Lawrence J. O'Neill, UNITED STATES CHIEF DISTRICT JUDGE.
This case arises out of Defendant Minnesota Life Insurance Company's ("Minnesota Life") denial of insurance benefits to Plaintiff Susan Vogt ("Ms. Vogt" or "Plaintiff"), the beneficiary of an accidental death insurance policy, after the death of her husband, Mr. Frank Vogt, on January 18, 2017. On November 28, 2017, Minnesota Life removed this action from California Superior Court, County of Kern on the basis of diversity jurisdiction pursuant to 28 U.S.C. § 1332. ECF No. 1. Plaintiff's complaint alleges two causes of actions against Minnesota Life for breach of contract and breach of the duty of good faith and fair dealing. ECF No. 1-1, Ex. B.
On January 3, 2019, Minnesota Life filed a motion for summary judgment pursuant to Federal Rule of Civil Procedure 56. ECF No. 20. Mrs. Vogt filed an opposition on January 31, 2019. ECF No. 22. Minnesota Life filed a reply on February 7, 2019, ECF No. 23, and Mrs. Vogt filed a sur-reply on February 11, 2019. ECF No. 25. The issue presented on this summary judgment motion is whether Mr. Vogt's death is a covered loss under the terms of the accidental death policy and whether the terms of the insurance policy preclude insurance coverage for Mr. Vogt's death. The Court finds it appropriate to rule on the motion without oral argument. See Local Rule 230(g).
On October 1, 2016, Minnesota Life issued Policy Number 39512-G-US-286 ("the
The Policy provides an accidental death and dismemberment insurance benefit. Declaration of Kathy Schmidt, ECF No. 20-4 ("Schmidt Decl."), Ex. A. Under the heading "Exclusions and Covered Losses[,]" the Policy in pertinent part provides as follows:
Schmidt Decl., Ex. A at 7.
The Defendant documents a long history of Mr. Vogt's health issues over the years. See UMF 6-23. While much of this is not material for the purposes of this motion, the Court will briefly note it here for context. Between 2000 and 2006, Mr. Vogt had knee issues requiring injections. UMF 6. Mr. Vogt broke his hip in 2010, which required Mr. Vogt to use a walker at times thereafter. UMF 7. Between 2012 and 2016, Mr. Vogt had "some dementia problems and he had some walking problems from his knee," as well as pulmonary artery disease. UMF 9-10. In September 2016, Mr. Vogt was having circulatory problems and also fell and broke his hip. UMF 11. In or around September 2016, Mr. Vogt's dementia was getting worse and he experienced night terrors and shaking of his hands. UMF 12.
In December 2016, Mrs. Vogt and her husband requested that Mr. Vogt enter palliative care, because Mrs. Vogt was having difficulty helping him since Mr. Vogt was weak in his legs and Mrs. Vogt had a shoulder issue which made it difficult for her to lift him off his bed when he was having trouble with his knee. UMF 13; PUF 115-116. However, after a nurse from Kaiser Permanente ("Kaiser") evaluated Mr. Vogt, she felt that he needed more help than palliative care would provide and arranged, together with Mr. Vogt's doctor, for Mr. Vogt to receive hospice care. UMF 13; PUF 117. Part of the reason Mr. Vogt was admitted to hospice was because of his terminal diagnosis of Parkinson's disease which was significant enough to cause
On January 10, 2017, Mr. Vogt suffered a fall in his bedroom. UMF 24; PSF 118. The fire department was called and he was taken to the hospital where he was treated and diagnosed with a contusion to his hip. UMF 25. Plaintiff disputes that this was the only injury caused by the fall and states that he also hit his head and complained of head pain and headaches. Id. When Mrs. Vogt first found her husband on the floor of his bedroom he complained that his hip, ribs, and head hurt. UMF 121. When the fire department arrived and tried to help move him, Mr. Vogt screamed in pain and it was determined that Mr. Vogt needed to be transported to the hospital. PSF 121. The ambulance and emergency room records document Mr. Vogt's complaints of head pain. PSF 124-125. After Mr. Vogt's fall, his functionality noticeably declined and the hospice nurses increased their weekly visits from twice a week to every day as a result of this decline. PSF 133-134. Mr. Vogt was unable to eat food between the time of his fall and his death one week later and he was bedbound following the fall. UMF 135-136. Within a few days of the fall, Mr. Vogt became completely nonverbal and was no longer able to take oral medications. PSF 139. Within five days of the fall, Mr. Vogt was unable to swallow and was restless and only taking water by swab. PSF 141-142. By January 17, 2017, Mr. Vogt was still not eating, was unresponsive, bedbound, and imminently dying. PSF 142-143. The hospice notes indicated that Mr. Vogt had "significantly declined since his fall on 1-10-17." PSF 141. On January 18, 2017, Mr. Vogt died at the age of 80 years old. UMF 26.
