Court Opinion

ID: 9713612
Source: CourtListenerOpinion
Date Created: 2023-08-26 05:18:48.300719+00
Date Added: 2024-06-11T18:23:19.580994
License: Public Domain

KIRSCH, Judge,

dissenting.

I respectfully dissent.
The majority concludes as a matter of law that the phrase “any occupation for wage or profit” contained in the exclusion section of the Tippecanoe Valley School Corporation employee benefit plan excludes health insurance coverage for medical expenses incurred by Landis who was injured while performing casual labor during his summer recess from teaching.
As construed by the majority, the phrase “any occupation for wage or profit” would bar coverage for any insured teacher or covered family member injured while performing any activity for profit. It would bar coverage for a teacher injured while farming a small plot of land during the summer time, and it would bar recovery for the children of an employee injured while babysitting for a neighbor, mowing grass, delivering newspapers or selling lemonade at a stand on the sidewalk. I believe such a construction is neither good law, nor good policy.
The purpose of the exclusion here at issue was to prevent double recovery for covered individuals injured while in the course of employment for which they could receive benefits under the Worker’s Compensation laws, not to deny health benefits to a covered employee or family member who, like Wayne Landis, will otherwise be uninsured.
Historically, the Tippecanoe Valley employee benefit plan was construed to provide coverage to insureds like Landis who perform casual labor. The designated materials before the trial court on summary judgment show that the plan extended benefits to children of insureds while the children were babysitting, and that teachers were assured that their health coverage extended to farming and other similar activities. When Tippecanoe switched to Employee Plans as plan administrator, Tippecanoe’s superintendent specifically assured the teachers that benefits had not changed. It was only when the plan changed reinsurers after Landis’ accident, that the reinsurer began construing the exclusion as the majority now construes it and notified teachers that it now considered children injured while babysitting not covered under the plan.
This court’s decision in Alderfer v. State Farm Mut. Auto. Ins. Co., 670 N.E.2d 111 (Ind.Ct.App.1996), trans. denied, upon which the majority relies, is distinguishable from the present ease. Alderfer involved an automobile insurance policy, not a health insurance policy; there are significant differences *1223between the two. To the extent Alderfer cannot be distinguished, it should be reconsidered.
When an ambiguity exists in an insurance policy, the policy is generally construed in favor of the insured. Barga v. Indiana Farmers Mut. Ins. Group, 687 N.E.2d 575, 578 (Ind.Ct.App.1997), trans. denied. It is this rule upon which the trial court’s ruling that the exclusion did not bar Landis’ health insurance benefits for an injury occurring while performing casual labor was based, and it is this rule which should guide our decision on appeal.
By excluding coverage to Landis, the majority makes the plan’s benefits illusory. A person who engages in casual employment for which worker’s compensation benefits are not required, see IC 22-3-2-9; IC 22-3-6-1, must either procure another health insurance policy or accept the risk of no coverage. Requiring the insured individual to procure other health coverage renders the benefits of the benefit plan at issue illusory.