F I L E D
United States Court of Appeals
Tenth Circuit
UNITED STATES COURT OF APPEALS
JUL 11 2000
TENTH CIRCUIT
__________________________ PATRICK FISHER
Clerk
LAJUAN C. JOHNSON and STEVEN JOHNSON,
Plaintiffs-Appellees and Cross-Appellants,
v. Nos. 98-4120
98-4121
LIFE INVESTORS INSURANCE COMPANY OF 98-4122
AMERICA, an Iowa corporation, and (D. Utah)
MONUMENTAL LIFE INSURANCE COMPANY, (D.Ct. No. 96-CV-283-K)
a Maryland corporation,
Defendants-Appellants and Cross-Appellees.
____________________________
ORDER AND JUDGMENT *
Before TACHA, BRORBY, and EBEL, Circuit Judges.
This case arises out of a dispute over insurance policies issued by Life
Investors Insurance Company of America (Life Investors), and Monumental Life
Insurance Company (Monumental) in favor of Marvin Johnson, deceased. Life
Investors and Monumental appeal the order of the district court granting summary
*
This order and judgment is not binding precedent except under the doctrines of
law of the case, res judicata and collateral estoppel. The court generally disfavors the
citation of orders and judgments; nevertheless, an order and judgment may be cited under
the terms and conditions of 10th Cir. R. 36.3.
judgment in favor of LaJuan Johnson and Steven Johnson, the plaintiffs and
beneficiaries of insurance policies issued by the two insurance companies.
LaJuan and Steven Johnson (the Johnsons) cross-appeal the denial of attorney
fees. We exercise jurisdiction pursuant to 28 U.S.C. § 1291 and affirm the grant
of summary judgment in favor of the Johnsons in their case against Monumental,
affirm the denial of attorney fees to the Johnsons from Monumental, and reverse
and remand the grant of summary judgment against Life Investors, and denial of
attorney fees to the Johnsons from Life Investors, to the district court for further
proceedings in accordance with this opinion.
I. FACTUAL BACKGROUND
For the purpose of ruling on the summary judgment motions, the district
court relied on the following undisputed material facts. In February 1989, Mr.
Johnson bought an accidental death policy from American Express Life Assurance
Company (AMEX). In December 1989, Mr. Johnson and his wife, LaJuan
Johnson, completed a “request for increased benefits” form in response to a
request they received from AMEX. In February 1993, Life Investors assumed
responsibility for the insurance policy issued by AMEX to Mr. Johnson. Also in
1993, Mr. Johnson purchased a policy for accidental death insurance from
Monumental, designating his wife, LaJuan, and his son, Steven, as beneficiaries.
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Years prior to his purchase of these policies, Mr. Johnson had been
diagnosed with myotonic dystrophy, a form of muscular dystrophy. He received
treatment for this disease until his death in 1995. Mr. Johnson developed muscle
weakness as a result of the myotonic dystrophy. Although he remained relatively
active, Mr. Johnson did occasionally stumble and fall down. In 1991, Mr.
Johnson fell down the stairs in his home and received treatment in the hospital for
his injuries.
On July 29, 1995, Mr. Johnson stumbled and fell while carrying a tray up
the stairs in his home, causing a cervical neck fracture and a possible thoracic rib
fracture. Mr. Johnson was admitted to the hospital in the early morning hours of
July 30, 1995 and was treated for his injuries. On August 1, 1995, while still in
the hospital, Mr. Johnson began to experience symptoms of pneumonia. His
doctor transferred him to the care of a pulmonologist in the intensive care unit.
Because Mr. Johnson began experiencing difficulty breathing, physicians
attempted to intubate him to clear his lungs. However, this proved extremely
difficult due to his neck fracture. During the next day, it became apparent Mr.
Johnson could no longer breathe on his own and would survive only with the
assistance of long-term ventilatory support. On August 2, 1995, authorized
hospital staff withdrew artificial life support measures and Mr. Johnson passed
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away. Dr. Edward Campbell filled out the death certificate and listed the
immediate cause of death as pneumonia, due to or as a consequence of a cervical
spine fracture, and the underlying cause of death as myotonic dystrophy. He
identified the manner of death as an “Accident.”
