by Prime, Inc. As an independent contractor, in the event of an injury arising in the course and scope of employment, Plaintiff would not be entitled to worker's compensation. As such, he purchased a Group Occupational Accident Insurance Policy from the Defendant to cover injuries sustained on the job.
On January 17, 2003, his first day of work, Plaintiff "blacked out" while driving, causing an accident. As a result of the collision, the Plaintiff allegedly sustained injuries to his neck, lower back, and lower extremities. Plaintiff made a claim against the disability policy, which was denied by the Defendant. Defendant claims that the collision was "precipitated by a physical illness or condition, rather than resulting from an accidental means independent of all other causes," as required under the Policy. That is, according to the Defendant, the collision occurred as a result of the Plaintiff's black out, which occurred as a result of some pre-existing condition. Plaintiff contends that the cause of his black out is unknown and that, as a result of the accident, the Plaintiff aggravated a pre-existing condition that has rendered him totally temporarily disabled. According to Plaintiff, he is entitled to benefits under the Policy.
Defendant also claims that the Plaintiff was never eligible to obtain coverage because his commercial driver's license was invalid. Defendant claims that the license was invalid because the Plaintiff intentionally misrepresented his physical and psychological conditions. Specifically, Defendant claims that the Plaintiff has suffered from heroine addiction since 1974, has abused cocaine for twenty years, has been diagnosed as schizophrenic, and has pre-existing back, neck, and heart conditions. According to the Defendant, the Plaintiff was never qualified to obtain a commercial driver's license and, as such, he is not eligible for coverage under the Policy.
II. Legal Standard
Summary judgment will be granted only if the pleadings, depositions, answers to interrogatories, and admissions, together with affidavits show that there is no genuine issue as to any material fact and that the defendant is entitled to a judgment as a matter of law. Fed.R.Civ.P. 56. If the party moving for summary judgment demonstrates the absence of a genuine issue of material fact "the nonmovant must go beyond the pleadings and designate specific facts showing that there is a genuine issue for trial." Willis v. Roche Biomedical Laboratories, Inc., 61 F.3d 313, 315 (5th Cir. 1995). "[A] dispute about a material fact is genuine if the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Id. To oppose a motion for summary judgment, the non-movant cannot rest on mere allegations or denials but must set forth specific facts showing that there is a genuine issue of material fact. See Celotex Corp. v. Catrett, 477 U.S. 317, 321-22 (1986).
The burden of demonstrating the existence of a genuine issue is not met by "metaphysical doubt" or "unsubstantiated assertions." Little v. Liquid Air Corp., 37 F.3d 1069, 1075 (5th Cir. 1994) (quoting Matsushita Elec. Indus. Co. v. Zenith Radio, 475 U.S. 574, 586 (1986)). The Court must "resolve factual controversies in favor of the nonmoving party, but only when there is an actual controversy, that is, when both parties have submitted evidence of contrary facts." Id. The Court does not, "in the absence of proof, assume that the nonmoving party could or would prove the necessary facts." Id. If the record taken as a whole could not lead a rational trier of fact to find for the nonmoving party, no genuine issue exists for trial. See Matsushita, 475 U.S. at 588. Finally, "the mere existence of some factual dispute will not defeat a motion for summary judgment; Rule 56 requires that the fact dispute be genuine and material." Willis, 61 F.3d at 315. If the evidence leads to only one reasonable conclusion, summary judgment is proper. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250 (1986).
III. Analysis
A. Plaintiff's medical condition
Under the Policy, a covered injury is defined as, "an accidental bodily injury that is caused solely by accidental means and is independent of all other causes." Among other things, the Policy excludes from coverage benefits that are "caused by, contributed to, or result from . . . illness, disease or infection." After considering the Plaintiff's claim for benefits, the Defendant denied the claim, stating, "the information submitted does not provide evidence there was an accidental bodily injury direct and independent of all other causes, but rather the injury was caused by, contributed to, or result [sic] from a medical condition, an exclusion under the policy."
Defendant claims that the black out was caused by Plaintiff's pre-existing cardiac condition, namely, ischemic heart disease. As such, Defendant argues that the accident and subsequent injuries were caused by the pre-existing cardiac condition. In support of this contention, Defendant cites the deposition testimony of Dr. Salazar who opined that the Plaintiff likely, though not absolutely, passed out "secondary to arrhythmias."