Mr. Vogt's original Certificate of Vital Record ("death certificate") was completed by Dr. Anthony H. Fung and listed Parkinson's Disease as the "Cause of Death." Schmidt Decl., Ex. C; UMF 27. When a patient who is in hospice dies, the death certificate usually indicates the terminal diagnosis that was the basis for the referral to hospice as the cause of death and Dr. Fung did not know that Mr. Vogt had fallen when he prepared the initial death certificate. See Plaintiff's Response to UMF 27. Dr. Fung amended Mr. Vogt's death certificate after Mrs. Vogt informed Dr. Fung of Mr. Vogt's January 10 fall. See UMF 28. The amended death certificate edits the "immediate cause" of death— defined as "final disease or condition resulting in death" which was previously listed on Line A of the death certificate as Parkinson's—to indicate "cardiopulmonary failure" as the immediate cause of death. Schmidt Decl., Ex. C. The amended certificate also includes additional causes of death. The certificate states "[s]equentially, list conditions, if any, leading to cause on Line A. Enter UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST." Id. Listing additional causes on the amended death certificate, Dr. Fung listed "recurrent falls" on Line B, and on Line C, he lists Parkinson's disease last. Id.
Mrs. Vogt submitted an accidental death claim for Mr. Vogt's death, including a letter explaining the January 10, 2017 fall, a Fall Questionnaire, and certain medical records from his fall. PSF 156-157; see also Declaration of Michael Horrow, ECF No.
On July 7, 2017, Minnesota Life denied Mrs. Vogt's accidental death claim, stating that there was not sufficient evidence that Mr. Vogt's death resulted "directly and independently from all causes, from injuries sustained in a fall on January 10, 2017." Schmidt Decl., Ex. B at 14. The denial letter refers to the amended death certificate and medical records that support the cause of death as Parkinson's and Alzheimer's in support of its denial.
After the commencement of this litigation, Minnesota Life learned during depositions of Minnesota Life witnesses in May 2018 that there were certain hospice records that it had not received. UMF 36. Minnesota Life then reviewed these additional records, including a review by Dr. Shapland, and again determined that there was no evidence to support Plaintiff's claim and denied benefits again in two subsequent letters dated November 15, 2018 and January 9, 2019. UMF 37-38; PSF 207.
Summary judgment is appropriate when there is no genuine issue as to any material fact and the moving party is entitled to judgment as a matter of law. Fed. R. Civ. P. 56. At summary judgment, a court's function is not to weigh the evidence and determine the truth but to determine whether there is a genuine issue for trial. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). The Court must draw all reasonable inferences in favor of the nonmoving party, and it may not make credibility determinations or weigh the evidence. See id. at 255, 106 S.Ct. 2505; see also Reeves v. Sanderson Plumbing Prods., Inc., 530 U.S. 133, 150, 120 S.Ct. 2097, 147 L.Ed.2d 105 (2000). But if the evidence of the nonmoving party is merely colorable or is not significantly probative, summary judgment may be granted. Liberty Lobby, Inc., 477 U.S. at 249-50, 106 S.Ct. 2505. A fact is "material" if its proof or disproof is essential to an element of a plaintiff's case. Celotex Corp. v. Catrett, 477 U.S. 317, 322-23, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). A factual dispute is "genuine" "if the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Liberty Lobby, Inc., 477 U.S. at 248, 106 S.Ct. 2505. "Where the record taken as a whole could not lead a rational trier of fact to find for the non-moving party, there is no genuine issue for trial." Matsushita Elec. Industrial Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 587, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986) (internal citation omitted).