Mrs. Johnson and Steven Johnson made claims under the insurance policies
following Mr. Johnson’s death. Both insurance companies denied these claims,
relying on language in their policies excluding death caused by sickness and
defining an “injury” as a bodily injury caused by an accident “independent of all
other causes.” 1
1
The relevant language in the Monumental policy is as follows:
DEFINITIONS
....
INJURY means bodily injury caused by an accident. The accident must
occur while the Covered Person’s insurance is in force under the Group
Policy. The Injury must be the direct cause of the Loss and must be
independent of all other causes. The Injury must not be caused by or
contributed to by Sickness.
....
EXCLUSIONS
We will not pay a benefit for a loss which is caused by, results from, or [is]
contributed to by:
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II. PROCEDURAL BACKGROUND
Following the insurance companies’ denial of coverage, the Johnsons filed
suit in the district court, claiming the companies breached their contracts.
However, rather than making a determination on whether the companies breached
the contracts, the district court instead concluded the companies were estopped
....
(5) Sickness or its medical or surgical treatment, including diagnosis ....
The pertinent language from the Life Investors/AMEX policy is as follows:
Definitions
....
“Injury” means bodily injury of a Covered Person which:
1. is caused by an accident which occurs when the Covered Person’s
insurance is in force under the Policy; and
2. results in loss insured by the Policy; and
3. creates loss due, directly and independently of all other causes, to such
accidental bodily injury.
....
General Exclusions
The Policy does not insure for any loss resulting from any Injury caused or
contributed to by, or as a consequence of ...
....
3. any sickness or infirmity unless the treatment of such is required as the direct
result of an accidental bodily injury ....
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from relying on the sickness exclusions to deny coverage because the companies
failed to disclose the sickness exclusions in the manner required by Utah
insurance regulations. Consequently, the district court granted the Johnsons’
motions for summary judgment in both cases, and denied the companies’ cross-
motions for summary judgment. The district court also denied the Johnsons’
request for attorney fees.
Monumental and Life Investors now appeal the district court’s grant of
summary judgment to the Johnsons and denial of their motions for summary
judgment. Neither company denies it failed to disclose the sickness exclusion in
the manner required by the regulation. 2 Instead, each argues the regulation is
inapplicable to its policy. Monumental contends the disclosure obligations do not
apply to accidental death policies. Life Investors concedes the disclosure
regulation applies to accidental death policies but contends the regulation is
inapplicable to its policy because Utah adopted the rule after AMEX issued the
original policy to Mr. Johnson. Both companies argue they are entitled to
summary judgment because the Johnsons failed to show Mr. Johnson’s death
2
The district court determined the language of the exclusionary provisions is
buried in each policy and not in bold or color typeface as required by Utah’s regulations.
The court also concluded the exclusions do not clearly inform laymen as to what coverage
exists.
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resulted from an accident and independently of all other causes. The Johnsons
cross-appeal the denial of their request for attorney fees.
III. APPLICATION OF THE DISCLOSURE REQUIREMENT TO THE
POLICIES
A. Standard of Review
Because the district court’s jurisdiction over this matter was based on
diversity of citizenship, it was required to discern and apply the substantive law
of Utah, the forum state, with the objective of reaching the same result as would a
Utah court. See Brodie v. General Chem. Corp., 112 F.3d 440, 442 (10th Cir.
1997). We review de novo the district court’s determinations of the substantive
law of Utah. See id. However, although the substantive law of Utah governs the
analysis of the underlying claim in this case, federal law controls the ultimate
procedural question – whether summary judgment is appropriate. See Oja v.
Howmedica, Inc., 111 F.3d 782, 792 (10th Cir. 1997); May v. National Union Fire
Ins. Co., 84 F.3d 1342, 1345 (10th Cir. 1996). “We review the grant of summary
judgment de novo, applying the same standard as did the district court. Summary
judgment is then appropriate if, after reviewing all of the evidence submitted in
the light most favorable to the non-movant, no genuine issue of material fact
survives to merit a trial.” Chambers v. Colorado Dep’t of Corrections, 205 F.3d
1237, 1241 (10th Cir. 2000) (citations omitted); Fed. R. Civ. P. 56(c). “Where, as
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here, the parties file cross motions for summary judgment, we are entitled to
assume that no evidence needs to be considered other than that filed by the
parties, but summary judgment is nevertheless inappropriate if disputes remain as
to material facts.” James Barlow Family Ltd. Partnership v. David M. Munson,
Inc., 132 F.3d 1316, 1319 (10th Cir. 1997), cert. denied, 523 U.S. 1048 (1998).
