Court Interprets Policy as Written

Med Pay Only Available for Reasonable & Necessary Expenses

Post 4826

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Kimberly Sisia appealed the district court’s dismissal with prejudice of her amended complaint against State Farm, as well as the district court’s denial of her motion for conditional class certification. In short, Sisia sought reimbursement from State Farm for medical expenses allegedly incurred because of an automobile accident that occurred in 2009. She claimed that her automobile insurance policy required State Farm to pay all of her medical expenses stemming from the accident up to the policy limit.

In Kimberly K. Sisia v. State Farm Mutual Automobile Insurance Company, No. 23-14201, United States Court of Appeals, Eleventh Circuit (June 6, 2024) the Eleventh Circuit resolved the dispute.

THE POLICY

Sisia’s automobile insurance policy states that State Farm “will pay reasonable medical expenses incurred, for bodily injury caused by accident,” and that “[t]hese expenses are for necessary medical, surgical, X-ray, dental, ambulance, hospital, professional nursing and funeral services, eyeglasses, hearing aids and prosthetic devices.” It further explains that State Farm has the right to review “medical expenses and services to determine if they are reasonable and necessary for the bodily injury sustained.”

ARGUMENT

Sisia argued that this policy unequivocally required State Farm to pay all of Plaintiff’s medical expenses incurred from her automobile accident. Sisia’s argument ignored the plain text of the policy, which unambiguously stated that State Farm must pay only for expenses that are “reasonable” and “necessary.” The policy explicitly contemplated the possibility that State Farm will not pay for medical expenses that it deems unreasonable or unnecessary.

ANALYSIS

Because the language of Sisia’s insurance policy plainly does not require State Farm to reimburse all medical expenses — only those expenses that it deems “reasonable” and “necessary.” The district court did not err in concluding that Sisia’s claim for breach of contract against State Farm could not survive a motion to dismiss. Likewise, the district court did not err in dismissing her claim that State Farm breached its duty of good faith and fair dealing. Such a claim is not actionable unless the allegations of breach are specifically tied to the breach of a contract provision.

There can be no breach of an implied covenant of good faith where a party to a contract has done what the provisions of the contract expressly give him the right to do.

Finally, the district court did not err in denying Sisia’s motion for class certification when it dismissed her complaint because her underlying claims lacked merit.

ZALMA OPINION

The Eleventh Circuit, like the USDC, did what the plaintiff did not do: they read the policy. Sisia wanted payment for all her medical expenses while the policy only allowed for payment of reasonable and necessary medical expenses relating to the accident. Therefore treatment for the common cold, a hangnail, diabetes or an illness not reasonable or necessary as a result of the accident could never be covered. Sisia was unable to change an automobile MedPay policy into a health insurance policy.

(c) 2024 Barry Zalma & ClaimSchool, Inc.

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About Barry Zalma

An insurance coverage and claims handling author, consultant and expert witness with more than 48 years of practical and court room experience.
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