Defendant Minnesota Life moves for summary judgment on Plaintiff's claims for breach of contract and breach of the duty of good faith and fair dealing relating to the accidental death and dismemberment Policy Minnesota Life issued to Mr. Vogt. ECF No. 20. Defendant argues that the breach of contract claim fails because Plaintiff cannot demonstrate Minnesota Life denied benefits that were due under the insurance contract and that denial of Plaintiff's claim for accidental death benefits was proper under the terms of the Policy. ECF No. 20 at 2; ECF No. 20-1 at 2. Minnesota Life determined Plaintiff's claim for accidental death benefits was not payable on July 7, 2017 because Mr. Vogt's death was caused by a combination of disease factors and was not due to an accident. ECF No. 20-1 at 5. In this regard, Minnesota Life contends: "Mr. Vogt's death was a combination of two primary causes: Parkinson's disease, and cardiopulmonary failure. He also experienced recurrent fails caused by his terminal diseases." ECF No. 20-1 at 5. Minnesota Life argues that even though Mr. Vogt suffered a fall during the last week of his life, this does mean that the already "weak, frail, and terminally ill Mr. Vogt ['s] ... death was caused by an accident" and that there is no medical evidence that links Mr. Vogt's January 2017 fall to his death. ECF No. 20-1 at 2. Minnesota Life also contends that the breach of the duty of good faith and fair dealing claim fails first because Plaintiff cannot show that benefits were due under the Policy and second, even if Plaintiff could show that benefits were due, she cannot show that withholding of benefits was unreasonable. ECF No. 20 at 4.
Plaintiff in opposition argues that the Policy is not enforceable as written, pointing to California Supreme Court precedent, as well as other California court cases, which have reinterpreted the language in the Policy to be less limited than it is written. ECF No. 22 at 17-19.
Because Plaintiff has presented evidence which creates a genuine dispute of material fact as to what proximately caused Mr. Vogt's death, Defendant's motion for summary judgment is denied.
As an initial matter, jurisdiction in this case is based upon diversity, and both parties agree that the interpretation of the subject insurance policy is governed by the law of the State of California. See Continental Insurance Co. v. Metro-Goldwyn-Mayer, Inc., 107 F.3d 1344, 1346 (9th Cir. 1997) (applying California insurance law in diversity case).
In moving for summary judgment, Minnesota Life contends that the express terms of the accidental death and dismemberment Policy are clear and unambiguous in providing that benefits are only provided when the "loss results directly — and independently — from all other causes, from an accidental bodily injury which was unintended, unexpected, and unforeseen[;]" "[t]he bodily injury must be the sole cause of [the insured's] loss[;]" and the policy specifically excludes coverage where the insured's "loss or injury is caused directly or indirectly by, results from, or there is a contribution from ... bodily or mental infirmity, illness, or disease." ECF No. 20-1 at 7. Minnesota Life further points that Mr. Vogt's death certificate indicates that the primary causes of Mr. Vogt's death were Parkinson's disease and cardiopulmonary failure and accordingly not accidental as defined by the Policy. Minnesota Life mentions in passing the amended death certificate also "mentioned recurrent falls" as a cause of death, however, it argues Plaintiff cannot demonstrate that Mr. Vogt's death resulted directly from an accident and was independent of all other causes. Id. at 7.
