In this first party medical benefits claim, accidental injury was covered but not loss resulting from disease. Prior to the insurer’s summary judgment motion, the record appeared to show the loss resulted from diabetes, which would not be covered. However, an affidavit submitted in opposition to summary judgment created a dispute of fact as to whether the loss arose from an accidental injury which may have been exacerbated by the diabetes, but was not caused by the diabetes. Thus, summary judgment was denied on the breach of contract claim.
Summary judgment was granted on the insured’s bad faith claim. The court observed that an insured “must show, by clear and convincing evidence, that [the insurer] ‘did not have a reasonable basis for denying benefits under the policy,] and that [it] ‘knew of or recklessly disregarded its lack of a reasonable basis in denying the claim.’”
In this case, none of the medical records mentioned injury, and most referred to diabetes as causing the loss. The only evidence the insurer had in evaluating the claim that supported an injury separate from the disease was the insured’s own language in his statement of claim. “But an insured cannot sustain a bad faith claim with merely ipse dixit.” Thus, the insured won summary judgment on the bad faith claim.
Date of Decision: June 28, 2018
Long v. Hartford Life & Accident Insurance Co., U. S. District Court, Middle District of Pennsylvania No. 4:16-CV-00138, 2018 U.S. Dist. LEXIS 108014 (M.D. Pa. June 28, 2018) (Brann, J.)