“Where different ultimate inferences may properly be drawn, the case is not one
for a summary judgment.” Seamons v. Snow, 206 F.3d 1021, 1026 (10th Cir.
2000) (quotation marks and citation omitted).
B. Monumental
We first address Monumental’s argument the Utah disclosure regulation
does not apply to its accidental death policy. The regulation at issue is found in
the portion of the Utah Administrative Code dealing with insurance
administration, and entitled “Individual and Franchise Disability Insurance,
Minimum Standards.” Utah Admin. Code R590-126. The disclosure regulation
provides:
Accident-Only Disclosure. All accident-only policies shall contain a
prominent statement on the first page of the policy, or attached
thereto, in either contrasting color or in boldface type at least equal
to the size of type used for policy captions, as follows: “This is an
accident-only policy, and it does not pay benefits for loss from
sickness.”
Utah Admin. Code R590-126-6G. The scope of Rule 590 is described as follows:
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This rule shall apply to all individual and franchise disability
insurance policies .... The rule shall apply only to coverage issued
after the effective date of the rule.
Utah Admin. Code R590-126-2B (emphasis added). Rule 590 provides a list of
definitions “[i]n addition to the definitions of Sections 31A-1-301 and 31A-22-
605(2), U.C.A. [the general provisions of the Utah Insurance Code],” which are to
“apply for the purposes of this rule.” Utah Admin. Code R590-126-3A. The term
“disability insurance” is defined in the general provisions of the Utah Insurance
Code as:
insurance written to indemnify for losses and expenses resulting from
accident or sickness, to provide payments to replace income lost
from accident or sickness, and to pay for services resulting directly
from accident or sickness, including medical, surgical, hospital, and
other ancillary expenses.
Utah Code Ann. § 31A-1-301(26) (Supp. 1996) (emphasis added). Monumental
contends the term “disability insurance” as defined above, is too narrow to
encompass an accidental death policy, and thereby argues the disclosure
requirement contained in the regulation section entitled “disability insurance,”
does not apply to its policy.
The Utah courts have never determined whether the rules set forth in the
“Individual and Franchise Disability Insurance” section of the insurance code
apply only to disability insurance policies or to other types of insurance policies
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such as those addressing accidental death insurance. However, the general
provisions of the Utah Insurance Code define “disability insurance” broadly to
include insurance policies covering “losses” resulting from accident or sickness.
See Utah Code Ann. § 31A-1-301(26). Nothing in the regulations indicates that
“losses” resulting from accident or sickness do not include death. Moreover, as
the district court noted, the regulations dealing with “disability insurance”
specifically mention policies providing for accidental death benefits in several
subsections. 3 Thus, it is clear Utah implemented the “disability insurance”
regulations with the intent to cover accidental death policies. Even though these
3
For example, the subsection entitled “Disability, Minimum Standards for
Benefits,” defines and sets the minimum standards for “Accident-Only Coverage” as
follows:
a policy of accident insurance which provides coverage, singly or in
combination, for death, dismemberment, disability, or hospital and medical
care caused by accident. Accidental death and double dismemberment
amounts under such a policy shall be at least $1,000 and a single
dismemberment amount shall be at least $500.
Utah Admin. Code R590-126-7H (emphasis added). Likewise, “Specified Accident
Coverage” is defined as:
an accident insurance policy which provides coverage for a specifically
identified kind of accident (or accidents) for each person insured under the
policy for accidental death or accidental death and dismemberment,
combined with a benefit amount not less than $1,000 for accidental death,
$1,000 for double dismemberment and $500 for single dismemberment.
Utah Admin. Code R590-126-7I(1) (emphasis added).
