Welshans v. Aetna Life Ins Co

RECOMMENDED FOR FULL-TEXT PUBLICATION
Pursuant to Sixth Circuit Rule 206
File Name: 07a0109p.06
UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT
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PEGGY WELSHANS WILLIAMSON, and VANESSA
Plaintiffs-Appellants, -
WELSHANS,
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No. 05-6911
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v. >
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Defendant-Appellee. -
AETNA LIFE INSURANCE COMPANY,
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Appeal from the United States District Court
for the Western District of Tennessee at Memphis.
No. 04-02851—J. Daniel Breen, District Judge.
Argued: December 7, 2006
Decided and Filed: March 22, 2007
Before: SILER, GILMAN, and GRIFFIN, Circuit Judges.
_________________
COUNSEL
ARGUED: Kathleen G. Morris, KATHLEEN G. MORRIS, ATTORNEY AT LAW, Nashville,
Tennessee, for Appellants. Herbert E. Gerson, FORD & HARRISON, Memphis, Tennessee, for
Appellee. ON BRIEF: Kathleen G. Morris, KATHLEEN G. MORRIS, ATTORNEY AT LAW,
Nashville, Tennessee, Kent J. Rubens, RIEVES, RUBENS & MAYTON, West Memphis,
ARKANSAS, for Appellants. Herbert E. Gerson, Thomas J. Walsh, Jr., P. Daniel Riederer, FORD
& HARRISON, Memphis, Tennessee, for Appellee.
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OPINION
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GRIFFIN, Circuit Judge. Plaintiffs Peggy Welshans Williamson and Vanessa Welshans
appeal the district court’s grant of summary judgment in favor of defendant Aetna Life Insurance
Company (“Aetna”). Plaintiffs initially brought suit in Tennessee state court alleging violations of
common law breach of contract, violations of the Tennessee Consumer Protection Act (“TCPA”),
TENN. CODE ANN. § 47-18-104, and the Tennessee “bad faith” statute, TENN. CODE ANN. § 56-7-
105. Specifically, plaintiffs alleged that Aetna wrongfully denied health insurance benefits for
Williamson’s daughter, Welshans, pursuant to an employee health plan administered by Aetna. In
October 2004, Aetna removed the matter to federal district court, and, in November 2005, the district
court granted Aetna’s summary judgment motion with respect to all of plaintiffs’ claims. Plaintiffs
1
No. 05-6911 Welshans, et al. v. Aetna Life Ins. Co. Page 2
now urge this court to reverse both the jurisdictional determination of the district court and its
subsequent grant of summary judgment in favor of Aetna.
For the reasons that follow, we affirm.
I.
Williamson was employed by General Agencies of the United Methodist Church (“General
Agencies”) from 1977 until she retired in 1995. General Agencies provided group health insurance
(the “plan”) to its employees, and, as part of Williamson’s retirement, she continued to be eligible
for the plan. Williamson was a member of the task force at General Agencies that designed the
employer’s insurance plan and recommended that Aetna be selected as the plan administrator.
Based on that recommendation, General Agencies contracted with Aetna to administer its group
health plan from January 1, 1990, through December 31, 2000.
Welshans is Williamson’s daughter. In May 1983, when Welshans was twenty-two years
old, she was severely injured in an automobile accident in which she sustained broken legs, a broken
pelvis, and a broken back. According to plaintiffs, her left knee was severely injured as a result of
the accident, and she has subsequently undergone seven surgeries. Her ability to sit, stand, walk,
climb stairs, or do any bending or squatting for a sustained period of time is impaired. Until 1986,
when Welshans reached the maximum age for coverage as a dependent child, she was eligible for
coverage under Williamson’s plan through General Agencies. After 1986, Welshans was provided
continued coverage by Cigna, the prior administrator of General Agencies’ health plan, as a “fully
handicapped dependent” because of the injuries she sustained in the accident. Welshans received
coverage as a “handicapped dependent” from 1986 to 1995 pursuant to the terms of the plan with
Cigna.