As Plaintiff points out, under California law, the Policy language referring to "directly and independently" of all other causes has been interpreted more broadly as permitting recovery if the accident is the "proximate cause" or "initiating cause" of the loss even if a disease may have contributed to the accident. ECF No. 22 at 17-18. Plaintiff cites three cases discussing the proper interpretation of the Minnesota Life Policy pursuant to California law: Brooks v. Metropolitan Life Ins. Co., 27 Cal.2d 305, 163 P.2d 689 (1945); Slobojan v. Western Travelers Life Ins. Co., 70 Cal.2d 432, 74 Cal.Rptr. 895, 450 P.2d 271 (1969); Nash v. Prudential Ins. Co. of Am.,
In Brooks v. Metropolitan Life Ins. Co., 27 Cal.2d 305, 163 P.2d 689 (1945), the Policy insured "against the results of bodily injuries ... caused directly and independently of all other causes by violent and accidental means" and further provided that the insurance would not cover "accident, injury, disability, death or any other loss caused wholly or partly, directly or indirectly, by disease or mental infirmity or medical or surgical treatment therefor." 27 Cal.2d at 306, 163 P.2d 689. The insured in Brooks was terminally ill and was confined to his room, spending most of his time in bed, when a fire started in his bedroom causing him second and third degree burns and resulting in his death. Id. at 307-309, 163 P.2d 689. In responding to the defendant's argument that there was no liability because insured's disease and infirmity contributed to his cause of death, the California Supreme Court held that the correct rule in interpreting the language of the policy is that:
Id. at 309-10. The Brooks Court, in finding liability could exist under the terms of the policy, held that it did not matter that the insured's weakened and infirm condition made him less able than a normal person to withstand the effects of injuries since there was "evidence from which the court could conclude that the proximate cause of his death was burns received in a fire of accidental origin." Id. at 310, 163 P.2d 689.
In Slobojan v. Western Travelers Life Ins. Co., 70 Cal.2d 432, 74 Cal.Rptr. 895, 450 P.2d 271 (1969), the insured, a police officer who made arrests, had a life insurance policy which provided for double indemnity if insured's death was accidental. The insured collapsed and died after chasing a robbery suspect in the course of his duties as a deputy sheriff. Id. at 439, 74 Cal.Rptr. 895, 450 P.2d 271. The accidental death benefit provision stated "in pertinent part that the death of the insured must have `resulted directly and independently of all other causes from bodily injuries caused by accident...' and must not have resulted from `disease' or `bodily or mental infirmity.'" Id. at 442, 74 Cal.Rptr. 895, 450 P.2d 271. The Slobojan Court reaffirmed that the correct rule for interpreting such policy provisions was the rule stated in Brooks and found, despite the insured's preexisting condition of mild atherosclerosis, revealed by the autopsy, the insured's accidental injury — the physical stress of the chase — "was a prime moving cause" of his death even though this aggravated his preexisting condition which contributed to his death. Id. at 442-43, 74 Cal.Rptr. 895, 450 P.2d 271.
Relatedly, in Nash v. Prudential Ins. Co. of Am., 39 Cal.App.3d 594, 114 Cal.Rptr. 299 (1974), the policy provided benefits if the insured "sustains accidental bodily injuries and ... suffers the loss of life ... as a direct result of such injuries and independently of all other causes" and expressly excluded coverage if the loss was "directly or indirectly from bodily or mental infirmity or disease or medical or surgical treatment thereof." Id. at 597, 114 Cal.Rptr. 299. The insured fell from a boat, suffered a heart attack and died. The autopsy revealed a severe coronary artery disease which pre-existed the accident. Id. at 596-597, 114 Cal.Rptr. 299. After a jury
Defendant does not argue that Brooks is not the correct rule under California law for interpreting accidental death policies such as the Policy it issued to Mr. Vogt. Defendant instead argues that "the evidence plainly does not show — and Plaintiff cannot prove — that Mr. Vogt's fall set `in progress the chain of events leading directly death.'" ECF No. 20-1 at 8 (quoting Happoldt v. Guardian Life Ins. Co. of Am., 90 Cal.App.2d 386, 402, 203 P.2d 55 (1949)). However, for the purposes of defeating summary judgment Plaintiff must only present evidence that indicates that there is genuine dispute of material fact as to whether the fall "set[] in progress the chain of events leading directly to death." See Brooks, 27 Cal.2d at 310, 163 P.2d 689. Plaintiff, having presented such evidence, has presented a genuine factual dispute of what proximately caused Mr. Vogt's death — a question properly left for the jury to determine. See, e.g., U.S. Fid. & Guar. Co. v. Blum, 270 F. 946, 956 (9th Cir. 1921) (when insured who suffered from fainting and dizzy spells fell out window, accidental death policy would cover loss unless death would have resulted without the fall but "it was within the province of the jury to inquire" about what "probable inference[s]" could be drawn "under all the circumstances surrounding his death"); Heighley v. J.C. Penney Life Ins. Co., 257 F.Supp.2d 1241, 1256 (C.D. Cal. 2003) ("It is evident that there is a genuine issue of material fact in dispute— whether an accident was the cause of Mrs. Heighley's death—which precludes a finding of summary judgment.").