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regulations are not codified, in Utah, insurance regulations “passed pursuant to a
statutory grant of authority have the full force and effect of law.” Horton v. Utah
State Retirement Bd., 842 P.2d 928, 932 n. 2 (Utah Ct. App. 1992) (citations
omitted); see also V-1 Oil Co. v. Department of Envtl. Quality, 904 P.2d 214,
218-19 (Utah Ct. App. 1995). Consequently, we conclude the mandatory
disclosure provision contained in section R590-126-6G of the Utah
Administrative Code applies to Monumental’s accidental death policy.
Because Monumental’s policy did not comply with the disclosure regulation
when issued, we also conclude the district court applied the appropriate remedy
by striking the exclusionary language of the policy. See General Motors
Acceptance Corp. v. Martinez, 668 P.2d 498, 502 (Utah 1983) (holding the
insurance company was estopped as a matter of law from denying coverage under
its policy due to its failure to comply with Utah insurance law). 4 See also Cullum
4
We reject Monumental’s argument Martinez cannot apply because it involved an
insurance company’s failure to comply with Utah codified law as opposed to mere
insurance regulations. In support of its argument, Monumental also contends estoppel
cannot apply to violation of an agency rule which it claims prohibits private relief.
Contrary to these contentions, nothing in Utah’s insurance regulations prohibits private
relief. Given Utah’s insurance regulations maintain the full force and effect of law,
Horton, 842 P.2d at 932 n.2, we see no difference in whether Monumental violated
codified or regulatory provisions. As a consequence, it follows that if the private remedy
of estoppel is available for one, it is also available for the other.
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v. Farmers Ins. Exch., 857 P.2d 922, 926-27 (Utah 1993) (concluding failure to
comply with Utah insurance law rendered an exclusion provision in the insurance
contract unenforceable). 5 As a result, under the circumstances presented,
Monumental’s claim Mr. Johnson’s myotonic dystrophy caused or contributed to
the fall which led to his death is irrelevant to our determination. 6 Because no
5
Monumental argues the district court erred by striking the language defining
“injury” in its policy. Monumental argues the district court acted overzealously by
striking this language as a consequence of its violating the disclosure regulation.
Monumental also contends even if the district court correctly determined its definition
was more restrictive than allowed by Utah insurance regulations, the proper remedy
would have been to substitute the statutory definition of “injury” provided in Utah
Admin. Code R590-126-3A(1)(a). Monumental further argues even if the district court
substituted the less restrictive language to define injury under the contract, it still would
not have been required to pay death benefits to the Johnsons. We disagree.
The purpose of the disclosure regulation is to alert the insured to the sickness
exclusion. See Utah Admin. Code R590-126-2A. It is nonsensical to assert the insurer
may violate the disclosure regulation and be estopped from relying on the sickness
exclusion, but then allow the insurer to nevertheless deny coverage based on other
language in the policy which effectively excludes injuries allegedly resulting, in part,
from sickness. Thus, we reject Monumental’s argument it is entitled to summary
judgment because myotonic dystrophy contributed to Mr. Johnson’s death.
6
Despite Monumental’s contentions, the district court’s ruling did not turn the
policy into a “disability” or “life insurance” policy. Rather, the district court recognized
the policy extended only accidental death insurance, but under the circumstances,
extended such coverage without determining if an underlying illness caused the
“accident,” given the policy’s failure to follow Utah’s disclosure requirements. While
Monumental argues the district court should have applied the exclusion and denied
benefits under our holding in Winchester v. Prudential Life Ins. Co. of America, 975 F.2d
1479 (10th Cir. 1992), it misses the point. First, the district court never reached the issue
on whether Winchester applied to this case given Monumental’s failure to comply with
Utah’s disclosure requirements. Consequently, even if we determined the exclusion
adequately discloses that coverage does not extend to accidents resulting from pre-
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material, controverted facts are left for a jury to decide in Monumental’s case, the
district court properly granted summary judgment in favor of the Johnsons.
D. Life Investors
Life Investors asserts the disclosure regulation does not apply to its policy
because AMEX issued the original policy before the disclosure regulation became
effective. 7 The district court concluded Life Investors/AMEX subjected itself to
the provisions of the regulation by accepting additional premiums for increased
benefits after the effective date of the disclosure rule. 8 Life Investors argues the
existing conditions, Monumental nevertheless violated Utah’s disclosure regulations by
burying the disclosure in the policy and not setting it out in bold or colored type.