Welshans has not been employed since the accident, but she has been a full-time student
since 1994. In 1994, she attended East Arkansas Community College in Wynne, Arkansas. In 1995,
she transferred to Lambuth University in Jackson, Tennessee. Following her graduation from
Lambuth, she earned a masters degree in American history from the University of Memphis in 2000
and has since enrolled in the doctoral program. At the time of her deposition, she expected to
complete a doctorate in American History and Modern Europe in 2004. According to Aetna’s brief,
she has since completed the doctorate. Welshans is physically and mentally able to care for herself,
and she lived independently in Wynne, Arkansas, while attending community college. She
occasionally lived with her mother while attending Lambuth University from 1995-1998, and, since
1998, has lived alone in the Memphis and Collierville, Tennessee area. Welshans has received
Social Security Disability income since 1984 and has no other source of disposable income.
Welshans transfers money from Williamson’s bank account into her own account each month as
needed to meet her living expenses, including rent, bills, and food.
Welshans and Williamson both participated in the indemnity provisions of General
Agencies’ group health plan during the time in which Aetna served as the administrator. The
indemnity provisions provided that the insured was responsible for the submission of claims to
Aetna. The plan further identified procedures and other health care services that were excluded from
the plan.
In January 1995, when Aetna began administering the plan, Welshans was thirty-four years
of age. Because of her age, Welshans was ineligible for coverage as a dependent child of
Williamson. The plan provided, however, that “Health Insurance Coverage for [the insured’s] fully
handicapped dependent may be continued past the maximum age for a dependent child, if he or she
has not been issued a personal medical conversion policy.” The plan defined a “fully handicapped
dependent” as a person:
No. 05-6911 Welshans, et al. v. Aetna Life Ins. Co. Page 3
not able to earn his or her own living because of mental retardation or physical
handicap which started prior to the date he or she reaches the maximum age for
dependents; and
he or she chiefly depends on [the insured] or another care provider for support.
“Dependent on another care provider” is defined as requiring a “Community Integrated Living
Arrangement, group home supervised apartment or other residential services licensed or certified
by the Department of Mental Health and Developmental Disabilities, the Department of Public
Health or the Department of Public Aid.”
According to the plan, once coverage has been established, it will continue until any one of
the following occurrences: (1) “cessation of the handicap and dependency”; (2) “[t]he end of a 60
day period from the date Aetna requests proof of the continuation of the handicap and dependency,
if proof is not provided within a 60 day period”; or (3) “Termination of Dependent Coverage as to
[the insured’s] dependent for any reason other than reaching the maximum age.” The plan
specifically confers upon Aetna the right to “request proof of the continuation of the handicap as
often as it may reasonably require, but not before 2 months prior to the dependent reaching the
maximum age.”
When Aetna took over the administration of the General Agencies health plan in 1995, it
initially rejected medical claims submitted by Welshans and other children of insured employees,
whom Cigna had previously provided coverage for as handicapped dependents, because of a
computer error. In response to the error, Aetna instituted a policy by which it would “cover all
incapacitated dependents [including Welshans] without question” for the calendar year 1995. Aetna
further stated that it expected to return to normal procedures to determine eligibility by January 1,
1996, at which time dependents could be terminated if they did not meet the plan’s eligibility
criteria.
On July 26, 1996, Aetna first denied Welshans’ coverage as a handicapped dependent.
According to Williamson and Aetna’s internal notes, Aetna determined that she was “not
handicapped as described in the plan because the physical limitations described do not seem to be
of a severity to preclude full time employment.” Williamson sent a second request for continuation
of coverage in August 1996, along with a statement from Welshans’ doctor, Dr. Thomas Limbird,
describing her injuries in detail and opining that she was unable to maintain employment. Aetna
requested additional information regarding Welshans’ dependent and marital status in a letter dated
September 14, 1996.
It is unclear whether further determinations were made as to Welshans’ eligibility in 1996,
1997, or 1998. Some form of litigation between the two parties has been ongoing since 1996.
Welshans originally filed suit against Aetna in federal district court in 1996, alleging diversity
jurisdiction and seeking payment of medical benefit claims. This matter was resolved by settlement
in June 1998, and Aetna states that “it is undisputed that Aetna extended coverage to Welshans as
a handicapped dependent from 1995-1999.”1
On October 8, 1999, and November 8, 1999, Aetna again requested verification of Welshans’
status as a handicapped dependent. It is unclear whether plaintiffs responded to these requests.
