United States District Court, W.D. Missouri, Central Division
IN RE THE ESTATE OF ROBERT J. BRAUER, PERSONAL REPRESENTATIVE PATRICIA B. ETIENNE, Plaintiff,
BANKERS LIFE AND CASUALTY COMPANY, Defendant.
NANETTE K. LAUGHREY DISTRICT JUDGE.
before the Court are the parties’ cross motions for
summary judgment, Docs. 46 and 48. For the following reasons,
Defendant’s motion is granted and Plaintiff’s
motion is denied.
Brauer’s Claims History
January 2009, Robert Brauer purchased a Limited Benefit
Convalescent Care Policy, Policy No. 209, 016, 196
(“the Policy”), from Brenda Welsh, a sales agent
for Defendant Bankers Life and Casualty Company. On February
23, 2009, the Policy was amended to increase the benefit and
monthly premium amounts.
in March 2010, Brauer required nursing home care services for
diabetes and progressive dementia. He submitted an
Application for Long Term Care Benefits, seeking
reimbursement under the Policy for the care he received.
Bankers Life paid him benefits totaling $72, 000 for Covered
Expenses incurred between March 22, 2010 and October 31,
continued to require nursing home care services after October
31, 2012 through his death on November 9, 2015. He requested
reimbursement for Covered Expenses received after October 31,
2012, but Bankers Life refused to make any further payments,
stating that the Maximum Benefit had been reached for that
period of expense. On October 2, 2014, Brauer’s counsel
sent a Claim for New Period of Expense to Bankers Life, but
the claim was denied in a letter dated November 21, 2014.
Brauer subsequently appealed this denial, but the appeal was
denied. All monthly premiums were paid on Brauer’s
Policy through his death on November 9, 2015.
Brauer’s Policy Terms
the operative terms of the Policy at the time Brauer first
submitted his claim, the Maximum Benefit for Any One Period
of Expense was $72, 000; the Lifetime Maximum Benefit was
$144, 000. The Policy defines these terms as follows:
“Any One Period of Expense”
begins when a Family Member first incurs a charge for Covered
Services under this policy. It ends on the earlier of: (a)
the date the Family Member has, for 180 consecutive days, not
received or required Covered Services for the same cause or
causes for which the previous Period of Expense began; (b)
the date the Maximum Benefit has been exhausted; OR (c) the
date the Lifetime Maximum Benefit has been exhausted.
“Lifetime Maximum Benefit” means
the maximum amount of benefits We’ll pay a Family
Member for all Covered Expenses for all Period of Expenses.
This amount is equal to two times the Maximum Benefit Amount
for Any One Period of Expense.
“Maximum Benefit” means the
maximum amount We’ll pay a Family Member for the
combined total of all Covered Expenses during Any One Period
of Expense. This amount is equal to the Maximum Daily Benefit
amount times the Maximum Benefit Multiplier. The Maximum
Benefit is shown in the Schedule.
[Doc. 49-3, p. 14]. The Policy states under the heading
ELIGIBILITY FOR BENEFITS”
that “We won’t pay more than the Maximum Benefit
for Any One Period of Expense for the total of all Covered
Expenses. . . . We won’t pay more than the Lifetime
Maximum Benefit over the lifetime of the policy.”
on in the Policy, under the heading
“RESTORATION OF POLICY
BENEFITS, ” it noted:
This policy’s Maximum Benefit for Any One Period of
Expense will be restored when a Family Member no longer
requires or receives treatment or services for 180
consecutive days for the same cause or causes for which a
previous Period of Expense began. . . . The Lifetime Maximum
Benefit does not restore.
[Doc. 49-3, p. 19].
judgment is appropriate if there are no genuine issues of
material fact and the moving party is entitled to judgment as
a matter of law. Fed.R.Civ.P. 56(a); Anderson v. Liberty
Lobby, Inc., 477 U.S. 242 (1986). There is no dispute of
material fact in this case. Therefore, the only question is