7
As stated previously, Mr. Johnson bought the accidental death policy from
AMEX in February 1989. Utah enacted the Regulations at issue on June 20, 1989. Mr.
Johnson increased his benefits in December 1989. In February 1993, Life Investors
assumed responsibility for the AMEX insurance policy.
8
Life Investors points out the district court relied on the wrong certificate when
rendering its decision. This mistake arose from the confusion generated when, during
discovery, Life Investors mistakenly produced a copy of a specimen certificate which it
did not send to the Johnsons. However, Life Investors drew the court’s attention to this
error in a motion to file a supplemental memorandum in support of its motion for
summary judgment. The district court granted Life Investors’ motion, and Life Investors
subsequently filed a supplemental memorandum in support of its motion for summary
judgment and attached the correct certificate. Although Life Investors maintains the
district court committed plain error by relying on the incorrect certificate in rendering its
decision, it contends the court would have reached the same decision even if it relied on
the correct certificate, and asks us to review the district court’s decision as if it relied on
the correct certificate. The district court reasoned the definition of a “covered injury”
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district court made this determination in error, and suggests the subsequent
agreement did not constitute the formation of a wholly new contract that brought
it under the auspices of the mandatory disclosure regulation.
Under Utah law, substantive statutes affecting vested rights do not apply
retroactively. See Olsen v. Samuel McIntyre Inv. Co., 956 P.2d 257, 260 (Utah
1998). However, because the Utah courts have never addressed whether an
agreement to increase benefits in a life insurance contract creates a new policy,
subject to statutes and regulations enacted after issuance of the original policy, we
look to “other state court decisions, federal decisions, and the general weight and
trend of authority” to determine how the Utah courts would resolve this issue.
May, 84 F.3d at 1345 (quotation marks and citations omitted). Other courts,
analyzing similar issues, have held an increase in premiums, benefits, or
coverage, does not constitute the creation of a new certificate of insurance subject
to regulations enacted after the original date the policy became effective. See,
contained on page five of the wrong certificate acted as an exclusion for sickness and
struck the provision because it lacked bold-faced or colored type as required by the
disclosure regulation. We agree the reasoning of the district court concerning the
applicability of the disclosure regulation to Life Investors’ policy would have been the
same whether it relied on the correct or incorrect certificate, and thus, in the interest of
resolving this dispute, we review the district court’s decision as if based on the correct
certificate.
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e.g., Gahn v. Allstate Life Ins. Co., 926 F.2d 1449, 1456 (5th Cir. 1991) (applying
Louisiana law and holding the modification of the terms of an insurance policy
does not create a new policy); Metropolitan Property and Liability Ins. Co. v.
Gray, 446 So.2d 216, 219-20 (Fla. Dist. Ct. App. 1984) (holding the mere
addition of another person on a policy does not amount to a reissuance of the
policy and thus, does not make the policy subject to statutes effective after the
issuance of the original policy); Crow v. Capitol Bankers Life Ins. Co., 891 P.2d
1206, 1211 (N.M. 1995) (construing the insurance policy and rider as part of same
contract for insurance); Massachusetts Mut. Life Ins. Co. v. Thacher, 222
N.Y.S.2d 339, 343 (N.Y. App. Div. 1961) (determining a rider attached to the
face of a policy containing an option for extended benefits on the payment of
additional premium merely amounts to an extended privilege and does not create a
new policy); Hidary v. Maccabees Life Ins. Co., 591 N.Y.S.2d 706, 710 (N.Y.
Sup. Ct. 1992) (finding increases in face amount of coverage for payment of
additional premiums did not constitute separate new policies); French v.
Insurance Co. of N. Am., 591 S.W.2d 620, 621-22 (Tex. Civ. App. 1979)
(reasoning the addition of a car to insurance policy did not create a new policy
subject to a statute which became effective after the issuance of the original
policy). We can see no reason why Utah would depart from the majority view on
this point of law. Nevertheless, we turn to the Johnsons’ argument the increase in
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benefits amounted to new “coverage” and thus, became subject to the disclosure
regulation.
