Bear v. Lifemap AssuranceBear v. Lifemap Assurance
Opinion
ORME, Judge:
¶1 Tomi Bear, an employee of the Tooele County School District (the District), applied for an increase in life insurance benefits for herself and her ailing husband (Husband) during the District‘s open enrollment period. The insurance provider, LifeMap Assurance Company, required medical histories as part of the application process, which Bear failed to provide. Despite this incomplete application, due to a software glitch, for several
BACKGROUND1
¶2 Bear was employed by the District from 1993 to 2016. As part of her employment benefits, Bear was eligible to purchase voluntary group life insurance coverage for herself and Husband, which the District had contracted with LifeMap to provide since 2012.
¶3 In 2014, the District elected to self-administer the group life insurance policy (the Group Policy). This included gathering applications from its employees and forwarding them to LifeMap for underwriting. For applications that LifeMap approved, the District calculated and gathered premium payments from employees through payroll deductions, added its own premium payments, and made monthly lump sum payments to LifeMap. Under the Group Policy, the District was precluded from collecting premium payments from an employee unless LifeMap first approved the employee‘s application. The
¶4 When making the aforementioned monthly aggregate payments, the District did not identify the individuals whose payroll deductions made up the lump sum to LifeMap. Instead, LifeMap provided a “bill” template that the District was required to fill out, which calculated the total amount of employee premiums the District collected. LifeMap would then review the amount collected to determine whether there was a 10% increase or decrease from the previous month. If the discrepancy was 10% or higher, LifeMap would ask the District to explain the reason for the change. LifeMap was not concerned with discrepancies that were under 10% and would not contact the District in those situations. When reporting on discrepancies exceeding 10%, the District would typically explain the discrepancy by informing LifeMap that employees were either laid off or hired, or that new coverage was added. Based on the District‘s size, a 10% discrepancy would typically equate to an amount between approximately $2,200 and $2,900 per month. During the 2015–2016 school year, LifeMap was aware that “the District repeatedly failed to provide all the required information in the bill it sent each month to LifeMap,” but LifeMap did not affirmatively act to resolve the discrepancies.
¶5 Under the Group Policy, eligible employees could apply within 31 days of eligibility for a guaranteed issue amount for themselves and their spouses without having to provide evidence of insurability (EOI).2 The maximum guaranteed issue amount was $400,000 for an employee and $50,000 for a spouse,
¶6 Employees could make changes to their benefits once a year during an open enrollment period. During the 2015–2016 school year, the District implemented a new software program, iVisions, for employees to make benefit elections during the open enrollment period. During that time, Bear, using the new software program, requested an increase in the voluntary life insurance policies for herself and Husband from $10,000 to $300,000. After checking the corresponding box to make that request, a pop-up box appeared displaying the following message:
REMINDER: If you are a new enrollee or increasing coverage, you MUST complete and submit a Health Statement (EOI) to the Benefits Department for approval from LifeMap.
To print out a form, please click the “Previous” button below to find the LifeMap Health Statement
link or you may visit the Information Center located under Employee Resources.3
To move to the next step, applicants were required to click a button labeled “OK.” Bear did not remember seeing the link to the EOI and did not complete and submit the EOI as part of her request for an increase in life insurance benefits for her and Husband. After Bear submitted the request, iVisions generated a “Benefit Enrollment Confirmation Statement” listing the benefits Bear had elected for the 2015–2016 school year, including an increase in voluntary life insurance benefits in the amount of $300,000 for herself and Husband. The statement also indicated that Bear was authorizing the District to make payroll deductions for the selected benefits.
¶7 At the time of Bear‘s selection, Husband suffered from several physical ailments, including type II diabetes, stage IV chronic kidney disease, end-stage renal failure, coronary artery disease, and hypertension. Bear would have been required to disclose these medical conditions in an EOI. And it is
¶8 Bear does not recall LifeMap notifying her that her request for an increase in voluntary life insurance benefits had been approved as contemplated by the terms of the Group Policy. LifeMap asserted that it “had no information or knowledge concerning any purported application for $300,000 in life insurance for [Husband] prior to [his] death and sent no notice to [Bear] or any communication at all to [Bear] on this subject prior to [Husband‘s] death.”
