United States District Court, Central District of California
(IN CHAMBERS) ORDER RE: MOTION FOR SUMMARY JUDGMENT
Plaintiff Halayne Kasoff (“Plaintiff”) is an elderly insured who purchased a long term care policy (the “Policy”) from Defendant Bankers Life and Casualty Company (“Defendant”). (See Docket No. 23-1 [Decl. of Richard P. Tricker (“Tricker Decl.”)] at Ex. 1 [First Amended Complaint (“FAC”)].) Plaintiff alleges that Defendant failed to properly pay benefits due under the Policy and is now liable under four causes of action: (1) breach of contract; (2) tortious breach of the implied covenant of good faith and fair dealing; (3) conversion; and (4) elder abuse. (See id.) Defendant denies that Plaintiff was entitled to Policy benefits and now moves for summary judgement. (Docket No. 23 [Mem. for Summary Judgment (“Mem.”)] at 1.) Each of Plaintiff’s legal theories necessarily rely on the allegation that Defendant improperly denied coverage. (FAC ¶¶ 27, 31, 38, 42.) Therefore, if it can be shown that Plaintiff’s claim was properly denied, then Defendant is entitled to summary judgment on all four counts of the FAC.
Both parties appear to agree that the question of Plaintiff’s coverage rests on the proper meaning of a single Policy provision: “Any One Period of Expense.” (Mem. at 1; Docket No. 24 [Plaintiff’s Opposition (“Opp.”)] at 12.) The Court finds no material facts are in dispute, that the meaning of the provision is clear and unambiguous and that, as a matter of law, Defendant’s denial of coverage was proper. Accordingly, Defendants Motion for Summary Judgment is GRANTED. The Court sets forth its reasoning in further detail below.
A. The Insurance Policy
On June 1, 2001, Defendant issued Plaintiff a home care Policy, which covered various “home and community-based care services.” (Docket No. 24-2 [Plaintiff’s Statement of Controverted and Uncontroverted Facts (“SCUF”)] ¶ 1; Tricker Decl. at Ex. 4 [Decl. of Rita Bennet (“Bennet Decl.”)] at Ex. A [Kasoff Policy at 8].) The “Benefits Limitations” provision of the Policy provides that the insurer will not “pay more than the Maximum Benefit for Any One Period of Expense for the total of all Benefits payable under this policy combined.” (Id. ¶ 114.) The Policy also provides the following relevant definitions:
‘Any One Period of Expense’ begins when the Insured first incurs a charge for expenses covered under this policy. It ends when, for six consecutive months, the Insured is no longer receiving Long-Term Care Services for the same cause or causes for which the previous Period of Expense began. Then provided the policy is in force, a new Period of Expense may begin. Under a new Period of Expense, the Maximum Benefit is fully restored and a new Deductible and Elimination Period apply.
‘Maximum Benefit’ means the maximum amount We’ll pay per each Insured for the combined total of all expenses incurred and payable under the policy during Any One Period of Expense.
(Id. ¶¶ 3, 111.)
B. Plaintiff’s Claims
Before the present dispute, Plaintiff received benefits under the Policy for two previous claims. (Id. ¶ 5.) First, on July 1, 2007, Plaintiff began receiving benefits for a knee injury and a “total right knee replacement.” (Id.) Next, during sometime in 2009, Plaintiff submitted claims for a shoulder injury. (Id. ¶ 6.) The parties disputed coverage of the shoulder injury, leading Plaintiff to file suit. (Id. ¶ 7.) The matter was eventually settled, and Plaintiff received Policy benefits for her shoulder disability beginning on January 24, 2011. (Id. ¶¶ 7, 10.) Defendant paid benefits until Plaintiff reached the Maximum Benefit amount for her shoulder injury on January 7, 2013. (Id. ¶ 10.)
In the meantime, while receiving payments for her shoulder injury, Plaintiff suffered another accident resulting in injury. On January 23, 2012, Plaintiff fell and injured her knee and nose, after which she continued to receive benefits due to the earlier coverage triggering injury to her shoulder. (SCUF ¶ 9.) Those benefits were exhausted on January 7, 2013.
On March 20, 2013, Plaintiff filed a claim for home care benefits for the 2012 knee injury. (Id. ¶ 14.) Because this claim was made less than six months after payments ceased for her prior injury, Defendant concluded that Plaintiff’s claim was not under a “new Period of Expense, such that additional benefits were owed to her after January of 2013, because . . . [Plaintiff] had continued to receive home care for her shoulder disability after the knee injury occurred.” (Id. ¶ 25.) Because six consecutive months had not passed since Plaintiff received “Long-Term care” resulting from the coverage-triggering shoulder injury, Defendants denied her claim. (Id.)
A. Legal ...