### IN THE COURT OF APPEALS OF TE NNESSEE AT KNOX VILLE D ec em be r 6, 200 6 S es sio n M. EIL EEN LI NGLE v. FORTI S HEAL TH I NSURANCE COMPANY

Direc t Appeal fromthe Chancer y Court for Ham ilton Coun ty No. 03-0377 Hon. W. F rank Brow n, III, Ch ancellor

No. E2006-00690-COA- R3-CV - F ILED MARCH 19, 2007

The Trial Court gr anted de fenda nt summary judgme nt on the g round that the medica l bills incurre d by plaintiff wer e excluded fr om cover ag e under the hea lth insurance pr ovided by defe ndant. On appea l, we vac ate the summary judgme nt and re mand.

Te nn. R . A pp. P .3 App e al a s o f Rig ht ; J udgm e nt of t he Cha nc e r y C our t v ac at e d.

H ER SCH EL P I CKE N S F RAN KS , P.J ., delivere d the opinion of the court, in which C H A RLES D. S US ANO , J R ., J ., and S HAR ON G. LEE , J ., joined.
Ron a ld J. B e rk e , Ch a tta no og a , T e nn e sse e , f or app e lla nt.
L . Marsha ll Albritton and EmilyH. Wilburn, Nashville, Tennesse e, for appellee

.

OP IN ION

I n this action the issue is w hether defe ndant was obligated under its he alth insurance c ov e ra g e wi th the plaint if f t o p a y the me dic a l a ndho sp ita l bi lls fo r p la int if f’ s h ip r e pla c e me nt. The Trial Court gr anted de fendant summary judgme nt on the basis that the pre

exis ting condition limit ation contained in the me dical ce rtificate absolved it of any obligation to pay plaint if f’ s me dic a l bi lls . T his pr ov isi on pr ov ide s: We will not pay

benef its for Covere d Charg es incurr ed due to a pre- exis ting-2- c on dit ion un til y ou ha ve be e n c on tinuo us ly ins ur e d u nd e r this plan f or 12 mon ths

. After this 12 mont h period, be nefits will be paid for a pre- exis ting condition on the same ba sis as any

other c ondition unless the condition ha s been specific ally excluded from cove rag e. A p re e xistin g c on dit ionis an I lln e ss or I nju ry a ndre la te d c omp lic a tio ns , n ot f ull y disclosed on the enr ollment form, if during the 12 month pe riod immediately prior to y our ef fec tive date:
y ou rec eived medic al t reatment, diag nosis, consultation, or took Prescription Drug s for the c ondition; or the condition produce d sy mptoms or was ca pable of being diag nosed. The policy ’s ef

fec tive date wa s J uly

16, 2002, and on Aug ust 8, 2002, plaintiff sought tr e a tme nt at Sp ine Sur g e ry As so c ia te s, P.C. She c omp la ine d of pa in i n h e r l ow e r b a c k a ndthi g hs

. The attending phy sician, Da vid L owry , D.O., noted the history of Ms. Lingle ’s condition: “About Oc t o b ero f 2 0 0 1 , s h e s t ar t ed h av i n g i n cr ea s ed p ai n i n b ac k , b o t h l egs , n u m b n es s an d t i n gl i n g. Patient states she has been tolerating pain and has not had any treatment since this started last y ear .” Dr. L owry

diag nosed her with Spondy lolist hesis, Spondy loly sis, and Deg ener ative Disc D isease of the “L umbar/Sacr al S pine” as well as “Osteoa rthritis Bilate ral Hips.” Dr. L owry ’s treatment plan stated, “Ref

er patient to a g ener al orthopedist for e valuation of hips. W e will ref er he r to Dr. B ruce Short or Dr. John Nash at Chattanoog a B one and Joint.”

Dr. Short eva luated plaintiff on Aug ust 23. The re sulting medica l rec ord stated,
CHI EF COMPLAINT: Bilate ral hip pain, rig ht gr eate r than lef t.
HI STO RY OF

PRE SEN T ILLNE SS: T his 52 -y e ar- old ambulatory wh ite fe ma le prese nts with about a y ear history of bilatera l hip pain, rig ht gr eate r than lef t. . . .

