Court Opinion

ID: 4248712
Source: CourtListenerOpinion
Date Created: 2018-02-27 21:00:36.700706+00
Date Added: 2024-06-11T07:48:10.782199
License: Public Domain

FILED
                           NOT FOR PUBLICATION
                                                                             FEB 27 2018
                    UNITED STATES COURT OF APPEALS                       MOLLY C. DWYER, CLERK
                                                                          U.S. COURT OF APPEALS

                            FOR THE NINTH CIRCUIT

JEFFREY ESTES,                                   No.   16-55837

              Plaintiff-Appellant,               D.C. No.
                                                 3:15-cv-00757-JAH-WVG
 v.

STATE FARM MUTUAL                                MEMORANDUM*
AUTOMOBILE INSURANCE
COMPANY,

              Defendant-Appellee.

                    Appeal from the United States District Court
                       for the Southern District of California
                     John A. Houston, District Judge, Presiding

                          Submitted February 14, 2018**
                              Pasadena, California

Before: BERZON and BYBEE, Circuit Judges, and WOODCOCK,*** District
Judge.

      *
             This disposition is not appropriate for publication and is not precedent
except as provided by Ninth Circuit Rule 36-3.
      **
             The panel unanimously concludes this case is suitable for decision
without oral argument. See Fed. R. App. P. 34(a)(2).
      ***
               The Honorable John A. Woodcock, Jr., United States District Judge
for the district of Maine, sitting by designation.
      Estes appeals the district court’s denial of his motion for summary judgment,

and the district court’s grant of State Farm’s motion for summary judgment. Estes

was insured under a State Farm policy providing “MedPay” coverage for

“reasonable medical expenses incurred, for bodily injury caused by accident, for

services furnished within three years of the date of accident.” Estes was injured,

obtained years of treatment, and scheduled a surgery nine days after the three-year

anniversary of his accident. He asked the district court to invalidate the three-year

bar as “arbitrary” under California’s “process of nature” rule. The district court

refused to do so, and Estes appealed.

      Estes claims the “process of nature” rule states: “when an insurer has agreed

to pay an insured for expenses incurred as a result of an accident or sickness, the

insurer cannot place arbitrary deadlines on when the treatment necessitated by that

accident or illness must occur.” Estes is incorrect. The rule . It is a judicially

created, equitable tool that relates an insured’s medical decay back to the original

accident.

      [The rule] holds that, within the meaning of policy provisions requiring
      disability within a specified time after the accident, the onset of disability
      relates back to the time of the accident itself whenever the disability arises
      directly from the accident “within such time as the process of nature
      consumes in bringing the person affected to a state of total (disability).”

                                           2
Willden v. Wash. Nat. Ins. Co., 557 P.2d 501, 503–04 (Cal. 1976) (quoting Schilk

v. Benefit Trust Life Ins. Co., 78 Cal. Rptr. 60, 63 (Ct. App. 1969)). The rule is

derived from basic tenets of medical science:

      The injured part often lies dormant for an indefinite period, with but little or
      no consciousness of its existence by the person injured, although from the
      very moment of the accident, perhaps, the processes of nature may be busily
      engaged in developing what may have seemed to be but a slight hurt into a
      most serious and perhaps fatal injury.

Nat’l Life & Accident Ins. Co. v. Edwards, 174 Cal. Rptr. 31, 34 (Ct. App. 1981)

(emphasis added) (quoting Rathbun v. Globe Indem. Co., 184 N.W. 903, 908 (Neb.

1921)). California courts apply the rule where a contractual provision to the

contrary would work an inequity. See Willden, 557 P.2d at 502–03 (insured

reached “total” disability after three years); Frenzer v. Mut. Ben. Health & Acc.

Ass’n, 81 P.2d 197, 201–02 (Cal. Dist. Ct. App. 1938) (insured eventually died

from injuries, and policy limited benefits to “immediately and totally disabling”

injuries); Edwards, 174 Cal. Rptr. at 34–35 (insured died two years after

paralyzing accident); Schilk, 78 Cal. Rptr. at 63–64 (insured’s condition slowly

worsened, and policy limited benefits to injuries that “within twenty days of the

date of the accident, totally and continuously disable the Insured”).

      The “process of nature” rule does not apply to the three-year limit on State

Farm’s coverage of medical services, directly or by analogy. Here, the bodily

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injury was apparently immediate; no relation back to the date of injury is at issue.

Instead, the limitation is one concerning duration of coverage, not whether there is

any coverage at all. The parallel for a disability policy would be the period

benefits are provided once disability begins, not the onset date of the disability

adjusted by the process-of-nature rule. See Willden, 557 P.2d at 502–03 (applying

the rule to a 30-day limit on the occurrence of disability, but not a 60-month limit

on the benefits arising thereafter). Benefit limits of the kind at issue in this case

are necessarily “arbitrary,” in a sense, but they are necessitated by the need to

adjust the cost of a policy to the extent of the benefits provided.1 Furthermore,

even if the process-of-nature rule applied as broadly as Estes wished, the reason the

medical services here at issue were rendered after the coverage cutoff was not due

to any “process of nature” inherent in the original injury, but rather due to Estes’s

decision to schedule surgery known to be necessary during the coverage period for

a date after coverage was to cease.

      The district court order is AFFIRMED.

      1
        State Farm’s reliance on a general principle of “liberty of contract” is
unhelpful. The process-of-nature rule, like many other doctrines of California
insurance law, is itself a limit on an insurer’s “liberty of contract,” in that it
prevents policy provisions reducing an insurer’s risk from being enforced as the
insurer would like, or even from being enforced at all. See, e.g., Delgado v.
Heritage Life Ins. Co., 203 Cal. Rptr. 672, 679 (Ct. App. 1984). That an insurer is
generally free to restrict coverage does not answer the question presented here.
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