Court Opinion

ID: 6862416
Source: CourtListenerOpinion
Date Created: 2022-07-23 20:50:18.292053+00
Date Added: 2024-06-11T16:05:15.998784
License: Public Domain

Alexander, J.
(dissenting)—I respectfully dissent. Al-
though I agree with the majority's conclusion that the provision in the certificate of insurance coverage relating to termination is not ambiguous, I disagree with its interpretation of the unambiguous provision. I read the certificate as providing coverage for Sherri Fittro for as long as she remains disabled. The provision reads:
In the event this insurance is terminated or employment terminated and the insured or his dependent is totally disabled, the disabled person will continue to be eligible to receive Major Medical benefits, providing he remains totally disabled for a period of 12 months following termination.
Language in an insurance policy must be interpreted in the way it would be understood by the average person. *511State Farm Gen. Ins. Co. v. Emerson, 102 Wn.2d 477, 687 P.2d 1139 (1984). It would seem logical that language in a certificate of insurance coverage would be interpreted in the same fashion. A plain reading of the above provision leaves one with the clear impression that a person "totally disabled" will be eligible for medical benefits for as long as his or her disability persists. While it may well be that the insurer unintentionally overstated the coverage, the writing seems clear. I cannot say that the extension of such coverage creates, as the majority suggests, an "absurd result." I would take the language of the certificate at face value.
Even assuming, however, that the provision is ambiguous, in that it is capable of two interpretations,6 any ambiguity must be resolved in favor of the insured and against the insurer. Safeco Ins. Co. v. Davis, 44 Wn. App. 161, 721 P.2d 550 (1986). Application of that rule of construction in this case, likewise, favors a finding of coverage for Fittro.
The real question, then, that is presented for this court's consideration is this: when a provision contained in a required certificate of insurance coverage describes greater coverage than is provided in the master policy, which provision controls? In contrast to the majority I would prefer to see this court adopt the view taken by courts in two of our neighboring states and thus, hold that in the case of a conflict between the certificate and master policy, the certificate prevails. See Cross v. Mutual Benefit Life Ins. Co., 173 Cal. App. 3d 821, 219 Cal. Rptr. 305 (1985); Humphrey v. Equitable Life Assur. Soc'y of Am., 67 Cal. 2d 527, 432 P.2d 746, 63 Cal. Rptr. 50 (1967); Lecker v. General Am. Life Ins. Co., 55 Hawaii 624, 525 P.2d 1114 (1974).
It is suggested in the concurring opinion that the language of the certificate should only govern over the policy *512language when there are facts showing detrimental reliance on the certificate by the insured.7 I must concede that there are no facts before us showing that before her unfortunate accident, Sherri Fittro was aware of the certificate language or that she changed her position in any way in reliance on the certificate. However, the aforementioned cases from California and Hawaii, which hold that the terms of the certificate are binding, notwithstanding conflicting language in the master policy, do not appear to be reliant on facts showing estoppel in that sense. Instead the results appear to be dictated by a recognition that only accurate information in a certificate will satisfy the statutory requirement that persons insured under group policies be given information about their coverage.8 To hold that an inaccurate description of coverage in a certificate is adequate would be to thwart that legislative purpose. Humphrey, 432 P.2d at 750; Cross, 219 Cal. Rptr. at 308.
The holdings are justified additionally on the basis that "the individual certificate is the only document which the employee sees or is given at any time and that the insurer who drafts the instrument in language it selects, cannot thereafter complain that it does not express the intention of the parties." (Italics ours.) Humphrey, 67 Cal. 2d at 534.
*513The majority suggests that the policy language should control over the certificate language in this case because the certificate states that it is subject to the terms of the master policy, and it directs the insured to look to the master policy. While, here, the face sheet of the certificate states that it is not the insurance policy and that it does not alter or amend the policy coverage, a succeeding sentence of the certificate reads: "The benefits are as described in this certificate booklet." In light of this conflicting language, the insurer should not be permitted to avoid its express assertion that the benefits provided in the insurance policy are as described in the certificate.
Perhaps it was a mistake or inadvertence that caused Lincoln Life to issue a certificate to Fittro which provides coverage for her disability to the degree she suggests. Regardless of the reasons for the language in the certificate, in my judgment, Lincoln Life should be estopped from now claiming reliance on a policy of insurance not given to Fittro that provides less coverage than the certificate which was given to her and other beneficiaries of the policy. I would reverse the trial court.
Review granted by Supreme Court February 1, 1988.

The provision, arguably, could be read as providing that: (I) the disabled person will continue to be eligible for major medical benefits indefinitely, provided that the insured has remained totally disabled for a period of 12 months following termination; or (2) the disabled person will continue to be eligible for major medical benefits for a period up to 12 months after termination provided that the insured remains totally disabled.

RCW 48.21.080 provides:
"In group disability insurance policies there shall be a provision that the insurer shall issue to the employer, the policyholder, or other person or association in whose name such policy is issued, for delivery to each insured employee or member, a certificate setting forth in summary form a statement of the essential features of the insurance coverage, and to whom the benefits thereunder are payable described by name, relationship, or reference to the insurance records of the policyholder or insurer. If family members are insured, only one certificate need be issued for each family. This section shall not apply to blanket disability insurance policies." (Italics ours.)

The concurring opinion also contains the statement that "[i]t is safe to assume that the lower group rates charged by Lincoln National reflect a much lesser risk than if it had agreed to pay major medical benefits in perpetuity." I find no evidence in the record that the premium paid for the group policy here was any less or more than any other group policy or even any individual policy. In any case, the amount of premium paid for the insurance would be immaterial to a resolution of the issues before us.