Aetna claims that plaintiffs did not respond, citing both the deposition testimony of Aetna’s
employee and internal notes recording the non-receipt of this requested information. Williamson
1
The parties appear to agree that this prior matter was resolved by settlement, but Aetna proffers that “[a]mong
the settlement terms was the requirement that Welshans submit all necessary proof and other documentation required
by the health plan to establish her coverage under the plan.”
No. 05-6911 Welshans, et al. v. Aetna Life Ins. Co. Page 4
did not produce any documentary evidence or recall a specific date, but generally alleged that she
responded to all requests for information.
Although the district court states that “It [was] undisputed that Aetna terminated Welshans’
coverage in 1999,” the termination date is unclear from the record. It is clear that Aetna denied
many of Welshans’ claims in 1999. Aetna’s internal notes, dated November 16, 1999, state that “no
incapacitated child info received[;] will close out the contact.” Further, Aetna’s list of claims states,
for the first time, on February 26, 2000, that a claim was denied because coverage was terminated.
Around the same time, however, Aetna mailed Williamson a “Certification of Prior Group Health
Coverage,” prepared on May 19, 2000, which provided “evidence of prior health coverage” for
Welshans from January 1, 1995, to January 2, 2000. Neither the district court opinion nor Aetna
addresses this document.
On January 22, 1999, plaintiffs filed separate complaints in district court2 alleging diversity
jurisdiction and stating claims for breach of contract and violations of the Tennessee Consumer
Protection Act and the Tennessee “bad faith” statute as a result of Aetna’s alleged failure to pay
Welshans’ medical claims. In September 2003, prior to the conclusion of a bench trial, plaintiffs
voluntarily non-suited their case, and the court dismissed the action without prejudice.
Subsequently, on September 15, 2004, plaintiffs filed a complaint in Tennessee state court setting
damages at less than $75,000. Aetna removed the action to federal district court based on diversity
of citizenship in October 2004. Plaintiffs filed a motion to remand, arguing that the amount in
controversy did not satisfy federal requirements. The district court rejected this argument, and
subsequently granted Aetna’s summary judgment motion on the merits of the case, concluding that
plaintiffs had failed to set forth any evidence that a breach of contract occurred, or that Aetna acted
deceitfully or in bad faith. Plaintiffs timely appealed.
II.
The district court denied plaintiffs’ motion to remand and granted Aetna’s summary
judgment motion; thus, the standard of review is de novo. Davis v. McCourt, 226 F.3d 506, 509 (6th
Cir. 2002); Terry Barr Sales Agency, Inc. v. All-Lock Co., 96 F.3d 174, 178 (6th Cir. 1996).
The first question we must address is whether the district court possessed subject matter
jurisdiction. Plaintiffs concede that the parties are diverse, but argue that the district court’s denial
of their motion to remand to state court was in error because the amended complaint alleged
damages of less than $75,000, thereby falling short of the amount-in-controversy threshold for
diversity jurisdiction. Aetna contends that diversity jurisdiction is established because it is “more
likely than not” that plaintiffs’ complaint seeks damages in excess of $75,000.
Removal of cases from state to federal court is governed by 28 U.S.C. § 1441(a), which
provides that “any civil action brought in state court of which the district courts of the United States
have original jurisdiction may be removed by the defendant or the defendants to the district court
of the United States . . . where such action is pending.” 28 U.S.C. § 1441(a). Federal district courts
have original jurisdiction over “all civil actions where the matter in controversy exceeds the sum or
value of $75,000, exclusive of interest and costs, and is between . . . citizens of different states.”
28 U.S.C. § 1332(a). A defendant seeking to remove a case to federal court has the burden of
proving that the district court possesses jurisdiction. Gafford v. Gen. Elec. Co., 997 F.2d 150, 155
(6th Cir. 1993). Jurisdiction is determined at the time of removal, and subsequent events, “whether
beyond the plaintiff’s control or the result of his volition, do not oust the district court’s jurisdiction
2
Plaintiffs’ separate complaints were thereafter consolidated by the state court in March 2000.
No. 05-6911 Welshans, et al. v. Aetna Life Ins. Co. Page 5
once it has attached.” St. Paul Mercury Indem. Co. v. Red Cab Co., 303 U.S. 283, 293 (1938);
Rogers v. Wal-Mart Stores, Inc., 230 F.3d 868, 872 (6th Cir. 2000).
