Combined insurance company of america sues for fraud and breach of contract. Plaintiff issued a Sickness Hospital Confinement Indemnity Policy to defendants. Defendants were hospitalized as inpatients, visited an Emergency Room for treatment.
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Original Title
COMBINED INSURANCE COMPANY OF AMERICA v. THOMAS et al Complaint
Combined insurance company of america sues for fraud and breach of contract. Plaintiff issued a Sickness Hospital Confinement Indemnity Policy to defendants. Defendants were hospitalized as inpatients, visited an Emergency Room for treatment.
Combined insurance company of america sues for fraud and breach of contract. Plaintiff issued a Sickness Hospital Confinement Indemnity Policy to defendants. Defendants were hospitalized as inpatients, visited an Emergency Room for treatment.
EASTERN DISTRICT OF ARKANSAS NOV O B ,. JONESBORO DIVISION . ZD12 COMBINED INSURANCE COMPANY OF AMERICA vs. DAVIDW. THOMAS and DEBBIE L. THOMAS PLAINTIFF Plaintiff Combined Insurance Company of America, by and through counsel Wright, Lindsey & Jennings LLP, submits the following as its complaint and prayer for damages against defendants David W. Thomas and Debbie L. Thomas: I. PARTIES 1. Plaintiff Combined Insurance Company of America is a corporation organized and existing under the laws of the State of Illinois, with its principle place ofbusiness in Glenview, Illinois. Plaintiff is authorized to and does conduct business in the State of Arkansas. 2. Defendant David W. Thomas is a natural person residing in Jonesboro, Craighead County, Arkansas. 3. Defendant Debbie L. Thomas is a natural person residing in Jonesboro, Craighead County, Arkansas. 4. This lawsuit is for fraud and breach of contract involving an insurance policy issued by plaintiff to defendants on March 21, 2005. 1147337-vl Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 1 of 24 5. A substantial part of the events giving rise to this lawsuit occurred in Jonesboro, Craighead County, Arkansas. 6. The amount in controversy exceeds $75,000.00, exclusive of interest and costs. II. STATEMENT OF JURISDICTION AND VENUE 7. This Court has jurisdiction pursuant 42 U.S.C. 1332. 8. Venue is proper in this Court pursuant to 42 U.S.C. 1391. III. STATEMENT OF THE CASE 9. On March 21, 2005, plaintiff issued a Sickness Hospital Confinement Indemnity Policy, No. R6286252-12830 ("the Policy") to defendants. A copy of the Policy is attached hereto as Exhibit A. 10. Pursuant to the terms of the Policy, the insured and any beneficiary of the Policy are entitled to monetary benefits for days the insured was hospitalized as an inpatient, visited an Emergency Room for treatment, recovered from a surgical procedure or recovered at home following a hospital confinement. 11. Defendant David W. Thomas was the insured under the terms of the Policy. 12. The Policy is guaranteed renewable and non-cancellable until the 75th birthday of defendant David W. Thomas. 13. Defendant David W. Thomas and defendant Debbie L. Thomas are husband and wife and were so related when the Policy was issued. 1147337-vl 2 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 2 of 24 14. Defendant Debbie L. Thomas was listed as the beneficiary to the Policy. 15. At the time the Policy was issued, defendant David W. Thomas was employed as a District Manager for plaintiff. 16. Prior to 2006, defendant David W. Thomas was diagnosed with cirrhosis of the liver and in 2006 underwent a liver transplant. 17. Defendant David W. Thomas received treatment for the above referenced medical conditions at St. Bernard's Medical Center in Jonesboro, Arkansas, and Methodist Hospital in Memphis, Tennessee. 18. Defendant David W. Thomas' treating physicians included Dr. Brad Moore from Jonesboro, Arkansas. 19. Defendants subsequently submitted valid claims for benefits under the Policy for the time periods of April21, 2006, through May 9, 2006; July 21, 2006, through July 29, 2006; and February 23, 2007, through February 27, 2007, occasioned by inpatient hospitalizations and recovery periods related to defendant David W. Thomas' liver disease. 