While Minnesota Life's contention that "[t]he fact that the fall on January 10, 2017 was the last fall Mr. Vogt experienced before his death does not require a finding that the fall somehow caused his death" may very well be true, its contention that "[t]here is no evidence from any of the medical records or any of the depositions of any of the witnesses that suggest the fall led to or caused Mr. Vogt's death" is not. See ECF No. 20-1 at 9. The fact that Mr. Vogt suffered a fall a week before his death may "not require a finding that fall somehow caused his death[,]" see id., however, Plaintiff has submitted sufficient evidence to present a genuine dispute of material fact on whether the fall was the "proximate cause" of Mr. Vogt's death such that it "set[] in progress the chain of events leading directly to death" as provide in Brooks, 27 Cal.2d at 309-310, 163 P.2d 689. Minnesota Life states that Mr. Vogt did not suffer a head injury as a result of the January 10, 2017 fall, only a contusion on his hip. ECF No. 20-1 at 7. However, the medical records submitted by Plaintiff, including the ambulance and emergency room records from January 10,
Minnesota Life also argues that "Plaintiff cannot show
Defendant attempts to distinguish Brooks and the related line of cases from this case by stating "none of the decedents in any of these cases were in declining health of the type Mr. Vogt experienced, nor were they on hospice." ECF No. 23 at 5.
Additionally, Defendant's argument implies that because Mr. Vogt was likely to die soon anyway, as evidenced by his placement in hospice, the insurance Policy could not provide coverage for him in his fragile and weakened state even if he experienced an accidental fall because his disease caused him to fall. ECF No. 23 at 4.
Defendant's motion for summary judgment on the breach of contract claim is DENIED.
Minnesota Life makes two arguments in support of summary judgment on the
Under California law, every contract contains an implied covenant of good faith and fair dealing. Foley v. Interactive Data Corp., 47 Cal.3d 654, 683-84, 254 Cal.Rptr. 211, 765 P.2d 373 (1988). "The implied promise requires each contracting party to refrain from doing anything to injure the right of the other to receive the benefits of the agreement. The precise nature and extent of the duty imposed by such an implied promise will depend on the contractual purposes." Egan v. Mut. of Omaha Ins. Co., 24 Cal.3d 809, 818, 169 Cal.Rptr. 691, 620 P.2d 141 (1979) (citations omitted) (dealing with disability insurance). A claim for a breach of the covenant of good faith and fair dealing requires showing: (1) benefits that are due under the policy are withheld; and (2) the reason for withholding such benefits was unreasonable, in bad faith, or without proper cause. Staefa Control-Sys. Inc. v. St. Paul Fire & Marine Ins. Co., 847 F.Supp. 1460, 1475 (N.D. Cal.), opinion amended on reconsideration, 875 F.Supp. 656 (N.D. Cal. 1994). If benefits are withheld for "proper cause," the implied covenant is not breached. Love v. Fire Ins. Exch., 221 Cal.App.3d 1136, 1151, 271 Cal.Rptr. 246 (1990).