Plaintiff claims that the diagnosis of ischemic heart disease came eight months after the accident. Plaintiff further claims that there is no evidence regarding when the onset of the heart disease occurred or that this condition caused the black out. In fact, Dr. Salazar also testified that he could not tell if the condition he diagnosed eight months after the incident was related to the accident. Plaintiff also argues that the Plaintiff underwent blood pressure, heart tones, and EKG rhythms testing after the accident, all of which were normal. Thus, the medical question concerning what caused the Plaintiff to black out is unresolved and in dispute at this time.
Summary judgment is not appropriate on this issue.
B. Whether commercial driver's license was valid
By its terms, the Policy requires a beneficiary to have a valid and current commercial driver's license. The requirements for a commercial driver's license are set forth in La.R.S. 32:401, et seq. In particular, La.R.S. 32:403.4 requires that an applicant "shall not have any physical or mental disability affecting the ability to exercise ordinary and reasonable control in the operation of a commercial motor vehicle." Applicants must submit a medical report "prepared by a duly licensed medical examiner, certifying that he is capable of exercising ordinary and reasonable control in the operation of a commercial motor vehicle." Id.
Defendant maintains that the Plaintiff misrepresented his medical information on the application form, particularly as it pertains to prior substance abuse, psychological impairment, spine disorder, and cardiac condition. Specifically, Defendant claims that the Plaintiff has suffered from heroine addiction since 1974 and that he has abused cocaine with regularity for nearly twenty years. Defendant claims that the Plaintiff completed an in-patient detoxification program just one month before the accident.
In addition to drug abuse, the Defendant claims that the Plaintiff has been diagnosed as a schizophrenic for which he has received medical treatment in the past. Defendant also claims that the Plaintiff has suffered from a long history of back problems stemming from two automobile accidents, one in Los Angeles in 1985 and one in New Orleans in 1995. Finally, Defendant claims that the Plaintiff had a pre-existing cardiac condition of which he was aware.
Defendant claims that the Plaintiff underwent an EKG on February 24, 2003, resulting in an abnormal finding. This was confirmed by an EKG taken on February 28, 2003, which was characterized as "grossly abnormal." The Court notes that these tests were performed after the accident.
Plaintiff does not dispute his long-standing drug addiction problem nor his psychological diagnosis of schizophrenia. The medical report submitted by the Plaintiff clearly shows that the Plaintiff failed to report his past drug use and schizophrenia. Plaintiff claims that he did report past back injury and that he did not report past cardiac problems because none had ever been diagnosed.
The undisputed facts, then, before the Court are that the Plaintiff, at least, misrepresented his prior drug use and schizophrenia on the medical report required to be submitted as part of his application to obtain a commercial driver's license. The parties dispute whether or not the Plaintiff lied about his prior back injuries. The parties agree that the Plaintiff did not report past heart problems, but the Plaintiff argues he had never suffered from heart problems. The issue before the Court as it pertains to these facts is whether or not the misrepresentations invalidate the commercial driver's license.
Defendant claims that the license was never valid due to the misrepresentations. Defendant cites no authority for this proposition, other than Black's Law Dictionary's definition of "valid." Plaintiff claims that, while the Department of Public Safety and Corrections must suspend, revoke, or restrict the license of a driver found to be incompetent or found to have provided false information, the Department does not retroactively invalidate the license. That is, upon issuance the license is valid until such time as the Department determines that the license should be revoked, suspended, or restricted. The Court agrees with the Plaintiff.
The Plaintiff may have his license suspended, revoked, or restricted for providing false information pursuant to La.R.S. 32:324 and may face criminal penalties and damages pursuant to 32: 414.4, 421, and 427. Nothing in the plain language of the revised statutes, however, supports the Defendant's argument that the license was never valid.
Section 421 provides:
Every person making application for a license under the provisions of this Chapter shall give and furnish such information as may be required by the department. The giving or furnishing of false, erroneous, or incorrect information shall be deemed a violation of this Chapter . . . In addition to the other penalties imposed by this Chapter, if the department determines, in its check of any applicant's license status and record prior to issuing a driver's license, or at any time after the driver's license is issued, that the applicant has falsified information, the department shall, and within no more than thirty days of discovering the falsification, suspend, revoke, or cancel the person's driver's license for up to sixty days. . . .
La.R.S. 32:421 (emphasis added).