. . . . X- RA YS:

. . . T he se sh ow se ve re de g e ne rativ e joi nt d ise a se wi th n e ar c omp le te los s of her cartilage clea

r spac e in both hips. . . .
I MPRES SI ON: Sever e deg ener ative joint disease bilater al hips as des cribed above. . . .
I n subsequent cor

responde nce w ith Dr. L owry , Dr. Sh o rt d escribed the history of plaintiff’s illnes s as “a n ap p ro x i m at el y o n e- y ea r h i s t o ryo f p ro gre s s i v el y wo rs en i n g b ilateral hip pain, ri g ht g re a te r tha n le ft.” On or abo ut N ov e mbe r 4 , 2 00 2, plaint if f u nd e rw e nt a

ri g ht t ota l hi p repla ceme nt

. Dr

. S h o rt perf ormed the pr ocedur e. F ortis refuse d to pay for the pr ocedur e on the-3-

g rounds that the proc edure treated a p re -e x i s t ing c ondition under the terms of the Medica l Certificate. This a ction was filed on April 1, 2003, ag ainst Fortis, a nd asked the Court “to decla re that the def

endant mus t p ay fo r b oth total hip replace ments”, along with pre-judg ment interest, a 25% B ad F aith Penalty

pursuant to T.C.A. § 56-7-105, and attorney fee s. On October 28, 2005, F ortis filed a Motion for Summary J udg ment, arg uing that the undisputed fac ts in the case showed that F ortis properly denied plaintiff’ s claims. Acc ompany ing the Motion was an af

fidavit of Kenne th B eckma n, M.D., Fortis’s Chief Medica l O ffice r. Upon re view of plaintiff’s me dical re cords, Dr . Be ckman c oncluded:

These me dical re cords d o c u me n t t h at M s . L in g le ’ s osteoarthritis produced sig nificant sy mptoms prior to the effe ctive date of co v er age and that these sy mptoms were sever e enoug h to limi t her phy sical ac tiviti es. He r conditio n was c apable of being diag nosed within the one y ear period immediately

prec eding the effective date of cover ag e, Jul y

16, 2002. Plaintiff responded to Fortis’s moti on and filed a n aff idavit of Dr. Short, in which he c on c lud e d th a t Ms L ing le ’s c on dit ion wa s n ot p re -e xistin g :

Acc ording to the medical rec ords and history as we ll as my

examination and entire c ou rs e of tr e a tme nt, the hip pr ob le ms o f [M s. L ing le ] wh ic h c a us e d m e to do hip re pla c e me nt s ur g e ry

did no t pr e date July 16 , 20 02

. F ro m a ll of the me dic a l r e c or ds , her history

and my examination and entire c ourse o f t re atm ent, her hip problem which r e s u lt e d in my p e r f o r mi n g h ip r e p la c e me n t s u r g e r y b e g a n in A u g u s t 2002. Fr om my revie w of the medical recor ds, any prior complaints of pain in her hip we re due to a ba ck proble m with refe rre d pain. M s. L ingle ’s hi p problems which c aused her to ha ve hip re place ment surg ery did n o t p re -exist t he medica l cover ag e of Fortis . . . . Responding to the Motion for Summary

J udg ment, the Trial Court e ntere d an Or der Gra nting de fenda nt Summ ary J udg ment.

“ The st and ardof

re vie w o f a

su mma ry jud g me nt d e te rm inatio n is de novo without any presumption of corr ectne ss a ccor ded the tria l court’s judg ment.” Gu y v . M utu al o f O ma ha In s. Co. , 79 S.W .3d 528, 534 (Tenn. 2002) . The a ppellate c ourt’s “only

task i n d eciding a motion for su mma ry jud g me nt i s to de te rm ine wh e the r ‘ the ple a din g s, de po sit ion s, a ns we rs to i nte rr og a torie s, a nd a dmi ssi on s o n f

ile , to g e the r w ith the a ff

ida vit s, if a ny , s ho w that th e re is n o g e nu ine iss ue a s to any materia l fac t and that the moving party is e ntitled to a judg ment as a matter of law .’” Id. (quoting Tenn. R. Civ. P. 56.04). W hen making thi s determination, “[c]ourts must view the evidenc e in the light most favor able to the nonmoving party and must al s o draw all rea sonable infe renc es in the nonmoving party ’s favor .” Staples v. CBL & Assocs., Inc

