Kurtz v. AF & L Insurance Co.
211 So. 3d 1115
| Fla. Dist. Ct. App. | 2017Background
- AF&L issued a long-term care policy to Charlotte James in 2000 providing: home health care, nursing home care, and an "assisted living facility" (ALF) benefit; Long Term Care Maximum Benefit Period = 3 years; home health daily max = $170.
- Policy defines "home" as independent residency and excludes ALFs; home health benefits payable for medically necessary services in the insured's home.
- While living independently, James received home health care at $170/day and premiums were waived after qualifying under the waiver provision (90 continuous days of benefits; for home health care, at least 5 days/week).
- On June 6, 2013 James moved into an assisted living facility; AF&L began paying the ALF benefit equal to the lesser of daily room & board ($116) or the nursing home daily amount ($170), and ceased the premium waiver.
- Kurtz (as POA) sued AF&L alleging breach: (1) James still qualified for home health benefits (so premiums should remain waived); and (2) marketing materials/application and policy language required AF&L to pay the $170 nursing-home maximum while James resided in the ALF (i.e., $170/day rather than $116).
- The trial court granted summary judgment for AF&L; on appeal the court reviews de novo and affirms, holding the policy unambiguous and AF&L in compliance.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether policy is ambiguous regarding overlap/"combination" of home health and ALF benefits | Kurtz: "in any combination" language allows stacking/combining ALF and home health benefits simultaneously (or creates ambiguity) | AF&L: "in any combination" refers to combination of days/time periods toward the 3‑year maximum, not concurrent daily stacking | Court: No ambiguity; benefits are mutually exclusive daily; "in any combination" refers to aggregated time periods toward the 3‑year cap |
| Whether James remained eligible for home health benefits after moving to ALF (and thus premium waiver continued) | Kurtz: Moving to ALF does not preclude home health benefit or premium waiver because policy permits combination | AF&L: Policy defines "home" to exclude ALF; once in ALF she is not receiving home health care and premium waiver ends | Court: Held AF&L properly terminated premium waiver when James entered ALF because home health applies only at "home" |
| Whether AF&L breached by paying $116/day (room & board) rather than $170/day (nursing home maximum) while in ALF | Kurtz: Marketing materials and application promised up-to the nursing home maximum while in ALF; policy ambiguous so interpret for insured | AF&L: Policy requires payment of the lesser of reasonable charges for ALF room/board or nursing home benefit; $116 is correct | Court: Held AF&L paid correctly under policy; no ambiguity from marketing/application alleged |
| Proper construction of policy "in any combination" phrase and scope of Long Term Care Maximum Benefit Period | Kurtz: "In any combination" could imply services can be provided concurrently or benefits stacked | AF&L: Phrase tied to the Maximum Benefit Period; means services count in combination over time toward the 3‑year limit | Court: Interpreted phrase as combination of time periods; confirmed policy read as whole supports AF&L's interpretation |
Key Cases Cited
- Washington Nat’l Ins. Corp. v. Ruderman, 117 So. 3d 943 (Fla. 2013) (courts must read insurance policies as a whole)
- U.S. Fire Ins. Co. v. J.S.U.B., Inc., 979 So. 2d 871 (Fla. 2007) (give every provision full meaning and operative effect)
- Swire Pac. Holdings v. Zurich Ins. Co., 845 So. 2d 161 (Fla. 2003) (avoid concentrating on limited provisions to exclusion of others)
- Garcia v. Fed. Ins. Co., 969 So. 2d 288 (Fla. 2007) (ambiguities require actual ambiguity; complexity alone insufficient)
- Penzer v. Transp. Ins. Co., 29 So. 3d 1000 (Fla. 2010) (policy interpretation is reviewed de novo)
- Barcelona Hotel, LLC v. Nova Cas. Co., 57 So. 3d 228 (Fla. 3d DCA 2011) (same)