Section 424(A) provides:
A. The department, having good cause to believe that a licensed driver or chauffeur is incompetent or otherwise not qualified to be licensed, may upon written notice of at least ten days to the licensee require him to submit to the knowledge or skills test required for issuance of a driver's license, or submit to a medical examination. Upon the conclusion of such test or examination, the department shall take action as may be appropriate, including permitting the licensee to retain the license or suspending, revoking, or restricting the license.
La.R.S. 32:424(A) (emphasis added).
Again, the applicable statutes do not provide for retroactive invalidation of the license.
While an exhaustive search resulted in no cases directly on point, one case is instructive. In Owen v. La. Dept. of Public Safety and Corrections, the court made note of La.R.S. 32:414(C)(2004), which states now (similarly to the time of the Owen case) that the Department of Public safety shall suspend the license of any person on evidence that the person has violated La.R.S. 32:414.1 (2004). 631 So. 2d 32 (La.Ct.App. 2nd Cir. 1994). This last article, La.R.S. 32:414.1, provides, in part, that, it is unlawful for anyone to "use a false or fictitious name in any application for an operator's or chauffeur's license or to knowingly make a false statement or to knowingly conceal a material fact or otherwise commit fraud in any such application, or to commit perjury by making any false affidavit, or knowingly swearing or affirming falsely to any matter or thing required by the terms of this Chapter to be sworn to or affirmed."
What is interesting in the Owen case is that the court enunciated the following principles: that penal statutes must be strictly construed, and any doubt concerning the coverage of a penal statute should be decided in favor of the accused and against the state. Then, the court, using these interpretive principles, stated that the statutory provisions which would result in the suspension of a driver's license must be strictly construed and any ambiguity must be interpreted in favor of the holder of the license and against the state. Owen, 631 So. 2d, at 35.
It would follow logically that if the provisions that would merely suspend a license must be construed narrowly, and against the State, the argument of the defendant insurance company to invalidate a license completely, should be construed against the insurance company. Furthermore, the language on which the defendant insurance company relies is not ambiguous, but nonexistent in the Revised Statutes. The Revised Statutes defines a driver's license (and we must assume a valid driver's license), not based on Black's Law Diction, but as "any license secured from the Department of Public Safety and Corrections, in accordance with this Chapter, to operate a motor vehicle on the highways of this state." La.R.S. 32:401(14).
The license appears to have been issued in accordance with the Chapter. The Plaintiff may have violated the law, however. The revised statutes provide a remedy for that situation, which would make him subject to the penalty of suspension or revocation, not retroactive invalidation. Thus, it follows, that until a license is suspended, revoked, or cancelled, it is valid. Accordingly, the requirement of a valid commercial driver's license under the Policy was met in this case.
Thus, summary judgment is not appropriate on this issue.
C. Whether policy is unenforceable because Plaintiff falsified his application for insurance
The policy issued to the Plaintiff was issued only to employees of Prime, Inc. The Plaintiff was not required to fill out a separate application for insurance. Defendant claims that their requirement that all applicants have a valid commercial driver's license presupposed that the applicants would have a minimum level of physical fitness. Defendant claims that they would not have provided coverage to the Plaintiff had they known of his true medical history. Thus, according to the Defendant, by falsifying his application for a commercial driver's license, the Plaintiff falsified his application for insurance.
Defendant cites the Court to La.R.S. 22:619, which provides in pertinent part:
B. In any application for life or health and accident insurance made in writing by the insured, all statements made therein made by the insured shall, in the absence of fraud, be deemed representations and not warranties. The falsity of 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.
However, as there is no written application for insurance, section 22:619 is inapplicable. Had the Defendant required the Plaintiff to complete a written application for insurance, its position might be stronger and the outcome of its motion might have been different.
The Court finds the Defendant's argument to be without merit. There is no application for insurance. Defendant essentially argues that the application for a commercial driver's license should qualify as a de facto application for insurance. However, there no evidence that such was the case. The insurance was provided to employees of Prime Inc., who held valid commercial driver's licenses. The Court has already found the commercial driver's license to be valid. Thus, the Policy is enforceable.
Accordingly, summary judgment is not appropriate on this issue.
D. Whether the accident was caused by "accidental means" as required under the Policy
Defendant next argues that the incident at issue was not caused by "accidental means" "independent of all other causes," and, as such, is not covered under the policy. The Policy does not define "accidental," however Louisiana courts have defined "accidental" as "whenever the results are such that an average person would deem them accidental. . . ." Murphy v. Continental Cas. Co., 269 So.2d 507, 517 (La.App. 1st Cir. 1972).