20. However, in addition to the valid claims cited above, defendants also submitted numerous fraudulent claims for benefits under the Policy. Specifically, defendants fraudulently submitted eighteen (18) claims representing to plaintiff that defendant David W. Thomas was hospitalized as an inpatient, visited the Emergency Room or was recovering from the hospitalization or a surgical procedure and seeking benefits for fifty (50) separate periods of time. 1147337-vl 3 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 3 of 24 21. To facilitate their fraud, the defendants submitted falsified billing documentation from St. Bernard's Medical Center in Jonesboro, Arkansas, and Methodist Hospital in Memphis, Tennessee, supporting their claim. 22. To further facilitate their fraud, the defendants presented falsified attending physician's statements to verify the insured's claimed hospitalization, ER visit or surgical procedure. Specifically, the defendants alternatively used a prior physician's statement which bore Dr. Brad Moore's signature or forged Dr. Moore's signature onto a new attending physician's statement. Such fraudulent conduct by the defendants is evident as the majority of the attending physician's statements submitted by the defendants as originating from Dr. Moore were dated and purportedly signed by Dr. Moore after September 21, 2007, the date on which Dr. Moore died. 23. To further facilitate their fraud, defendants used the trust inherent in defendant David W. Thomas' employment and managerial relationship with plaintiff, as well as defendant David W. Thomas' previously confirmed medical condition. 24. Moreover, to discourage inquiry by plaintiff, along with the false and fraudulent claims documents referenced above, defendants sent personal messages expressing their appreciation for plaintiff and detailing defendant David W. Thomas' declining health condition which included comments such as "We almost lost David last night" and falsely stating that defendant David W. Thomas had been admitted to hospice "comfort care." Each of these comments were false and were 1147337-vl 4 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 4 of 24 offered with the sole purpose to induce reliance by plaintiff and discourage questions regarding the payment of benefits under the Policy. 25. Both defendants David W. Thomas and Debbie L. Thomas jointly conspired and, by their individual actions, actively participated in concert in furtherance of a conscious agreement to pursue the fraudulent acts described herein. 26. To date, defendants' fraudulent acts have directly and proximately caused the plaintiff to pay to defendants $448,000.00 in benefits under the terms of the Policy. IV. CAUSES OF ACTION A. FRAUD/DECEIT 27. The allegations in paragraphs 1-26 are incorporated herein by reference pursuant to Fed. R. Civ. P. lO(c). 28. As outlined above, defendants made false representations of material fact, namely their entitlement to benefits under the terms of the Policy. 29. Specifically, defendants submitted falsified billing documentation from St. Bernard's Medical Center in Jonesboro, Arkansas, and Methodist Hospital in Memphis, Tennessee, as well as falsified and forged attending physician's statements, to support their claims for benefits under the terms of the Policy. 30. Defendants submitted the following fraudulent claims for benefits for the specified time periods: 1147337-vl 5 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 5 of 24 (a) Claim #26252355 09/09 - 09/12/06 10/16- 10/20/06 11117 - 11/22/06 12/19 - 12/23/06 01111- 01117/07 02/12- 02/15/07 03/16 - 03/22/07 07/06-07/10/09 (b) Claim #26435402 05/04- 05/10/07 (c) Claim #26468428 06/11- 06119/07 07/06- 07115/07 08/17 - 08/25/07 10/02- 10/19/07 12/11- 12/15/07 (d) Claim #26668985 03/01- 03/12/08 (e) Claim #26736973 06/03 - 06/13/08 (f) Claim #26787245 08/17 - 09/03/08 10/16- 10/21108 (g) Claim #26851197 11124 - 12/05/08 01105- 01109/09 (h) Claim #26932681 03/04 - 03/21109 04/21- 05/09/09 1147337-vl 6 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 6 of 24 (i) Claim #27033371 08/19 - 09/05/09 09/20 - 09/25/09 " 10/21- 11/09/09 12/10- 12/15/09 01111- 