¶9 In August 2015, as part of the process of closing the open enrollment period and preparing for the September 1 effective date, the District‘s insurance benefits specialist (Benefits Specialist) saw that the system was set to make deductions from Bear‘s payroll for two $300,000 life insurance policies, which LifeMap had not approved. Benefits Specialist explained that the system updated employees’ benefits based on the requests employees made during open enrollment and that she would later have to manually change the benefit amounts to whatever was actually approved. Accordingly, because Bear had not submitted EOIs for herself and Husband and because LifeMap had not approved an increase to $300,000 for either person, Benefits Specialist manually changed the policy amount back to the original $10,000 in both policies. But when changing the policy amount for Husband, Benefits Specialist neglected to include a dollar sign in front of the 10,000 figure. Benefits Specialist later speculated that this or some other “bug” resulted in an error in which her manual override for Husband‘s benefits did not take effect. Accordingly, although LifeMap never approved Bear‘s request for an increase in benefits, between September 4, 2015, and February 5, 2016, the District erroneously
¶10 Husband died in January 2016. Shortly after, Bear contacted Benefits Specialist to submit a claim for $300,000 in life insurance to LifeMap. In February, Benefits Specialist asked LifeMap for clarification because the District‘s records showed that Bear was entitled to $14,0005 in life insurance benefits but Bear was claiming to have an approval letter for $300,000. LifeMap replied that it never received an EOI for Husband and that its records did not show that it had issued an approval letter for the requested increase. In April, LifeMap issued a check in the amount of $14,085.34 to Bear, which consisted of the amounts explained in footnote 5, with interest. LifeMap denied Bear‘s claim for the additional $290,000. The District later refunded the increased premiums for Husband‘s life insurance policy that were erroneously deducted from Bear‘s paychecks.
¶11 In 2018, Bear sued LifeMap and the District, alleging breach of contract, breach of the covenant of good faith and fair dealing, and promissory estoppel against both defendants. Bear additionally alleged negligence, negligent supervision, breach of
¶12 Following discovery, the parties all filed motions for summary judgment. After a hearing on all three motions, the district court granted both defendants’ motions and denied Bear‘s motion. Accordingly, the court dismissed all claims against LifeMap and the District.
¶13 Bear appeals.
ISSUES AND STANDARDS OF REVIEW
¶14 Bear appeals the district court‘s denial of her motion for summary judgment on her claims for breach of contract and breach of the implied covenant of good faith and fair dealing and its grant of LifeMap‘s and the District‘s motions for summary judgment on those same claims.6 “Summary judgment is only appropriate ‘if the moving party shows that there is no genuine dispute as to any material fact and the moving party is entitled to judgment as a matter of law.‘” Arnold v. Grigsby, 2018 UT 14, ¶ 8, 417 P.3d 606 (quoting
ANALYSIS
I. Breach of Contract
¶16 “The elements of a prima facie case for breach of contract are (1) a contract, (2) performance by the party seeking recovery, (3) breach of the contract by the other party, and (4) damages.” America West Bank Members, LC v. Utah, 2014 UT 49, ¶ 15, 342 P.3d 224 (quotation simplified). Bear‘s claims for breach of contract against LifeMap and the District were at issue in all three motions for summary judgment. We address this claim as it was raised in each of the motions.
A. Bear‘s Motion for Summary Judgment
¶17 In seeking summary judgment on her breach of contract claim against LifeMap, Bear argued that Utah Code section 31A-23a-410 established the first and second elements of her claim. The statute provides,
Subject to Subsections (2) and (5), as between the insurer and the insured, the insurer is considered to have received the premium and is liable to the insured for losses covered by the insurance and for any unearned premiums upon cancellation of the insurance if an insurer, including a surplus lines insurer:
(a) assumes a risk; and
(b) the premium for that insurance is received by:
(i) a licensee who placed the insurance;
(ii) a group policyholder;
(iii) an employer who deducts part or all of the premium from an employee‘s wages or salary; or
(iv) an employer who pays all or part of the premium for an employee.
¶18 The district court rejected this argument. It held that the statute did not apply and therefore Bear did not establish the first two elements of her claim because regardless of “[w]hether the premiums were remitted,” LifeMap did not “assume the risk.” The court stated that under the Group Policy, LifeMap agreed to an assumption of risk only if certain “conditions were met for a particular employee.” Thus, because there “is a precondition to [the] statute applying,” and as that precondition—the requirement to submit an EOI—was not met, the court concluded that the statute “does not apply here.”
¶20 But even under Bear‘s interpretation that LifeMap “assume[d] a risk” by entering into the Group Policy with the District, that risk is not completely open-ended. Rather, that risk is defined by the terms of the Group Policy, and the two are inextricably interwoven. Accordingly, under either interpretation of the statute, the terms of the Group Policy determine the extent of the risk of loss LifeMap undertook. And the Group Policy expressly provided that LifeMap “will require [an EOI] for all persons applying for insurance” if, among other things, an employee wished to increase coverage or wished to apply for coverage over the guaranteed issue amount. Thus, even if LifeMap “assume[d] a risk,” as Bear contends, by entering into the Group Policy with the District, such a risk was not boundless—LifeMap expressly limited that risk, agreeing to extend coverage to an employee or their spouse above the guaranteed issue amount only upon its review of an EOI and subsequent acceptance of the application. Further, the statute does not require that an insurer assume a risk for any loss incurred by a person making premium payments where, under the terms of the policy, the insurer agreed to assume only a risk of a specific loss. See Utah Transit Auth. v. Greyhound Lines, Inc., 2015 UT 53, ¶ 33, 355 P.3d 947 (stating that in exchange for premium payments, an insurance carrier “assumes the risk of
B. LifeMap‘s Motion for Summary Judgment
¶21 Bear next contends that the district court erred in granting LifeMap‘s motion for summary judgment on her breach of contract claim. Specifically, she contends the court erred in determining that (1) the condition precedent for coverage was not met because the Group Policy unambiguously “require[s] an EOI in these circumstances” and (2) LifeMap did not waive the EOI requirement by accepting the higher premium payments.