The parties spend a great deal of time in their briefs attempting to analogize the facts of this case to other cases. It is clear to the Court that a determination of whether an injury resulted from "accidental" means or not is a fact specific question. In this case, the facts are not clear. As stated above, the parties do not know what caused the Plaintiff to black out. As such, it is inappropriate to resolve the issue on summary judgment.
E. Whether the policy covers inability to work based upon the awakening of a dormant but existing condition
The Policy excludes injuries that are "caused by, contributed to, or result from . . . illness, disease or infection." The Defendant argues that the primary cause of the Plaintiff's inability to work is back pain suffered as a result of the accident. However, according to the Defendant, the Plaintiff has a "long history of chronic back disease, and was forced to leave at least one position of employment as a direct result of his degenerative condition." As such, Defendant claims that the accident at issue "awakened" a "dormant" condition. Though the Defendant claims to have reviewed the Plaintiff's medical history, including "numerous instances of treatment for lack back pain and hospital admissions for the same," the Defendant provides no evidence in support of its contentions, other than the conclusion of the doctor who performed the independent medical examination, Dr. Moss.
Dr. Moss concluded,
The examinee had significant clincial and radiological problems of his lumbar spine prior to the accident of 1/17/03. The current condition of his lumbar spine and his symptomatology can be related to the normal progression of the pre-existing spondylolisthesis and spondylosis.
(Ex. B, Def,'s Reply Memo. to Plaintiff's Opp.). Thus, Defendant claims that the Plaintiff's injuries were an exacerbation of a pre-exiting condition.
The Defendant cites Thibodeaux v. Pacific Mut. Life Ins. Co., in support of their contention that the Policy does not cover situations where disability is caused by the awakening of a dormant condition. 112 So.2d 423 (La. 1959). The Defendant, however, misinterprets the holding in that case. In Thibodeaux, the Plaintiff injured his back and was rendered totally disabled. As a result of the medical treatment, it was discovered that the Plaintiff suffered from a pre-existing, developmental or congenital condition of spondylolisthesis. The Plaintiff had not suffered symptoms from this condition prior to the accident, but it appeared to the medical experts that the accident awakened the condition, which resulted in the total disability of the Plaintiff. The policy at issue in the Thibodeaux contained similar language to the Policy in the case at bar as it pertained to covered events. The Thibodeaux policy covered only losses "resulting directly and independently of all other causes from bodily injuries accidentally sustained," and excluded losses which "resulted from or was contributed to by bodily infirmity."
Prior to his accident, the Thibodeaux Plaintiff was a rice farmer who performed very labor-intensive work. He had never suffered from back problems in the past. It was only after the accident that pre-existing condition became symptomatic. Thus, the Court concluded that "the injury which plaintiff suffered was the cause of his loss. It was effected by accidental means . . . The injury was independent of plaintiff's pre-existing condition, which was awakened by the occurrence." Thibodeaux, 112 So.2d at 428. The Court went on to say, "a review of authorities convinces us that where an insured has a dormant condition and such condition is awakened by the accident, the condition is not deemed the cause of the disability or loss which the insured suffers." (emphasis added). Id. Thus, the Court concluded that the plaintiff's injuries were caused by accidental means and were covered under the language of the policy.
Plaintiff in this case does not dispute that he suffers from spondylolisthesis and spondylosis and that those conditions were aggravated by the accident. He also cites the Thibodeaux case, but for the correct proposition that, at least under those facts, a dormant condition awakened by an "accident" will be a covered event.
In this case, it is not clear what caused the black out, it is not clear if and to what extent the Plaintiff suffered from back problems. As a general proposition, however, the Policy would likely cover an injury caused by accidental means which resulted in the awakening of a dormant condition.
Thus, summary judgment is not appropriate on this issue.
IV. Conclusion
The Court finds that material facts in the matter are in dispute and, thus, that the case is not in a posture for summary disposition. For the foregoing reasons, the Court hereby DENIES the Defendant's Motion for Summary Judgment.
This result is required under a fair reading of the insurance policy in question and the applicable and relevant cases authority cited above. But the Plaintiff's credibility will be a significant issue during the trial of this case and much of his past experience and medical history may well be relevant and admissible. Moreover, the Court may be required to re-focus on this matter in a timely motion made pursuant to Federal Rule of Civil Procedure 50, if that becomes necessary and appropriate.