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In re Estate of Brauer

United States District Court, W.D. Missouri, Central Division

August 1, 2016

IN RE THE ESTATE OF ROBERT J. BRAUER, PERSONAL REPRESENTATIVE PATRICIA B. ETIENNE, Plaintiff,
v.
BANKERS LIFE AND CASUALTY COMPANY, Defendant.

          ORDER

          NANETTE K. LAUGHREY DISTRICT JUDGE.

         Pending 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.

         I. Undisputed Facts

         A. Brauer’s Claims History

         In January 2009, Robert Brauer[1] 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.

         Beginning 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, 2012.

         Brauer 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.

         B. Brauer’s Policy Terms

         Under 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 “CONDITIONS ON 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.”

         Later 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].

         II. Discussion

         Summary 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 whether ...


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