"The covenant of good faith and fair dealing has `particular application' to insurers because they are `invested with a discretionary power affecting the rights of another[.]'" Amadeo v. Principal Mut. Life Ins. Co., 290 F.3d 1152, 1161 (9th Cir. 2002) (quoting Carma Developers (Cal.), Inc. v. Marathon Dev. Cal., Inc., 2 Cal.4th 342, 372, 6 Cal.Rptr.2d 467, 826 P.2d 710 (1992)). "For the insurer to fulfill its obligation not to impair the right of the insured to receive the benefits of the agreement, it again must give at least as much consideration to the latter's interests as it does to its own" which requires "that an insurer fully inquire into possible bases that might support the insured's claim." Egan, 24 Cal.3d at 818-19, 169 Cal.Rptr. 691, 620 P.2d 141 (emphasis added). "While an insurance company has no obligation under the implied covenant of good faith and fair dealing to pay every claim its insured makes, the insurer cannot deny the claim `without fully investigating the grounds for its denial.'" Wilson v. 21st Century Ins. Co., 42 Cal.4th 713, 720-21, 68 Cal.Rptr.3d 746, 171 P.3d 1082 (2007),
Under California law, bad faith liability does not exist if the defendant on summary judgment can show that there was a genuine dispute as to coverage. Guebara v. Allstate Ins. Co., 237 F.3d 987, 992 (9th Cir. 2001). A genuine dispute exists only where the insurer's position is maintained in good faith and on reasonable grounds. Wilson, 42 Cal.4th at 723, 68 Cal.Rptr.3d 746, 171 P.3d 1082. An insurer is entitled to summary judgment based on a genuine dispute over coverage only where the summary judgment record demonstrates the absence of triable issues as to whether the disputed position upon which the insurer denied the claim was reached reasonably and in good faith. Id. at 724, 68 Cal.Rptr.3d 746, 171 P.3d 1082. In Wilson, the plaintiff had suffered neck injuries in a car accident and submitted an insurance claim. The defendant insurance company rejected her claim, on the grounds it was a preexisting injury. Before rejecting the claim, the insurance company did not attempt to contact the plaintiff's doctor or speak with any other medical practitioner about the claim. Because the dispute was as to liability on a factual dispute—not a dispute as to policy interpretation —the Wilson court found that, without investigation, the dispute was not "genuine," and the insurance company did not have a reasonable factual basis to deny the claim. See id. at 724-26, 68 Cal.Rptr.3d 746, 171 P.3d 1082. The Court denied summary judgment.
While Minnesota Life seems to argue that the genuine dispute rule applies here, the Court finds that Plaintiff has presented evidence showing Minnesota Life failed to thoroughly investigate Mrs. Vogt's claim — including a failure to investigate the fact Mr. Vogt fell a week prior to his death and its potential consequences in leading to his death. Minnesota Life seems to have concluded that no inquiry into the circumstances and consequences of Mr. Vogt's fall was necessary since Mr. Vogt was on hospice and his health was deteriorating prior to his fall. See ECF No. 23 at 4. However, this ignores California case law interpreting accidental death policies such as this one, which holds that a preexisting disease will not relieve an insurer from liability if the accident is the proximate cause of death by setting in progress a chain of events leading directly to death. See Brooks, 27 Cal.2d at 309-10, 163 P.2d 689. Minnesota Life claims that "[i]t certainly did not `ignore evidence which supports coverage,' because no such evidence exists." ECF No. 23 at 8. However, the fall and Mr. Vogt's rapid deterioration after the fall are evidence supporting coverage which Minnesota Life continues to ignore.