. , 1 5 S. W.3 d 8 3, 89 (T e nn . 2 00 0) . “ I f b othA moving pa rty may demonstrate e ntitlem ent t o a judg ment as a matter of law by 1 “conc lusively

establish[i ng ] an affirmative defe nse that def eats the nonmoving p a

r ty ’s claim.” By rd , 847 S.W .2d at 215 n.5. -4- the fa ct s an d co n clusions to be draw n there from permit a rea sonable pe rson to rea ch only one conclusion, then summary judgme nt is appropriate .” Seave rs v. Methodist Med. Ctr

. of Oak Ridge , 9 S.W. 3d 86 , 91 (T e nn . 19 99 ). “ I f, a ft e r su c h c on sid e ratio n, a g e nu ine iss ue of

fa c t r e ma ins fo r t

ri a l, or if ther e is doubt as t o whether or not such g enuine issue r emains for trial, the summary

judgme nt must be overr

uled.” Buddy Lee Attractions, Inc. v. W illiam Morris Agency, Inc

. , 13 S.W .3d 343, 347 (Tenn. Ct. App. 1999).

Whil e the doc tors’ af

fidavits rea ched opposite c onclusions, Fortis ar g u es t hat Dr. Short’s aff

idavit is not sufficiently

specific to raise a

g enuine issue of

materia l fac t. As the moving party , Fortis held “the burde n of demonstrating to the court that there are no dis pu te d, mate ri a l f a c ts c re a tin g a

g e nu ine iss ue fo r t

ri a l . . . a ndthat [it] is e nti tle d to judgme nt as a matter

of law.” By rd

v . H all , 847 S.W .2d 208, 215 (Tenn. 1993). F ortis’s arg ues the Pre-e x isting Conditi ons L imitation in the Certificate relieve d it of any obligation to pay

the medica l expenses. I n support of its motion, Fortis f iled a copy of the Medica l Ce rtificate , plaintiff’s medica l rec ords from Spine Surg ery Associates and Chattanoog a Bo ne and Joint S urg eons, and D r. B e c kman’ s a ff

ida vit . D r . B e c km an ’ s a f

f ida vit state d th a t pl a int if

f w a s d ia g no se d w ith “ os te oa rthriti s of the bilater al hips” and that “osteoa rthritis is a chronic, dege nerative joint dis ease , occur ring over a period of time, and cha rac terized by

sever al things, i n cl u d i n g chronic deterioration of the joint cartilage .” The doctor c oncluded that plaintiff’ s osteoarthritis produce d sy mpto m s p ri o r t o the eff ective date of c overa g e and c ould have be en diag nosed prior to that date. He based hi s conclusion upon his review of plaintiff’s me dical re cords f rom Spine Surge ry

Associates a nd Chattanoog a B one a ndJoint Sur g e on s. F ortis ’ M oti on a ndits c on te nts e sta bli sh e d a n affir mat iv e de fe ns e that c ou ld de fe a t pl a int if

f’ s c la im.
Be cause Fortis presented a proper ly supported mot ion, the burden shifted to plaintiff 1 “to set forth specific f

acts, not leg al conc lusions, byusing a ffidavits or the discovery materia ls list ed in Rule 56.03, establishing that there are indeed disput ed, material fac ts creating a g enuine issue that needs to be resolved by

the trier of

fac t and that a tr i al i s theref ore ne cessa

ry .” By rd , 847 S.W .2d a t2 1 5

. P l a i n t i f

f c o u l d s a t i s f

y t h i s b u r d e n b y (1) pointing to evidence overlooke d or ig nored by the moving party

that establishes a material fac tual dispute, (2) by reha bilitating the evidenc e attac ked in the moving party ’s pape rs, (3) by p roducing a dditional evidence showing the exist ence of a g enuine iss u efor tria l, or (4) submitting a n aff idavit expl aining why

further discovery is nece ssary

as provided f

or in [Tenn. R. Ci v. P., Rul e 56.06].
Id. at 215 n.6 (Te nn R. Civ. P ., Rule 56.06 was re numbere d as Rule 56.07 ef fec tive J uly