1. Ambiguity
¶22 Bear asserts that the Group Policy “is ambiguous regarding whether LifeMap‘s receipt of an EOI is a condition precedent before coverage will start.”8 She relies on Mellor v. Wasatch Crest Mutual Insurance, 2009 UT 5, 201 P.3d 1004, which noted that “an ambiguity in a contract may arise . . . because two or more contract provisions, when read together, give rise to different or inconsistent meanings, even though each provision is clear when read alone.” Id. ¶ 13 (quotation simplified). Bear contends an ambiguity exists because, with our emphasis, the
¶23 Under Mellor, “an ambiguity in a contract may arise . . . because two or more contract provisions, when read together, give rise to different or inconsistent meanings, even though each provision is clear when read alone.” 2009 UT 5, ¶ 13 (emphasis added) (quotation otherwise simplified). Accordingly, an ambiguity may arise from the inconsistency to which Bear points only if the heading is a substantive provision of the contract. And we have previously held that “[c]ontract headings are more appropriately regarded as organizational tools than substantive contract provisions.” McEwan v. Mountain Land Support Corp., 2005 UT App 240, ¶ 25, 116 P.3d 955. See also Vanderwood v. Woodward, 2019 UT App 140, ¶ 26 n.7, 449 P.3d 983 (stating that a court, in examining the plain meaning of contractual language, may “give the section heading some weight” where “the section heading is completely in harmony with the section‘s text“). Accordingly, “because the contract heading is not actually part of the contract,” no ambiguity arises from any apparent
¶24 The substantive language of the contract provision in issue unambiguously provides, with our emphasis, that LifeMap ”will require [an EOI] for all persons applying for” an increase in coverage or insurance that exceeds the guaranteed issue amount. This language created a condition precedent, which Bear undisputedly failed to satisfy when she did not submit an EOI for Husband. See Wade v. Utah Farm Bureau Ins., 700 P.2d 1093, 1095–96 (Utah 1985) (holding that failure to satisfy a condition precedent—a medical exam, in that case—resulted in no life insurance coverage). Accordingly, the district court did not err in granting summary judgment to LifeMap on this ground.
2. Waiver
¶25 In granting summary judgment to LifeMap on the issue of waiver, the district court held “that there was no waiver by LifeMap [of the EOI requirement] simply by accepting and receiving the premiums that were paid by Ms. Bear.” In the court‘s view, LifeMap‘s acceptance of the premiums “could not affect intentional or knowing waiver of its right to demand that EOI simply because it received a lump sum payment of premiums every month from the school district.” Bear contends this ruling was in error because “there is [a] genuine issue of fact regarding whether or not LifeMap—through its actions—implicitly intended to enter into a contract with [Bear], and whether it waived the EOI.” Specifically, Bear argues that LifeMap knew the District was incorrectly administering the Group Policy because the District failed to provide all required information in the monthly bills it sent to LifeMap during the 2015–2016 school year. Bear asserts that by not immediately
¶26 “A waiver is the intentional relinquishment of a known right.” McCleve Props., LLC v. D. Ray Hult Family Ltd. P‘ship, 2013 UT App 185, ¶ 10, 307 P.3d 650 (quotation simplified). “To constitute waiver, there must be (1) an existing right, benefit or advantage, (2) a knowledge of its existence, and (3) an intention to relinquish it.” Id. (quotation simplified). “Courts do not lightly consider a contract provision waived“—waiver can be established only “where there is an intentional relinquishment of a known right.” Mounteer Enters., Inc. v. Homeowners Ass‘n for the Colony at White Pine Canyon, 2018 UT 23, ¶ 17, 422 P.3d 809 (quotation simplified). Such relinquishment may be express or implied, but if the latter, “the party asserting implied waiver must establish that the other party intentionally acted in a manner inconsistent with its contractual rights.” Id. (quotation simplified). “Courts should exhibit caution in finding implied waiver on the part of [a party] unless the totality of the circumstances demonstrates an unambiguous intent to waive” a contract right. U.S. Realty 86 Assocs. v. Security Inv., 2002 UT 14, ¶ 16, 40 P.3d 586 (quotation simplified). To that end, due to the “intensely fact-dependent” nature of the waiver inquiry, summary judgment on the issue of waiver is appropriate only “if, under the totality of the circumstances, no reasonable fact finder could conclude that [a party] intended to waive its rights.” IHC Health Services v. D & K Mgmt., 2008 UT 73, ¶¶ 15, 19, 196 P.3d 588 (quotation simplified).