01/28110 03/01- 03/03/10 G) Claim #27161843 03/25-04/05/10 (k) Clahn #27178300 05/12- 05/15/10 06/08- 06/25/10 07/26- 07/29/10 (l) Claim #27243126 09/11- 09/22/10 11105- 11/22/10 (m) Claim #27303507 01102- 01107/11 (n) Claim #27332912 02/23 - 03/12/11 03/25 - 04/05/11 05/04 - 05/09/11 (o) Claim #27382318 06/22 - 06/27/11 (p) Claim #27401751 08/01- 08/12/11 09/07- 09/10/11 09/22- 10/03/11 (q) Claim #27 445805 11104- 11121111 12/13 - 12/18/11 01102 - 01120/12 02/17 - 02/28/12 03/24 - 03/29/12 1147337-vl 7 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 7 of 24 (r) Claim #27522934 04/27 - 05/08/12 06/09- 06/14/12 07/08- 07/19/12 31. Defendants knew that their representations of material fact, namely their entitlement to benefits sought in the above claims, were false. 32. Defendants intended to induce plaintiff to rely on their false representations of material fact by paying benefits sought in the above claims and, further, intended to induce plaintiff to refrain from investigating the above claims by falsely portraying its employee defendant David W. Thomas as terminally ill. 33. Plaintiff justifiably relied on defendants' false representations of material fact by paying benefits sought in the above claims and, further, by refraining from investigating the claims and as a direct and proximate result, sustained damages. B. ACTING IN CONCERT 34. The allegations in paragraphs 1-33 are incorporated herein by reference pursuant to Fed. R. Civ. P. 10(c). 35. As illustrated by their joint and active participation in the acts alleged herein, defendants David Thomas and Debbie Thomas entered into a conscious agreement to pursue a common plan or design to commit the fraud/deceit alleged herein. 36. Both defendants, David Thomas and Debbie Thomas, actively took part in the fraud/deceit alleged herein. 37. Defendants did commit the fraud/deceit alleged herein. 1147337-vl 8 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 8 of 24 38. Thus, defendants David Thomas and Debbie Thomas are jointly and severally liable for the damages caused by their fraud/deceit. C. CIVIL CONSPIRACY 39. The allegations in paragraphs 1-38 are incorporated herein by reference pursuant to Fed. R. Civ. P. 10(c). 40. Defendants David W. Thomas and Debbie L. Thomas knowingly entered into an agreement to accomplish a purpose that is unlawful or oppressive or to accomplish, by unlawful or oppressive means, a purpose that is not in itself unlawful or oppressive. Specifically, defendants entered into a conspiracy to commit the fraud/deceit alleged herein. 41. Both defendants David W. Thomas and Debbie L. Thomas committed one or more overt acts in furtherance ofthis conspiracy. 42. In entering into this conspiracy, defendants David W. Thomas and Debbie L. Thomas had the specific intent to harm plaintiff. 43. Defendants did commit the fraud/deceit alleged herein. 44. Thus, defendants David W. Thomas and Debbie L. Thomas are jointly and severally liable for the damages caused by their fraud/deceit. D. BREACH OF CONTRACT 45. The allegations in paragraphs 1-44 are incorporated herein by reference pursuant to Fed. R. Civ. P. 10(c). 46. The Policy is an insurance contract between plaintiff and defendants. 1147337-vl 9 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 9 of 24 47. The Policy set the terms by which defendants are entitled to certain monetary benefits from plaintiff for days defendant David W. Thomas was hospitalized as an inpatient, visited an Emergency Room for treatment, recovered from a surgical procedure or recovered at home following a hospital confinement. 48. Pursuant to the terms of the Policy, defendant David Thomas was required to submit written proof of his claims. 49. Plaintiff did what was required of it pursuant to the terms of the Policy. 50. By making claims for benefits to which he was not actually entitled and by submitting invalid and fraudulent documentation in support of those claims, defendant David Thomas did not do what was required of him pursuant to the terms of the Policy which constitutes a breach of contract which directly and proximately resulted in damages to plaintiff. E. INTENTIONAL INTERFERENCE WITH CONTRACTUAL RELATIONS 51. The allegations ofparagraphs 1-50 are incorporated herein by reference pursuant to Fed. R. Civ. P. lO(c). 