On September 15, 2004, plaintiffs filed their second amended complaint3 in the Circuit Court
of Shelby County, Tennessee, which was amended on September 20, 2004. In the second complaint,
plaintiffs reassert the previously dismissed claims and request
judgment three times the amount of their actual damages [$74,999] (including pre-
judgment interest), which are to be determined at trial, or alternatively, their actual
damages (including pre-judgment interest) plus the 25 percent penalty provided by
Tenn. Code Ann. § 56-7-105, but limited to $74,999 exclusive of interest, costs, and
attorneys fees.
Plaintiffs aver that this limitation means that Aetna cannot demonstrate that the amount in
controversy exceeds $75,000.
The district court held that, although generally plaintiffs “may choose to claim less than the
federal requirement in order to preclude removal from state court,” Tennessee’s rules of civil
procedure enabled plaintiffs to claim an amount lower than the jurisdictional amount in the
complaint, yet seek to recover damages in excess of that amount (citing TENN. R. CIV. P. 54.03).
Tennessee Rule 54.03 provides that “every final judgment shall grant the relief to which the party
in whose favor it is rendered is entitled, even if the party has not demanded such relief in the party’s
pleadings.” TENN. R. CIV. P. 54.03. Thus, the district court concluded, Aetna must demonstrate
that it was “more likely than not” that the amount in controversy would exceed $75,000. See
Rogers, 230 F.3d at 871 (6th Cir. 2000).
To this effect, the district court continued:
The amount in controversy is determined by the allegations in the complaint.
National Nail Corp. v. Moore, 139 F. Supp. 2d 848, 850 (W.D. Mich. 2001) (citing
Laughlin v. KMart Corp., 50 F.3d 871, 873 (10th Cir. 1995)). In their complaint,
Plaintiffs allege that, as a result of Defendants wrongful acts in denying Welshans
medical insurance claims during the period of 1995-2000, they have suffered
damages in the amount of $74,999. . . . Plaintiffs further aver that they are entitled
to recover treble the amount of actual damages pursuant to Tenn. Code Ann. § 47-
18-109 and an additional twenty-five percent penalty on all sums recovered under
Tenn. Code Ann. § 56-7-105. . . . Calculating the relief requested using the damages
suffered, the complaint asserts that Plaintiffs are entitled to recover up to $74,999
under Count I; $223,997 under Count II; and $93,748.75 under Count III.
On appeal, plaintiffs attempt to reargue the same objections they made before the district
court; namely, that the stipulation in their Motion to Remand that “they do not and will not seek or
request judgment in the amount of $75,000 or greater, exclusive of interest and costs,” precludes
federal jurisdiction. We need not reach this argument because we hold that the request for attorneys’
fees properly placed this case within the purview of federal jurisdiction, and we thereby affirm the
district court’s exercise of jurisdiction on other grounds. City Mgmt. Corp. v. U.S. Chem. Co., Inc.,
43 F.3d 244, 251 (6th Cir. 1994) (“[W]e may affirm on any grounds supported by the record, even
though they may be different from the grounds relied on by the district court.” (citing Hilliard v.
U.S. Postal Service, 814 F.2d 325, 326 (6th Cir. 1987)).
3
Plaintiffs’ first complaint in federal court sought actual damages “in an amount as yet undetermined but in
excess of $75,000.” As stated, in September 2003, plaintiffs voluntarily non-suited their case, and the district court
dismissed the action without prejudice.
No. 05-6911 Welshans, et al. v. Aetna Life Ins. Co. Page 6
As a general rule, attorneys’ fees are excludable in determining the amount in controversy
for purposes of diversity, unless the fees are provided for by contract or where a statute mandates
or expressly allows the payment of such fees. Clark v. Nat. Travelers Life Ins. Co., 518 F.2d 1167,
1168 (6th Cir. 1975) (“It is settled that the statutory penalty and a statutory attorney’s fee can be
considered in determining whether the jurisdictional amount is met.”).
We have recently applied this principle, albeit in an unpublished opinion.4 In Woodmen of
the World/Omaha Woodmen Life Ins. Soc’y v. Scarbro, 129 F. App’x 194, 195-96 (6th Cir. 2005)
(unpublished), we examined what constituted “costs” in a plaintiff’s claim for declaratory judgment.