¶27 Bear, in effect, argues that LifeMap intentionally relinquished its right to review an EOI for Husband because it could have discovered that the District was erroneously
C. The District‘s Motion for Summary Judgment
¶28 Bear next challenges the district court‘s grant of the District‘s motion for summary judgment on her breach of contract claim.9 In relevant part, the court granted summary
¶30 Bear contends the court overlooked evidence she presented of the District‘s offer of life insurance to eligible employees, including herself. She first points to an agreement that the Tooele Educational Support Professional Association negotiated with the District on behalf of the District‘s employees. The agreement indicated that “Insurance Coverage will be provided for all seven (7) hour employees” and that “Employees are responsible for updating dependent coverage, change in status, and open enrollment.” Bear also points to a flyer the District distributed to its employees informing them of the dates of the 2015–2016 open enrollment period and indicating that they could enroll in, among other things, voluntary life insurance. Lastly, Bear relies on the deposition testimony of Benefits Specialist confirming that Bear had applied for $300,000 in life insurance benefits for herself and Husband.10
¶32 Indeed, the evidence supports the opposite conclusion—that the District offered to facilitate (and pay for part of) various insurance benefits through third-party insurance carriers. For example, in addition to providing the dates for the 2015–2016 open enrollment period, the flyer to which Bear points also indicated changes made to insurance carriers from the previous year. Also, the flyer informed employees that the District had switched carriers for long-term disability insurance and that it had added another carrier option for vision insurance. As concerns voluntary life insurance, the flyer indicated that no changes had been made from the previous year. And Bear has not provided evidence that prior to the 2015–2016 enrollment period, the District directly paid life insurance benefits to its employees. To the contrary, the record is clear that the District contracted with LifeMap to provide life insurance benefits to its employees as early as 2012. Furthermore, although the District deducted increased premiums from Bear‘s pay over a four-month period, it is undisputed that the District forwarded
¶33 Thus, because the evidence to which Bear points does not contradict the evidence in the record that the District offered to facilitate life insurance benefits for eligible employees through the Group Policy it entered with LifeMap—and not to directly pay the benefits itself—a dispute of material fact does not exist on this point. See
II. Implied Covenant of Good Faith and Fair Dealing
¶34 “The implied covenant of good faith and fair dealing . . . inheres in every contract.” Backbone Worldwide Inc. v. LifeVantage Corp., 2019 UT App 80, ¶ 16, 443 P.3d 780 (quotation simplified). It “prohibits the parties from intentionally injuring the other party‘s right to receive the benefits of a contract, and prevents either party from impeding the other‘s performance of [their] obligations by rendering it difficult or impossible for the other to continue performance.” Id. (quotation simplified). But the covenant of good faith and fair dealing (the covenant) cannot, among other things, “compel a contractual party to exercise a
¶35 Bear challenges the district court‘s grant of summary judgment on its claim against LifeMap and the District for breach of the covenant. As against LifeMap, Bear merely asserts that it “purposefully injured [her] right to the foregoing $300,000 in voluntary life insurance benefits when it denied [her] rightful claim.” But as discussed above, the Group Policy is unambiguously clear that Bear was required to submit an EOI for Husband as part of the application process, which contractual right LifeMap did not waive, and it is undisputed that she failed to include an EOI as part of her application. It is further undisputed that had she submitted an EOI, LifeMap would have denied the application based on Husband‘s highly problematic medical history. Accordingly, LifeMap had the contractual right to deny Bear‘s claim and therefore did not violate the covenant by doing so. See id. ¶ 24 (“As long as the party has an express and objectively determined [contractual] right, and absent elements of legal waiver being met, that party may exercise that right, and its motives for doing so are irrelevant, despite the existence of the implied covenant.“) (quotation simplified).
¶36 And concerning the District, Bear‘s argument is even more meager. Her argument on this point is limited to the assertion that “[a]s the implied covenant of good faith and fair dealing inheres in all contracts, there is also a genuine issue of fact on [her] claim for breach of [the] implied covenant of good faith and fair dealing against the District based upon the above facts.” Other than vaguely referencing “the above facts,” Bear does not identify what conduct on the part of the District constituted a breach of the covenant. Because we have concluded that there was no contract by which the District would be required to directly pay Husband‘s life insurance benefits, the District‘s refusal to make such payment and its erroneous
CONCLUSION
¶37 The district court did not err in denying Bear‘s motion for summary judgment and in granting LifeMap‘s and the District‘s motions for summary judgment. Affirmed.