Opinion ID: 1097684
Heading Depth: 3
Heading Rank: 6

Heading: Reliance Upon A Credible Medical Opinion Obtained In Good Faith As A Matter Of Law Furnishes An Insurer An Arguable Reason For Denial Of A Claim

Text: Remembering that our core question is whether Bankers Life had an arguable reason for refusal to pay Crenshaw's claim, the majority's dispatch of Bankers Life's reliance upon Dr. McParland's opinion is further troublesome. I would have thought it a relatively uncontroversial proposition that, where the outcome determinative question is medical in nature, an insurer's reliance upon a physician's opinion would as a matter of law furnish an arguable reason for denial of a claim. I would have thought this particularly so against the backdrop of our decisions in Blue Cross and Blue Shield of Mississippi, Inc. v. Campbell, 466 So.2d 833 (Miss. 1984) and Consolidated American Life Insurance Co. v. Toche, 410 So.2d 1303 (Miss. 1982). In Blue Cross we held as a matter of law that an insurer had an arguable reason for refusal to pay a hospitalization claim where the insurer relied on the opinion of a registered nurse. In Consolidated American it does not appear that the claims adjuster who rejected the claim relied on an expert medical opinion at all, in the context of which Justice Bowling in dissent chides the company for its failure to consult or seek an opinion of its full time medical director. 410 So.2d at 1307. Here Bankers Life consulted its medical director and relied upon his opinion. This generally ought to be enough. Peel v. American Fidelity Assurance Co., 680 F.2d 374 (5th Cir.1982) is quite important here. On analogous facts and applying Mississippi law, the Court of Appeals concluded that the findings and report of Dr. Attix [a physician retained by the insurer] that Mrs. Peel was not disabled to return to ... [work] constitute an arguable defense as a matter of law. Hence, the trial court correctly refused to submit the issue of punitive damages to the jury. 680 F.2d at 376. [emphasis added] The Peel case is cited prominently in Bankers Life's brief. The rule of law found in Peel  which is the Fifth Circuit's Erie -bound [11] articulation of Mississippi law  strongly supports Bankers Life's position on this appeal. Inexplicably Peel is not mentioned by the majority (although the majority shows great affection for other Fifth Circuit bad faith refusal cases applying Mississippi law). In this state and elsewhere the law is and ought to be that reliance upon the opinion of a qualified expert physician or surgeon should as a matter of law furnish an insurer an arguable reason for refusal to pay a claim. [12] To be sure there must be limits on such a rule, see Younan v. Equifax, Inc., 111 Cal. App.3d 498, 169 Cal. Rptr. 478, 487 (1980); Little v. Stuyvesant Life Insurance Co., 67 Cal. App.3d 451, 136 Cal. Rptr. 653, 659 (1977). Unless the Court holds that the medical expert was not qualified to give the opinion, or that his opinion was inadmissible because fraudulently rendered, the rule should hold. See Georgia Farm Bureau Mutual Insurance Company v. Troupe, 154 Ga. App. 108, 267 S.E.2d 834, 836 (1980); Hermitage Health and Life Insurance Co. v. Baggs, 115 Ga. App. 138, 154 S.E.2d 270, 273 (1967). In the case at bar Bankers Life sought the opinion of a physician highly qualified in the field of vascular diseases and surgery. That opinion was that the sole cause of the amputation of Lloyd Crenshaw's right leg was its pre-existing arteriosclerotic condition. Bankers Life relied on this opinion. With respect, there is no dispassionate basis upon which one might say this was anything other than a bona fide opinion entitled to credit. In my view such a medical opinion as a matter of law furnished Bankers Life an arguable reason for refusal to pay Crenshaw's claim. To do otherwise requires that we set ourselves up as medical experts (which is precisely what the majority ultimately does). The potential for mischief in such an approach is to my mind great and obvious.