The plaintiff, Woodmen, appealed a district court’s order granting summary judgment to the
defendant in an action filed by the insurance company seeking to force Scarbro to arbitrate a dispute
under an insurance contract previously entered between the parties. The district court found that the
amount in controversy was insufficient to establish subject matter jurisdiction in federal court and
entered an order of dismissal. We reversed, stating:
It is generally agreed in this circuit that the amount in controversy should be
determined “from the perspective of the plaintiff, with a focus on the economic value
of the rights he seeks to protect.” Buckeye Recyclers v. CHEP USA, 228 F. Supp. 2d
818, 821 (S.D. Ohio 2002); see Pennsylvania R. Co. v. City of Girard, 210 F.2d 437
(6th Cir. 1954); Goldsmith v. Sutherland, 426 F.2d 1395, 1398 (6th Cir. 1970);
Wright, Miller & Cooper, Federal Practice and Procedure: Jurisdiction § 3708 (3d
ed. 1998).
Woodmen, 129 F. App’x at 195-96. This amount, we concluded, included not only the face value
of the insurance contract, but also compensation awardable by law for mental anguish and for loss
of business income, attorneys’ fees, and punitive damages. Id. In short, “the ‘object’ of th[e]
litigation, cannot be determined without reference to the potential cost of the state claim to the
insurance company.” Id. at 196.
Although the Woodmen case is neither factually identical to this case, nor precedentially
binding, we have affirmed the general principle of considering statutorily authorized attorneys’ fees
for purposes of establishing jurisdiction, Clark, 518 F.2d at 1168-69, and determine that it is
likewise appropriate in this case. See also Stokes v. Reeves, 245 F.2d 700 (9th Cir. 1957) (holding
that where there is a state statute allowing attorneys’ fees, it is applicable in diversity cases, and the
amount claimed thereunder may be taken into account in determining whether the jurisdictional
amount is involved); Johnson v. America Online, Inc., 280 F. Supp. 2d 1018 (N.D. Cal. 2003)
(holding that, typically, attorneys’ fees are not considered part of amount in controversy for diversity
purposes; however, where underlying statute authorizes award of attorney fees, those fees may be
included in calculating amount in controversy); In re High Fructose Corn Syrup Antitrust Litig., 936
F. Supp. 530 (C.D. Ill. 1996) (holding that attorneys’ fees can be considered in determining whether
plaintiff has satisfied amount-in-controversy requirement for diversity jurisdiction, where statute
mandates or allows payment of such fees, although as general rule attorneys’ fees are excluded in
determining amount in controversy); Hendrickson v. Xerox Corp., 751 F. Supp. 175 (D. Or. 1990)
(holding that for purposes of determining if amount in controversy satisfies jurisdictional
requirements, attorneys’ fees may be taken into account if statute authorizes awarding fees to
successful litigant); Hall v. Travelers Ins. Co., 691 F. Supp. 1406 (N.D. Ga. 1988) (holding that
where attorneys’ fees are allowable by applicable law, they may be included in assessing
jurisdictional amount in controversy for purposes of diversity jurisdiction).
4
Unpublished opinions of this court are not precedentially binding under the doctrine of stare decisis. United
States v. Sanford, Nos. 05-6489/6500, – F.3d – , 2007 WL 325742, at *4 (6th Cir. Feb. 6, 2007).
No. 05-6911 Welshans, et al. v. Aetna Life Ins. Co. Page 7
Here, two of the statutes upon which Williamson relies clearly allow the awarding of
attorneys’ fees. See TENN. CODE ANN. §§ 47-18-109(e)(1), 56-7-105. Further, as the district court
recounted, the plaintiffs second complaint requested:
judgment three times the amount of their actual damages [$74,999] (including
pre-judgment interest), which are to be determined at trial, or alternatively, their
actual damages (including pre-judgment interest) plus the 25 percent penalty
provided by Tenn. Code Ann. § 56-7-105, but limited to $74,999 exclusive of
interest, costs, and attorneys fees.
Accordingly, we hold “it was more likely than not” that the “potential cost of the state claim to the
insurance company,” Woodmen, 129 F. App’x at 196, would exceed $75,000, and, thus, the district
court correctly concluded that it possessed subject matter jurisdiction based on diversity of
citizenship.