52. The Policy was a valid contract between the plaintiff and defendant David W. Thomas. 53. Defendant Debbie L. Thomas had knowledge of the Policy. 54. By aiding and abetting defendant David W. Thomas's making claims for benefits to which he was not actually entitled, by actively participating in submitting invalid and fraudulent documentation in support of those claims, and by 1147337-vl 10 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 10 of 24 other acts of intentional and improper interference, defendant Debbie L. Thomas induced or caused defendant David W. Thomas to breach the Policy. 55. Defendant Debbie L. Thomas's intentional interference with defendant David W. Thomas's obligations under the policy directly and proximately resulted in damage to plaintiff. F. FRAUDULENT CONCEALMENT, WAIVER, AND ESTOPPEL 56. The allegations in paragraphs 1-55 are incorporated herein by reference pursuant to Fed. R. Civ. P. lO(c). 57. By submitting falsified and forged supporting documentation, abusing the trust inherent in defendant David W. Thomas' employment and managerial relationship with plaintiff, and submitting false facsimile messages designed to deter inquiry of plaintiff into defendants' claims, defendants committed positive acts of concealment that were distinct from the conduct that forms the basis of plaintiffs claims, namely defendants' false representations as to their entitlement to benefits under the Policy, and that were so secretly planned and executed as to keep plaintiffs causes of action hidden. 58. In the alternative, by submitting falsified and forged supporting documentation, abusing the trust inherent in defendant David W. Thomas' employment and managerial relationship with plaintiff, and submitting false personal messages designed to deter inquiry of plaintiff into defendants' claims, defendants' conduct that forms the basis of plaintiffs causes of action was perpetrated in such a way that the basis of plaintiffs claims concealed itself. 1147337-vl 11 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 11 of 24 59. Plaintiff exercised reasonable diligence to discover the facts of its causes of action. 60. The point at which plaintiff knew or had reason to know of the basis for its causes of action occurred within any applicable statute of limitations. 61. Accordingly, any applicable statute of limitations was tolled and did not begin to run until the point at which plaintiff knew or had reason to know of the basis for its causes of action. 62. In the alternative, defendants have waived and/or are estopped from asserting the statute of limitations as an affirmative defense to plaintiffs causes of action. 63. Plaintiffs causes of action are therefore timely brought, for the purposes of any applicable statute of limitations, as to each fraudulent claim submitted by defendants. V. DEMAND FOR RELIEF SOUGHT A. DAMAGES 64. The allegations in paragraphs 1-63 are incorporated herein by reference pursuant to Fed. R. Civ. P. 10(c). 65. As a direct and proximate result of the actions of defendants set forth above, plaintiff has made payments totaling $448,000.00, which is the amount of compensatory damages to which plaintiff is entitled to receive from defendants. 66. Pursuant to Ark. Code Ann. 16-22-308, defendants are entitled to their attorney's fees. 1147337-vl 12 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 12 of 24 67. In addition to compensatory damages, as a result of defendants' intentional, willful and wanton conduct in disregard ofplaintiffs rights, punitive damages should be imposed to punish defendants and to deter similar intentional, willful and wanton conduct in others. B. DECLARATORYJUDGMENT 68. The allegations in paragraphs 1-67 are incorporated herein by reference pursuant to Fed. R. Civ. P. 10(c). 69. As alleged above, defendants have breached the Policy, which is an insurance contract between the parties. 70. Defendants' breach of the Policy was a material breach. Plaintiff is therefore exc:used from further performance under the Policy. 