In April 2017, Mrs. Vogt completed a fall questionnaire concerning Mr. Vogt's fall and she sent a letter explaining Mr. Vogt's fall and included the amended death certificate, the ambulance records, emergency room records, and photos of Mr. Vogt's injuries. PSF 156, 157. In June 2017, Mrs. Vogt also appears to have sent an email to the Minnesota Life claims administrator, Tamara Davis, containing a link for a file containing medical records which included evidence of the fall and Mr. Vogt's complaints of head pain. PSF 153, 166. However, it appears that Ms. Davis was not aware that Mr. Vogt complained of head pain after his fall when Plaintiff's claim was denied. PSF 170. Ms. Davis requested the hospice records sometime in May 2017 but never obtained nor saw Mr. Vogt's hospice progress notes before denying Plaintiff's claim on July 7, 2017. PSF 153, 158-161. The hospice notes documented
On June 22, 2017, Ms. Davis referred the file to medical indicating that the death certificate listed Parkinson's and Alzheimer's disease, without reference to the amended death certificate's inclusion of cardiopulmonary failure and recurrent falls as additional causes of death. PSF 169. In her notation to medical, Ms. Davis also indicated that the family claimed the insured fell and was taken to the hospital and discharged the same day. Id. Ms. Davis stated "Please review this information and comment on the cause/manner of death. Also, please comment as to what role, if any, the fall on 1/10/17 played in this insured death as well as bodily or mental infirmity, illness or disease." Id. Ms. Davis did not mention Mr. Vogt's complaints of head pain because she apparently was not aware of such complaints despite the medical records that indicated as much. PSF 170. In response to Ms. Davis' referral to medical, Dr. Shapland, a medical examiner for Minnesota Life, made note of the January 10, 2017 fall and indicated complaints of hip pain and an X-ray, but does not mention the complaints of head pain even though they presumably would have been part of the same file reviewed. PSF 171. Dr. Shapland concluded: "The records here reveal that the claimant had baseline poor balance and weakness due to his comorbid conditions, which led to his falling. Therefore, it was his advanced PD and AD that lead to his death. The information here is consistent with and supportive of the cause of death as noted on the death certificate, and the manner of death is natural." PSF 171. Dr. Shapland in her deposition acknowledged that complaints of head pain, as Mr. Vogt's record indicates, can be evidence of a head injury. PSF 173. Dr. Shapland also did not review the hospice progress notes before the denial letter was issued. PSF 174.
Neither Ms. Davis or Dr. Shapland knew that Mr. Vogt may have had a head injury as a result of the January 10, 2017 fall prior to the denial of benefits. PSF 170, 173, 176. And while Ms. Davis was aware of the existence of hospice records and wanted to obtain them before making a determination of coverage, such records were not obtained before the denial letter was sent. PSF 160-161. It also appears that Minnesota Life did not attempt to determine California law on such accidental policies before writing its denial letter, and even Defendant's briefing glosses over the proper interpretation of its Policy under California law. See PSF 197-201. After the commencement of this litigation, Minnesota Life determined it was necessary to review deposition testimony of the emergency room doctor, the doctor who completed the death certificate, and one of the hospice nurses, as well as the hospice notes. PSF 202; see also Horrow Decl, Exs. 31-32. However, after such review it reiterated its denial in a January 9, 2019 letter that there were no records to indicate Mr. Vogt suffered any sort of head injury that could have caused or contributed to his death without doing any further investigation. PSF 205. It is not clear how Minnesota Life could determine there was no head injury that could have caused or contributed to Mr. Vogt's death without investigation. Even Dr. Shapland admitted in her deposition that complaints of head pain after a fall could be indicative a head injury but Minnesota Life concluded that there was no head injury without indicating the basis for this conclusion. See PSF 173.
In this case, there is sufficient evidence in the record from which a jury could conclude that Minnesota Life denied Mrs. Vogt's claim unreasonably and in bad faith. A triable issue of fact exists as to whether it was reasonable to deny Mrs. Vogt's claim on the grounds stated without evaluation or investigation of facts which supported Plaintiff's claim and whether Minnesota Life fairly evaluated the claim or considered controlling law when making its determination.
Defendant's motion for summary judgment on the breach of the duty of good faith and fair dealing claim is DENIED.
For all the foregoing reasons, the Defendant Minnesota Life's motion for summary judgment (ECF No. 20) is
IT IS SO ORDERED.