III.
Next, plaintiffs contend that the district court erred in holding that there were no genuine
issues of material fact with respect to their asserted claims and, accordingly, urge this court to
reverse. The thrust of plaintiffs’ argument, however, remains the same. Instead of addressing the
grounds on which the district court held that Aetna permissibly terminated Welshans’ coverage –
that she did not reply to Aetna’s request for more information – plaintiffs argue that Aetna had all
of the information it needed on file and, accordingly, was wrong in denying Welshans’ claims. We
disagree.
A. Tennessee Consumers’ Protection Act.
The district court correctly noted that to establish a claim pursuant to the Tennessee
Consumers’ Protection Act (“TCPA”), a plaintiff must prove “(1) that the defendant engaged in an
unfair or deceptive act or practice declared unlawful by the TCPA; and (2) that the defendant’s
conduct caused an ‘ascertainable loss of money or property, real, personal, or mixed, or any other
article, commodity, or thing of value wherever situated . . . .”’ (citing Tucker v. Sierra Builders, 180
S.W.3d 109, 115-16 (Tenn. Ct. App.), app. denied (Tenn. 2005) (quoting TENN. CODE ANN.
§ 47-18-109(a)(1))). In a well-reasoned discussion, the district court examined plaintiffs’ arguments
and concluded that they had not alleged these elements with any specificity, excepting Welshans’
eligibility as a handicapped dependent. With respect to this allegation, the district court concluded
that, at worst, these denials amounted to an “erroneous denial” of a claim and, accordingly, did not
constitute an act of deception or unfairness (citing Hamer v. Harris, 2002 WL 31469213, *1 (Tenn.
Ct. App. Nov. 6, 2002)). We see no reason to disturb this holding or analysis.
B. Bad Faith Claims.
Plaintiffs further contend that the district court erred in concluding that they had submitted
insufficient evidence to substantiate their claims of bad faith. Plaintiffs allege that Aetna
“knowingly disregarded the evidence in its file and the language of the Plan” that Welshans was a
handicapped dependent and, further, “took affirmative steps to secretly alter the Plan terms for
handicapped dependent without ever actually modifying the Plan or advising Appellants and other
insureds.”
The district court correctly set forth the elements of a bad faith claim pursuant to Tennessee
law. See TENN. CODE ANN. § 56-7-105. In the context of a claim for bad-faith denial of insurance
coverage, a plaintiff must demonstrate: “(1) that the insurance policy, by its terms, became due and
payable; (2) that a formal demand for payment was made; (3) that Plaintiffs waited sixty days after
making demand before filing suit; and (4) that Aetna’s refusal to pay was not in good faith.” (citing
No. 05-6911 Welshans, et al. v. Aetna Life Ins. Co. Page 8
Palmer v. Nationwide Mut. Fire Ins. Co., 723 S.W.2d 124, 126 (Tenn. Ct. App. 1986). Plaintiffs,
the insured, bear the burden of proving bad faith on the part of Aetna in denying payment. See id.
“A penalty is not appropriate when the insurer’s refusal to pay rests on legitimate and substantial
legal grounds.” Tyber v. Great Central Ins. Co., 572 F.2d 562, 564 (6th Cir. 1978).
As Aetna notes, plaintiffs’ attempt to shift the burden of proof, thereby requiring Aetna to
prove that it acted in good faith, is without merit. Plaintiffs have simply not put forth any evidence
which disproves Aetna’s proffered reasons for denying Welshans’ claims. In short, plaintiffs ask
us to hold that Aetna’s failure to accept the ten-year old, previously-submitted letter from her doctor
rendered their denial of Welshans’ claims erroneous and in bad faith. The record reflects, and the
district court concluded, that all of Aetna’s refusals to pay claims were based upon legitimate
grounds for disputing the claims consistent with the terms of the plan. Plaintiffs have not put forth
evidence to demonstrate otherwise. Plaintiffs’ allegation that Aetna “took affirmative steps to
secretly alter the Plan terms for handicapped dependent without ever actually modifying the Plan
or advising Appellants and other insureds” is unsupported by the record. The document that
plaintiffs direct us to is a summary of the plan benefits, not the language of the contract. The very
next exhibit, presumably a portion of the same document, contains a disclaimer characterizing the
document as a summary and cautions, “[i]f there is a difference between the information in this
summary and the Plan documents, the Plan documents and contracts will govern.” Thus, plaintiffs’
unsupported allegation is without merit.