In support of their argument Life Investors became subject to the disclosure
regulation when it accepted the Johnsons’ additional premium payment after the
disclosure regulation became effective, the Johnsons focus on the word
“coverage” and point out the disability insurance rules “apply only to coverage
issued after the effective date of the rule.” Utah Admin. Code R590-126-2B
(emphasis added). In applying this provision to their policy, the Johnsons point
out AMEX sent them a letter after it received the additional premium payment
stating:
I have enclosed your revised Data Page for your Certificate
APG1000984 which reflects your increase in coverage. Please
replace the original Data Page with this new one.
Your new quarterly premium will be $82.32. A charge of $56.95 has
been placed on your American Express Card account. This
represents the difference in premium due for your additional
coverage.
(Emphasis added.) Based on this language, the Johnsons maintain that by
increasing the benefits under the policy, AMEX issued new “coverage” after the
effective date of the disclosure regulation, making Life Investors subject to the
disclosure regulation. We disagree.
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The term “coverage” when used in the context of an insurance contract is
widely held to mean “[i]nclusion of a risk under an insurance policy; the risks
within the scope of an insurance policy.” Black’s Law Dictionary 372 (7th ed.
1999). See Traders State Bank v. Continental Ins. Co., 448 F.2d 280, 283 (10th
Cir. 1971) (“The word coverage is, indeed, a term of art in the insurance industry,
meaning the sum of all the risks assumed under the policy.”) (quotation marks and
citation omitted); see also In re Joint E. and S. Dist. Asbestos Litig., 993 F.2d
313, 315 (2d Cir. 1993); Guaranty Nat’l Ins. Co. v. Bayside Resort, Inc., 635 F.
Supp. 1456, 1458 (V.I. 1986); Illinois Farmers Ins. Co. v. Tabor, 642 N.E.2d 159,
163 (Ill. App. Ct. 1994); Delcampo v. New Jersey Auto. Full Ins. Underwriting
Ass’n, 630 A.2d 415, 422 (N.J. Super. Ct. Law Div. 1993); Farmers Ins. Co. of
Washington v. Frederickson, 914 P.2d 138, 140 (Wash. Ct. App. 1996). On the
other hand, the term “benefit” is defined in Black’s Law Dictionary as: “Financial
assistance that is received from an employer, insurance, or a public program (such
as social security) in time of sickness, disability, or unemployment.” Black’s Law
Dictionary 151 (7th. ed. 1999). See Vogel v. Wells, 566 N.E.2d 154, 161 (Ohio
1991) (quoting Black’s Law Dictionary to define “benefit”); Kratz v. Kratz, 905
P.2d 753, 755 (Okla. 1995) (relying on Black’s Law Dictionary to define
“benefit” in the context of an insurance contract).
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Hence, neither definition persuades us an increase in “benefits” alone
increases the “coverage” or assumed risks of an insurance contract, thereby
creating a new or different contract or policy. Under the circumstances presented
we conclude the increase in premiums and benefits did not change the nature of
the coverage or create a new policy subject to the disclosure regulation because it
did not alter the type of risk Life Investors assumed under the policy – it only
altered the amount of the benefits Life Investors was obligated to pay in the event
a legitimate claim arose under the policy. For these reasons, the district court
erred by determining Life Investors was estopped as a matter of law from refusing
to honor the Johnson’s claim. We therefore remand to the district court for
further proceedings in accordance with this opinion on the Johnsons’ claims
against Life Investors, including their breach of contract claim. 9
9
The Johnsons contend they are entitled to summary judgment even if the district
court erred by determining Life Investors was estopped from relying on the sickness
exclusion to deny coverage. In support, the Johnsons argue the majority of jurisdictions,
examining language in insurance contracts similar to the exclusionary language contained
in their policy, refused to allow the insurance companies to rely on such language to deny
coverage unless the preexisting illness constituted the “predominant cause” of the injury,
or the preexisting illness “substantially contributed to the loss.” In response, Life
Investors argues the Utah Supreme Court would interpret the definition of “injury” in its
policy to preclude coverage. Relying on Winchester v. Prudential Life Ins. Co. of
America, 975 F.2d 1479 (10th Cir. 1992), Life Investors urges us to reverse the district
court’s denial of its cross-motion for summary judgment and rule the Johnsons are not
entitled to coverage under the policy as a matter of law because they cannot prove Mr.