71. Accordingly, pursuant to 28 U.S.C. 2201 and Fed. R. Civ. P. 57, plaintiff is entitled to a declaration that defendants' material breach of the Policy has terminated the Policy and extinguished all of plaintiffs duties and obligations under the Policy. C. CANCELLATION 72. The allegations in paragraphs 1-71 are incorporated herein by reference pursuant to Fed. R. Civ. P. 10(c). 73. The Policy is guaranteed renewable and non-cancellable until the 75th birthday of defendant David Thomas, meaning that under the terms of the Policy, plaintiff does not have the ability to unilaterally cancel the Policy before that date. 1147337-vl 13 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 13 of 24 74. Accordingly, if defendants' material breach of the Policy did not, as alleged above, automatically terminate the Policy and excuse plaintiffs performance under that contract, plaintiff will be required to pay future, properly supported claims and will be unable to assert the defendants' conduct as alleged herein as a defense to payment of any future claims. 75. However, based on the defendants' conduct as alleged herein, it would be unjust and inequitable to require plaintiff to continue in a contractual relationship with defendants and in its duties and obligations under the Policy. 76. Moreover, based on defendants' conduct as alleged herein, plaintiff would be required to devote extraordinary time and expense to the investigation of all future claims submitted by defendants to ensure that any such claims were valid and not fraudulent. 77. Plaintiff will therefore suffer irreparable injury if it is required to continue in its duties and obligations under the Policy. 78. To the extent that it is not granted the declaratory judgment requested herein, plaintiff has no adequate remedy at law. 79. Considering the balance of the hardships between plaintiff and defendants, equitable relief is warranted. 80. Therefore, as an alternative remedy to the declaratory judgment requested herein, plaintiff requests that the Court exercise its equitable powers to cancel the Policy. 1147337-vl 14 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 14 of 24 VI. JURY DEMAND 81. Plaintiff demands a trial by jury on all factual issues. VII. PRAYER WHEREFORE, plaintiff Combined Insurance Company of America prays that a judgment will be entered against defendants David W. Thomas and Debbie L. Thomas and that plaintiff be awarded compensatory and punitive damages, together with costs, pre- and post-judgment interest, and attorneys' fees; declaratory and/or equitable relief cancelling and terminating plaintiffs duties and obligations toward defendants; and all other just and proper relief to which plaintiff may be entitled. 1147337-vl WRIGHT, LINDSEY & JENNINGS LLP 200 West Capitol Avenue, Suite 2300 Little Rock, Arkansas 72201-3699 (501) 371-0808 FAX: (501) 376-9442 By _ (89118) Michael A. Thompson (2010146) Attorneys for plaintiff Combined Insurance Company of America 15 Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 15 of 24 EXHIBIT A Legal Reserve Stock Corporation (herein called Combined) . Home Office and pollcyhoJder Service Center . 5050 Broadway Chicago, Illinois 60640 1-BOD-225-4500 NON-CANCELLABLE AND GUARANTEED RENEWABLE SICKNESS HOSPITAL CONFINEMENT INDEMNITY POLICY . .. LIMITED BENEFIT HEALTH COVERAGE .POLICY TERMINATES AT AGE 75 . . JHIS IS A SICKNESS ONLY POLICY AND DOES NOT PAY.BENEFITS FOR.LOSS FROM ACCIDENT$ . Premiums and Benefits will increase each: year, for the first ten years, as . scheduled in the Schedule of Premit,Jms and Benefits .. . This is a legal contract between the Insured and Combined. READ YOUR POLICY CAREFULLY. Benefits': . Hospital Income Dailylntensive .Care Income . Emergency .Room . Outpatient Surgery Recovery .Recovery'. Income Following Hospital Confinement Claim lnformati.on Definitions Exceptions GUIDE TO YOUR POLICY Page .Page. Grace Period 4 2 Payable in Addition to Other Insurance 3 . 2 Pre-existing Cpnditions Limitation . 3 .. 2 Premlum and Benefit Increases 2 2 Reinstatement .4 Renewability 1 2 . Right to Examine Policy . 1 4 Schedule of Premiums and Benefits . 