1, 1997). “The evidenc e off

ere d by [Ms . L ingle ] m ust be taken a s true.” Id. at 215.-5- Plaintiff’s response was to produc e Dr . Short’s aff idavit. He conc luded that plaint if f’ s “ hip pr ob le ms . . . did no t pr e date July 16 , 20 02 ” a nd that “ a ny prior c omp la int s o f p a in in her hip wer e due to a back problem with ref err ed pain.” Fortis arg ues that Dr. Short’s r efe renc e to “hip problems” is not sufficie ntly specific to dispute Dr. B eckma n’s conc lusion t h at plaintiff’s osteoarthritis produced sy mptoms prior to the effe ctive date of cove rag e and c ould have be en d i agnosed prior to that date. Althoug h Dr. Short’s af fidavit does not spec ifically mention

“ os te oa rthriti s o f the bil a te ra l hi ps ,” we are re qu ir e d to vie w his a ff ida vit in the lig ht m os t f

a vo ra ble to plaintiff and to dra w all re asonable infere nces in plaintiff’ s favor

. Staples v. CBL & Assocs., Inc

. , 15 S.W .3d 83, 89 (Tenn. 2000) . Acco rding ly , we must infer that “hip problems” inc lude “osteoa rthritis of the bilatera l hips”; theref ore, D r. Short’s af

fidavit does dispute Dr. B eckma n’s conclusion. F orti s al s o arg ues that “thestatements in Dr. Short’s af fidavit are illogica l in light of his own rec ords.” This ar g ument g oes to the weig ht or cre dibilit y of Dr. Short’s state ments, but the summary judgme nt proce dure is not the appropriate mechanism to evaluate the we ight of evidenc e or cr edibilityof witnesses. By rd , 847 S.W .2d at 216.

Fo rt i s fu rt h er a

rg ues that Dr. Short’s a ffidavit does not a ddress fa cts in the rec ord; there fore , under Om ni A v iat ion v . P e rry , 80 7 S.W. 2d 27 6 (T e nn . Ct. Ap p. 19 90 ), the a ff ida vit sh ou ld be disallowed. In Omni , the issue was w hether the def endants neg lige ntly allowed an airc raf t to r un out of fuel a nd cra sh. Id. at 280. The de fendants supported their motion for sum m ary judge ment with a detailed aff

idavit show ing that the airc raf t had not run out of fue l at the time of the c rash. Id. The plaintiff oppose d the m otion and filed an expert’s af fidavit conc luding that the aircra ft cra shed beca use it ran out of f

uel. Id. The e x pert’s c oncl u sion was partially based upon f

acts with no foundation in the re cord. Id. at 281. There fore , this Court conclude d that the expert’s af fidavit was proper ly disallowed bec ause the fa ct s u n d erlying theexpert’s opinion indicated a la ck of trustworthiness. Id. I n contra st, the fac ts underly ing D r. Short’s conc lusions do not i ndicate a lack of trustworthiness. Dr . Short based his conc lusion upon the same medica l rec ords used byDr. Be ckman a s well as re cords p roduce d by additional treating phy sicians. Dr. Short’s c onclusions were also based upon his pe rsonal experienc e as the plaintiff’s tre ating phy sician.

Thus, Dr. B eckma n and Dr . Short disputed two facts: whethe r Ms. L ingle ’s condition could have been dia g nosed prior to the e ff ective date of c overa g e and w hether her c ondition produce d sy mptoms prior to that date. These disputed fac ts are materia l beca use t hey both must be decide d in order to r esolve the substantive le g al issue, i.e., whe ther the Pre -existi ng Condi t i o ns L imitat i on protec ts Fortis from liability

. By rd , 8 47 S.W. 2da t 21 5 ( “ A d isp ute d f a c t is ma te ri a l if it m us t be de c ide d inor de r t o r e so lve the su bs ta nti ve c la im o r d e fens e at wh ic h th e mot ionis direc ted.”) . Dec iding these disputes will necessarily require weig hing the evidenc e and de termining the which of

the doctors’ testimony i s more c redible. “ [W ]hen the cre dibilit y of witnesses is an int e g ra l pa

rt of the fa c tua l pr oo f, or

wh e n e vid e nc e mus t be we ig he d, a tr ia l is ne c e ssa

ry be c ause such issues ar e not appr opriately resolved on the basis of af fidavits.” Id. at 216. According ly , under these c ircumstance s, summary judgme nt was not appropriate.
We vacate the Judgment of the T rial Court and re mand, with the cost of the a ppeal-6-

a s s e s s e d t o F o r t i s H e a l t h In s u r a n c e C o m p a n y.

______________________________ H ER SCH EL P I CKE N S F RAN KS , P

. J.