Johnson’s death resulted directly from an accident, independent of all other causes. We
leave the determination of this issue to the district court on remand.
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IV. ATTORNEY FEE ISSUE
Finally, we address the Johnsons’ contention the district court erred by
denying them attorney fees. In a diversity suit, the issue of attorney fees is
considered a substantive matter and is controlled by state law. Jones v. Denver
Post Corp., 203 F.3d 748, 757 (10th Cir. 2000). However, our standard of review
is a matter of federal law and “[w]e review a district court’s award of attorney
fees for abuse of discretion. The district court’s factual findings are only
reversed if clearly erroneous. Legal conclusions and statutory analysis are
reviewed de novo.” Parks v. American Warrior, Inc., 44 F.3d 889, 892 (10th
Cir.1995) (citations omitted).
In Utah, the general rule is attorney fees are recoverable only if provided
After filing their brief with this Court, the Johnsons filed a motion for us to certify
this issue to the Utah Supreme Court, contending certification is proper because the Utah
courts have not yet determined “how, under state law, language limiting coverage under
accidental death policies where an insured suffers a preexisting disease should be
interpreted ....” Life Investors filed no response to the Johnsons’ motion to certify, but in
its opposition to the Johnsons’ motion for certification, Monumental argues this Court
should interpret the “direct cause of loss, independent of all other causes” language as
allowing it to deny coverage based on Winchester and without resorting to certification to
the state court. We deny the Motion for Certification without reaching its merits, and
decline addressing Monumental’s motion in opposition, leaving the Johnsons free to
reassert their motion to certify in the district court on remand.
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for in a contract at issue or by statute. Occidental/Nebraska Fed. Sav. Bank v.
Mehr, 791 P.2d 217, 221 (Utah Ct. App. 1990). However, exceptions to this
general rule exist. In an insurance contract dispute where the insured sues the
insurer for breach of contract, attorney fees may be recovered as consequential
damages for either a breach of the express terms of the contract or for a breach of
the implied covenant of good faith and fair dealing. Billings v. Union Bankers
Ins. Co., 918 P.2d 461, 468 (Utah 1996).
A. Breach of the Express Terms of the Contract
An insured may recover attorney fees as consequential damages for the
breach of an express term in the insurance contract if the fees “were reasonably
within the contemplation of, or reasonably foreseeable by, the parties at the time
the contract was made.” Billings, 918 P.2d at 468 (quotation marks and citation
omitted). Thus, in order to recover attorney fees as consequential damages
flowing from a breach of express terms in the contracts, the Johnsons need to first
show the companies breached the contracts. However, the district court never
ruled on whether either company breached the express or implied terms of its
contract. The district court instead found Monumental and Life Investors were
estopped from relying on the sickness exclusions in their policies, and under the
doctrine of estoppel, held the Johnsons could not recover attorney fees.
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Given our and the district court’s holdings that Monumental is estopped
from denying coverage, we must examine the principles of estoppel to determine
if attorney fees from Monumental are warranted in this case. To begin, estoppel
does not operate to alter the terms of the contract as originally written. See
Perkins v. Great-West Life Assurance Co., 814 P.2d 1125, 1131 (Utah Ct. App.
1991). Rather, estoppel is normally asserted as a defense to a claim or right and
does not create an independent cause of action. See Raymond v. Halifax Hosp.
Med. Ctr., 466 So.2d 253, 255 (Fla. Dist. Ct. App. 1985); Lohse v. Atlantic
Richfield Co., 389 N.W.2d 352, 357-58 (N.D. 1986); see also General Motors,
668 P.2d at 502 (“Although estoppel is usually a factual defense, it may be
established as a matter of law to preclude an insurance company from relying on
an exclusion in a credit life and accident policy.”). Estoppel merely abates the
insurer’s right to defend against the insured’s claim for breach of contract by
relying on the language in its policy. See id. Moreover, unlike breach of contract
where the award of attorney fees is reasonably contemplated at the time of the
contract, Billings, 918 P.2d at 468, estoppel is not an independent cause of action
like breach of contract, or a circumstance in which attorney fees are ever
contemplated. It is not the same as breach of contract for the purpose of awarding
attorney fees.
