177 So. 3d 807
La. Ct. App.2015Background
- On June 1, 2010, nine-year-old Reid Folley was struck in the mouth by a baseball during practice and required extensive and future medical/dental treatment.
- Nationwide issued a medical expense benefit policy to USSSA that limited payment to “covered expenses incurred within 3 years from such date” of the accident.
- Plaintiffs sued Nationwide (medical-payments), the liability insurer, USSSA, and the coach; plaintiffs alleged future treatment would be needed after the three-year window.
- Nationwide paid $18,589.86 and moved for summary judgment, asserting it had paid all expenses “incurred within three years” and that the policy bars payments for treatment after that period.
- Plaintiffs produced medical opinions and estimates showing diagnosis and a recommended course of treatment before the 3‑year cutoff but with procedures that could not be completed within three years.
- The trial court denied Nationwide’s summary-judgment motion; after an intermediate writ denial this court, and remand from the Louisiana Supreme Court, the appellate court denies Nationwide’s writ and affirms denial of summary judgment.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Meaning of “incurred” in policy limiting coverage to expenses “incurred within 3 years” | Expenses are "incurred" if injury manifested, diagnosis and recommended treatment obtained within period, even if actual procedures occur later | “Incurred” means expenses actually paid or for treatment received within the 3‑year period; expenses after cutoff not covered | Ambiguity exists; factual dispute whether recommended-but-future treatment constitutes expenses "incurred" precludes summary judgment |
| Applicability of Hoffman precedent | Hoffman is distinguishable because there plaintiff’s recoverable amount depended on discounted payment actually made; here plaintiffs will actually pay future costs | Hoffman supports limiting recovery to amounts the insured became obligated to pay during coverage | Court finds Hoffman distinguishable and not controlling; different factual posture regarding obligation/payment |
| Whether policy ambiguity must be construed for coverage | Plaintiffs urge construing ambiguity against insurer to preserve coverage | Nationwide argues policy language is clear and bars post‑period expenses | Court finds ambiguity ("incurred" undefined) and applies contra proferentem; summary judgment denied |
| Appropriateness of summary judgment | Plaintiffs: genuine issue of material fact about when expenses are incurred | Nationwide: no genuine issue; paid all incurred within 3 years | Because ambiguity and factual disputes exist, summary judgment was improperly granted for mover; denial stands |
Key Cases Cited
- Hoffman v. Travelers Indem. Co. of America, 144 So.3d 993 (La. 2014) (addresses when medical expenses are considered "incurred" in the context of insurer-provider payment arrangements)
- Valladares v. Monarch Ins. Co., 282 So.2d 569 (La. App. 4 Cir. 1973) (insurer liable where injury manifested and treatment plan obtained within policy period though treatment could not be completed within that period)
- Barton v. Avoyelles Parish Sch. Bd., 153 So.3d 448 (La. App. 3 Cir. 2014) (ambiguous policy terms construed against insurer and preclude summary judgment)
- Herlitz Const. Co., Inc. v. Hotel Investors of New Iberia, Inc., 396 So.2d 878 (La. 1981) (appellate supervisory jurisdiction may decide merits to avoid wasted litigation)