M. Eileen Lingle v. Fortis Health Insurance Company

Citation: Not availableDocket: E2006-00690-COA-R3-CV

Court: Court of Appeals of Tennessee; March 19, 2007; Tennessee; State Appellate Court

Original Court Document: View Document

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The Court of Appeals of Tennessee addressed the case of M. Eileen Lingle against Fortis Health Insurance Company, stemming from a summary judgment granted by the trial court, which ruled that the plaintiff's medical bills were not covered under her health insurance due to a pre-existing condition exclusion. The policy stipulated that benefits for pre-existing conditions would not be paid until the insured had been continuously covered for 12 months. The effective date of the policy was July 16, 2002, and the plaintiff sought treatment shortly thereafter for conditions related to severe back and hip pain, which had been ongoing since October 2001. 

The attending physician diagnosed her with multiple spinal and hip conditions and referred her for further evaluation. Following this, the plaintiff underwent a right total hip replacement on November 4, 2002. Fortis denied coverage, citing the procedure as related to a pre-existing condition. In her lawsuit filed on April 1, 2003, Lingle sought a court declaration requiring Fortis to pay for her hip replacements, along with pre-judgment interest, a 25% bad faith penalty under Tennessee law, and attorney fees. The appellate court vacated the trial court's summary judgment and remanded the case for further proceedings.

On October 28, 2005, Fortis filed a Motion for Summary Judgment, asserting that the undisputed facts indicated it correctly denied the plaintiff's claims. This motion included an affidavit from Dr. Kenneth Beckman, Fortis's Chief Medical Officer, who reviewed the plaintiff's medical records and concluded that Ms. Lingle's osteoarthritis symptoms were present before her coverage effective date of July 16, 2002, and were severe enough to restrict her physical activities. In response, the plaintiff submitted an affidavit from Dr. Short, who opined that Ms. Lingle's hip problems did not predate the effective date, asserting that her need for hip replacement surgery arose in August 2002, and prior complaints were due to a back issue, not hip problems.

The Trial Court granted Fortis's Motion for Summary Judgment. The standard of review for such decisions is de novo, meaning the appellate court assesses the facts without deferring to the trial court's judgment. The court evaluates whether there are genuine issues of material fact based on the evidence presented, viewing it favorably towards the nonmoving party. If the facts and conclusions allow for only one reasonable outcome, summary judgment is deemed appropriate; otherwise, it must be overruled if any doubts or genuine issues remain.

Fortis contended that Dr. Short’s affidavit lacked specificity to create a genuine issue of material fact. As the moving party, Fortis had the burden to show no material facts were in dispute that warranted judgment as a matter of law. Additionally, Fortis cited a Pre-existing Conditions Limitation in the medical coverage certificate, claiming it negated any obligation to cover medical expenses. Supporting documents included the Medical Certificate, the plaintiff’s medical records, and Dr. Beckman’s affidavit, which confirmed a diagnosis of osteoarthritis in both hips as a chronic condition developing over time.

The doctor determined that the plaintiff’s osteoarthritis symptoms manifested before the coverage effective date and could have been diagnosed then, based on medical records from Spine Surgery Associates and Chattanooga Bone and Joint Surgeons. Fortis presented a motion showing an affirmative defense that could negate the plaintiff’s claim, shifting the burden to the plaintiff to provide specific factual evidence demonstrating disputed material facts warranting a trial, as outlined in Rule 56.03. The plaintiff attempted to meet this burden by submitting Dr. Short’s affidavit, which asserted that the plaintiff's hip issues did not exist before July 16, 2002, attributing earlier pain to a back issue. Fortis contended that Dr. Short’s testimony lacked specificity regarding osteoarthritis and was unconvincing against Dr. Beckman's conclusions. However, the court favored the plaintiff’s interpretation of Dr. Short’s statements, inferring that "hip problems" included "osteoarthritis of the bilateral hips." Fortis’s claims regarding the credibility of Dr. Short's affidavit and its foundation were deemed inappropriate for summary judgment evaluation since credibility issues necessitate a trial setting. The dispute between Dr. Beckman and Dr. Short over whether the plaintiff’s condition could have been diagnosed before the coverage start date and whether it produced symptoms during that time was deemed material to the case. These factual disputes require resolution through trial, leading the court to vacate the trial court's judgment and remand the case, with appeal costs assigned to Fortis Health Insurance Company.