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In applying this conclusion to the facts of this case, we note neither we nor
the district court ever reached the issue of whether Monumental breached its
contract with the Johnsons when holding Monumental is estopped as a matter of
law from relying on the sickness exclusion. Therefore, the Johnsons are not
entitled to attorney fees from Monumental under the theory Monumental breached
the express terms of the contract. However, because we are reversing and
remanding the district court’s grant of summary judgment in favor of the
Johnsons on their claim against Life Investors, we leave the determinations of
whether Life Investors breached the express terms of its contract, and whether the
Johnsons are entitled to attorney fees under Utah law, to the district court.
B. Implied Covenant of Good Faith and Fair Dealing
The Johnsons alternatively assert an award of attorney fees is proper
because the companies breached the implied covenant of good faith and fair
dealing. 10 In Beck v. Farmers Ins. Exch., 701 P.2d 795 (Utah 1985), the Utah
10
The Johnsons assert because Life Investors did not answer their cross-appeal
from the denial of attorney fees, it waived the issue. Although an appellant who chooses
not to brief an issue may be deemed to waive the issue, see Sheets v. Salt Lake County, 45
F.3d 1383, 1390 (10th Cir.), cert. denied, 516 U.S. 817 (1995), this rule does not apply to
appellees. The Johnsons, as the appellants, retain the burden to prove on appeal the trial
court erred. If the insurance companies, as the appellees, choose not to defend the trial
court’s decision, this does not relieve the Johnsons of their burden to convince us of the
district court’s errors.
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Supreme Court recognized attorney fees may be available as consequential
damages flowing from a breach of the implied covenant of good faith and fair
dealing by an insurance company. Id. at 801. Under Beck, an insurer may be
found to breach the implied covenant of good faith and fair dealing if it fails to
diligently investigate the facts underlying a claim, fairly evaluate the claim, or
“act promptly and reasonably in rejecting or settling the claim.” Id. “[T]he
overriding requirement imposed by the implied covenant is that insurers act
reasonably ... in dealing with their insureds.” Billings, 918 P.2d at 465.
However, “when an insured’s claim is fairly debatable, the insurer is entitled to
debate it and cannot be held to have breached the implied covenant if it chooses
to do so.” Id.
The Johnsons contend “[a]s a matter of law, the Companies could not have
acted diligently, fairly or reasonably in rejecting the Johnsons’ claims, as they
violated applicable Utah Insurance Department Regulations by which they were
bound, and denied the claims in the face of the Regulations.” However, they cite
no case where failing to comply with insurance regulations has been found to be
the equivalent of failing to fairly evaluate a claim or act promptly and reasonably
in rejecting the claim. Nor are we persuaded by the Johnsons’ argument.
Monumental’s contention the disclosure regulation did not apply to its contract is
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“fairly debatable” as the Utah courts have not ruled directly on the issue of
whether the disability insurance regulations apply to accidental death policies.
Obviously, because we agree with Life Investors that the regulation does not
apply to its contract, we cannot hold Life Investors violated the covenant of good
faith and fair dealing by asserting it is not estopped from relying on the sickness
exclusion. However, on remand, the Johnsons might prove Life Investors
breached the covenant of good faith and fair dealing on other grounds and that
they are entitled to attorney fees in accordance with Utah law.
V. CONCLUSION
For the foregoing reasons, and applying the principles for reviewing
summary judgment determinations, we REVERSE the district court’s order
granting summary judgment to the Johnsons in their suit against Life Investors,
and REMAND for further proceedings consistent with this opinion. As to the
issue of attorney fees, we REVERSE and REMAND the district court’s denial of
attorney fees to the Johnsons from Life Investors for further proceedings
consistent with this opinion. We AFFIRM the district court’s grant of summary
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judgment in favor of the Johnsons against Monumental and AFFIRM the denial
of attorney fees to the Johnsons from Monumental.
Entered by the Court:
WADE BRORBY
United States Circuit Judge
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