C. Breach of Contract.
Finally, plaintiffs contend that the district court erred in its ruling that there was insufficient
evidence to demonstrate that Aetna breached the contract. Under Tennessee law, an insurance
policy is to be “given its plain and ordinary meaning.” Sec. Ins. Co. of Hartford v. Kevin Tucker &
Assoc., Inc., 64 F.3d 1001, 1006 (6th Cir. 1995). The court must read the policy according to its lay
terms. Davidson Hotel Co. v. St. Paul Fire & Marine Ins. Co., 136 F. Supp. 2d 901, 905 (W.D.
Tenn. 2001). “Where there is an ambiguity or uncertainty with regards to the terms of an insurance
policy, the court must interpret the terms strictly against the drafter of the policy.” NSA DBA Benefit
Plan, Inc. v. Conn. Gen. Life Ins. Co., 968 S.W.2d 791, 795 (Tenn. Ct. App. 1997).
One of the problems in ascertaining the key dates in the life and termination of this contract
is that Aetna paid some claims while simultaneously denying other claims. The district court
divided the claims into two groups: (1) claims submitted between 1995 and 1998, some of which
were paid, and some of which were denied for reasons – Aetna proffers – at least facially consistent
with the plan; and (2) claims following Aetna’s request, and plaintiffs’ apparent failure to provide,
for continued documentation of Welshans’ handicapped dependent status.
With respect to claims submitted from 1995 to 1998, the district court held that plaintiffs had
not submitted sufficient evidence for it to determine that a breach of contract took place, stating:
[F]rom the information provided by Plaintiffs, the Court is unable to make any
determination regarding the validity of Aetna’s actions under the contract. Plaintiffs’
list of claims provides only the date, provider name, amount claimed and response
by Aetna. Because the Plaintiffs have not provided any information or argument to
the Court regarding the basis for the claim and how Aetna’s action departed from the
terms of the Plan, the Court is unable to make any determination as to whether the
claim for the service or product was wrongfully processed. Where Plaintiffs have not
supplied an argument for breach of contract on any of the more than 180 claims
listed, the Court will not endeavor to do it for them. See Skotak v. Tenneco Resins,
Inc., 953 F.2d 909, 916 n.7 (5th Cir. 1992) (“Rule 56 does not impose upon the
district court a duty to sift through the record in search of evidence to support a
No. 05-6911 Welshans, et al. v. Aetna Life Ins. Co. Page 9
party’s opposition to summary judgment. . . . Rule 56 allocates that duty to the
opponent of the motion, who is required to point out the evidence, albeit evidence
that is already in the record, that creates an issue of fact.”).
This conclusion is correct. Although Aetna decidedly paid some of Welshans’ claims and denied
others, plaintiffs put forth no evidence as to why the denial of the contested claims was inconsistent
with the contract. Unfortunately, plaintiffs have proffered the same unsupported arguments on
appeal.
Regarding the claims submitted after December 9, 1999, the district court held that Aetna
could permissibly deny the claims. Specifically, it held:
As noted above, the Plan provided Aetna with the authority to request proof of
Welshans’ continued handicap and dependency as it may “reasonably require” to
make determinations regarding her eligibility for coverage. . . . As the Court has
already determined that Aetna’s requests for such information in 1999 were
reasonable in light of the circumstances, the only remaining issue is whether Aetna
was within its contractual rights to terminate Welshan’s [sic] coverage in 1999. The
contract provides Aetna with authority to terminate at “[t]he end of a 60 day period
from the date Aetna requests proof of the continuation of the handicap and
dependency, if proof is not provided within the 60 day period.” The uncontroverted
evidence demonstrates that Aetna requested such proof on October 8, 1999.
Defendant avers that Plaintiffs failed to respond to the request. Plaintiffs have not
directed the Court to any evidence to demonstrate that this fact is in dispute.
Accordingly, pursuant to the terms of the contract, Aetna could rightfully terminate
Welshans’ coverage on December 9, 1999.
We agree with the district court’s analysis and adopt it as our own.
IV.
For the foregoing reasons, we affirm.