Interpreting Insurance Policies: What does a Term really Mean?

Insurance policy terms may appear to be easily understandable and concise. However, the interpretation a lay person may give to an insurance policy agreement’s meaning versus a court’s interpretation of the same policy, may substantially differ. It is true that under Louisiana law, words in a contract are presumed to have the plain and ordinary meaning they are generally given. However, an insurer may bear the burden of proof and demonstrate that a certain provision in an insurance policy exempts coverage for such an event in question.

A recent decision by Louisiana’s Second Circuit Court of Appeal, explored the meaning of an insurance policy in order to determine whether or not the insurer was responsible for the plaintiff’s additional damages. The court looked at the totality of the circumstances to aid their decision. The facts are as follows:

In DeSoto Parish, a series of connected collisions occurred which permanently injured one man, and killed another. The chain of events started with Mr. Mike Miles McCauley, who was employed by the defendant, Steve Kent Trucking Inc., he traveling in his 18-wheeler on Highway 5 through DeSoto Parish. Mr. McCauley dropped his cell phone on the floorboard of the truck and decided to retrieve it, at this point he crossed the center line of the highway, then overcorrected and lost control of the vehicle. The 18-wheeler turned over on its side and onto a vehicle, driven by the plaintiff, Henry Washington, who was traveling in the opposite direction on Highway 5. As a result of the size and ass of the 18-wheeler, Mr. Washington’s vehicle was pushed into a small body of water, the 18-wheeler was still sliding at this point and collided with a car driven by Allan C. Richard, who was killed instantly. Mr. Washington suffered numerous serious injuries which left him permanently incapacitated.

Mr. Washington at trial, sought to recover for numerous damages as a result of the serious injuries he incurred from the accident. Mr. Washington sought past and future mental and physical pain and suffering; past and future physical disability and physical impairment; past and present and future loss of enjoyment of life; past and present and future medical expenses; and the loss of economic opportunity. The trial court entered a judgment allowing Mr. Washington’s curator to settle claim arising from the accident for $4.5 million. The defendant insurer, Greenwich paid $4 million and Steve Kent Trucking, Inc., paid $500,000. The only claim left at this point, was the plaintiff’s claim against defendant insurer Greenwich for an additional $1 million in coverage remained. Greenwich filed a motion for summary judgment and subsequently won, as a result of the interpretation of a term in the policy agreement. The defendant insurer, Greenwich was released from liability to the plaintiff on the basis of the court’s interpretation of one single phrase within the policy, “one accident.”

The defendant insurer relied on the company’s interpretation of the policy agreement in order to evade additional liability to the plaintiff. The defendant argued that the policy specified a $5 million “per accident” limit and that an accident is defined as “the continuous or related exposure to the same exposure to the same conditions resulting in bodily injury.” Greenwich also contended that the limit was a combined single limit.” Essentially, this means that according to the policy agreement, if there are multiple parties that are involved within event, their ability to collect for any resulting damages will be combined and they may all collect no more than $5 million collectively. The court reasoned that there was one accident in this matter, although there were two collisions. Greenwich’s liability was limited to no more than $5 million per accident, thus, the company had paid the policy limits by settling with Mr. Washington for $4 million and the second fatally injured driver’s survivors for $1 million. Therefore, according to the court’s interpretation, the defendant insurer had fulfilled their contractual obligation under the policy and were dismissed. Obviously, the plaintiff was not satisfied with this result in consequence to the numerous future medical procedures needed as a result of the accident, so he appealed the decision.

The appeal consists of essentially a battle of interpretations. On the one hand, the plaintiff assert that under the language of the policy, “accident” and “loss” are different and alternative bases of coverage. Further, they urged that Mr. Washington and Mr. Richard, the deceased second driver involved, sustained separate losses and the policy limit is $5 million per loss. The focal concern of the court, is whether or not the $5 million policy limit is to be applied to each person who suffers bodily injury or death, not all such persons. On the other hand, the defendants assert that the plain, ordinary meaning that Louisiana asserts shall be given to contract terms, is that “per accident” a maximum of $5 million shall be allocated. Here, even though there were two victims, they were involved within one incident that caused such injury, thus, they fulfilled the policy limit by allocating between the two victims, a total of $5 million.

Interpretation of an insurance policy is usually resolved by a summary judgment motion, which is what the defendant insurer claimed. When determining whether a policy affords coverage for an incident, the insured bears the burden of proving that the incident falls within the policy’s terms. The court determined that a lack of coverage under the insurance policy was appropriate because there was no reasonable interpretation of the policy, and when applied to the undisputed material facts shown by the evidence supporting the motion, coverage was not additionally afforded to the plaintiff.

The court in this case, made their determination based on the totality of the circumstances. The accident or occurrence was explored in order to determine the extent of the harm, the seriousness of the injuries, and the insurance coverage in light of the facts presented by the various factors involved. The 18-wheeler fatally killed one man as a result of sliding into the man’s vehicle, and caused the other driver to become permanently incapacitated. These injuries occurred from one event, by one negligent act of the driver, and therefore, was not going continue or persist in injuries to the plaintiff. rather, the plaintiff was suffering as a result of the one act by the driver, thus, according the court’s interpretation of the insurance policy, the plaintiff and the deceased driver’s survivors together, obtained $5 million from the injuries they sustained from the tragic accident. Thus, the insurer fulfilled their contractual obligations and were not responsible for any additional amounts urged by the plaintiff.

Interpretation is a powerful tool, as this case illustrates, contractual terms may be difficult and hard to understand.

In order to be confident in the meaning of a contract, please call the Berniard Law Firm. The Berniard Law Firm will help you understand the policies and the law involved, and advise you of your rights under such insurance policy.

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