Court Opinion

ID: 6759228
Source: CourtListenerOpinion
Date Created: 2022-07-21 00:29:55.770875+00
Date Added: 2024-06-11T16:02:32.755277
License: Public Domain

Clifford F. Brown, J.,
dissenting. Today the majority unfairly interprets an insurance policy strictly against the insured, and liberally in favor of the insurer; accordingly, I must dissent.
It is undisputed that by the terms of Aetna’s master policy, James Pedler would not have been eligible for supplemental coverage until he had been employed by General Highway Express, Inc. for two years, and that he had been so employed for only a few months at the time he applied for supplemental coverage. Further, the parties stipulated that all employees received a booklet explaining available insurance coverage. That booklet contained a “plan summary” which, as the majority correctly notes, provided: “In order to be eligible for Supplemental Life you must have two full years of employment prior to December first of each year.”
However, the first paragraph of the “plan summary” which Pedler presumably received also contained the following language pertinent to this appeal: “When you become covered, or when your benefits change, you will receive an individual Certificate Insert which will indicate the benefits for which you have actually become covered * * *.” (Emphasis added.) Thus, by the terms of its own “plan summary,” Aetna induced Pedler to rely on the accuracy of his individual certificate.
In Talley v. Teamsters Local No. 377 (1976), 48 Ohio St. 2d 142 [2 0.0.3d 297], this court denied coverage, as erroneously stated upon an in*12dividual certificate, upon the basis that the insured had not and could not have bargained for the coverage stated thereon. Here, however, Pedler did so bargain for and personally pay for precisely the coverage that was expressed within his individual certificate, and Aetna does not deny receiving Pedler’s payments for the supplemental coverage at issue. Thus, in my view, Talley has no application to the case at bar.
Rather, much like the insurer in Carucci v. John Hancock Mut. Life Ins. Co. (1968), 15 Ohio App. 2d 1 [44 O.O.2d 37], in the case at bar, Aetna issued Pedler’s individual certificate as the result of the insurer’s unilateral mistake of fact. The insurer designed its own application forms for supplemental life insurance coverage, and in doing so, failed to make any inquiry of the applicant as to his tenure of employment. The insurer’s failure to inquire about the very fact upon which it now relies should estop the insurer from denying coverage in the amount evidenced by Pedler’s certificate and for which Aetna accepted Pedler’s premium payments. Just as in this court’s decision in Insurance Co. v. Williams (1883), 39 Ohio St. 584, in my view, the insurance company in the case at bar is responsible for the mistake.
In addition, Aetna’s failure to inquire as to the basic facts upon which it could determine (prior to issuing an individual certificate) an applicant’s eligibility for supplemental life coverage takes this case out of the language of the disclaimer found in Section 3, Article VI of Aetna’s master contract: “If any relevant facts pertaining to any individual to whom insurance relates shall be found to have been misstated, an equitable adjustment of premiums shall be made, and if such misstatement affects the existence or the amount of insurance, the true facts shall be used in determining whether insurance is in force under the terms of this policy and in what amount.” Aetna has not alleged that Pedler “misstated” his tenure with his employer in any manner, as envisioned by that language; rather, Aetna simply failed to ask about a fact which it now claims “affects the existence * * * of insurance.” Thus, the very condition which purports to allow Aetna to avoid its contractual obligation to Pedler was not met. Because we have often held that language in a contract of insurance reasonably susceptible of more than one meaning will be construed liberally in favor of the insured and strictly against the insurer, Buckeye Union Ins. Co. v. Price (1974), 39 Ohio St. 2d 95 [69 0.0.2d 262], in this case, then, by the very terms of the master policy, Aetna should not be heard to deny coverage. Rather, the insurer should be required to suffer the consequences of its own omissions and mistakes.
The majority appears to ignore the fact that this case was decided on motions for summary judgment.4 There was no evidence presented that *13Pedler had actual knowledge of the two-year tenure requirement at issue. And, given the conflicting contract terms and “plan summary” provisions, to charge Pedler with constructive knowledge of how this policy would be interpreted amounts to basic unfairness. Instead, in my view, Aetna should be required to pay the face amount evidenced by the certificate, in the absence of fraud.
Accordingly, I would reverse the judgment of the court of appeals.

 Additionally, I note that the person who solicited Pedler’s purchase of supplemental life insurance is characterized by the majority exclusively as an employee of General Highway Express, Inc. That characterization ignores an emerging trend to consider such insurance plan administrators, at a minimum, to be dual agents, acting both for the employer and for *13the insurer who designs the solicitation system and benefits from it. Thus, as appellant suggests, on the facts of this case, the “solicitor” was not merely an employee of General Highway Express, Inc.; rather, the solicitor also acted as Aetna’s agent, for Aetna’s convenience. Because of that agency relationship, the agent’s presumed knowledge of Pedler’s short tenure should be imputed to the insurer. Mass. Life Ins. Co. v. Eshelman (1876), 30 Ohio St. 647.