6 & 7 . 3 Termination . 5 3 Time Limit o.n Certain Defenses . 4 10.DAY RIGHTTO EXAMINE POLICY . . . A . If this policy is not satisfactory for any reason, within 10 days of the.issue date you can return it to . Combined or its agent. Any premium.. paid will be refunded and this- policy will be void from its . beginning.. NONCANCELLABLE AND GUARANTEED RENEWABLE Combined guarantees .your right to renew this policy -until the first premium due-date after your 75th birthday so long as the premium is paid on or before the due. date or within the grace period. For the first ten years the policy is in force the premiums and benefits. will increase each Policy Anniversary Year in accordance with the Schedule . of Premiums and Benefits . for the plan selected on the application. Combined cannot. change .the. premiums shown in the Schedule of Premiums and
. This policy shall terminate on the first premium due date after you reach age 75. If Combined accepts any after that date, the policy. continues in force while premium is accepted. Form. No. 12815-AR Combined.lnsurance Company of America -1996 . 11196 Printed in U.S.A. . Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 16 of 24 - 2- CONSIDE.RATION This. policy is issued in consideration of the statements. contained in the application and payment of the first premium. Combined agrees to pay you, the Insured named in the application, subject to the terms and limitations of this policy. B.enefits will be paid for the following losses sustained by you and caused by Covered Sickness as defined herein .. Benefits will be .paid in accordance with the Schedule of Premiums and Benefits (herein also referred to as "Schedule") for the plan selected and the appropriate Policy Anniversary Year. Both premiums and benefits will Increase each Policy Anniversary Year In accordance with the Schedule and subject to the Premium and Benefit Increases Section. SECTION A DAILY HOSPITAL INCOME- SICKNESS If because of a Covered Sickness and beginning while this. policy is in force, you are confined overnight as an Inpatient in a Hospital, Combined will pay you for each day of such confinement, starting with the first day and for up to your lifetime, the. benefit amount shownin the Schedule under Section A. . SECTION 8 . DAILY INTENSIVE CARE INCOME - SICKNESS If because of a Covered Sickness you are confined in an Intensive Care Unit during a period for which benefits are payable under Section A, Combined will pay you for each day of such confinement, in addition to Section A, the benefit amount shown in the Schedule under Section B. SECTION C RECOVERY INCOME FOLLOWING HOSPITAL CONFINEMENT - SICKNESS If because of a Covered Sickness you are continuously Totally Disabled following a period of confinement in a Hospital for which benefits are payable under Section A, Combined will pay you while you remain so disabled, but not to exceed four times the number of days of such Hospital confinement, the benefit amount shown in the Schedule under Section C. SECTIOND OUTPATIENT SURGERY RECOVERY - SICKNESS If because of a Covered Sickness you require Outpatient Surgery while this policy is in force, Combined will pay you the benefit amount shown in the Schedule under Section D for any one sickness. The amount of the benefit depends upon whether the Outpatient Surgery is classified as Major or Minor. "Outpatient Surgery" is the cutting of tissue, the repair or removal of bodily parts that have been damaged due to sickness followed by the suturing of the resulting wound. Outpatient Surgery .is classified as "Major'' when performed in a Hospital operating room as an outpatient or Ambulatory Surgical Center. Outpatient Surgery is classified as "Minor" when p.erformed in an Emergency Care Facility, emergency room, Physician's office, clinic, or any other location not classified. Outpatient Surgery must be performed by a Physician. SECTION E EMERGENCY ROOM- SICKNESS If because of a Covered Sickness, you. require emergency. room treatment at a Hospital emergency room, Hospital affiliated Emergency Care Facility or 24 hour Emergency Care Facility while this policy is in force, Combined will pay you the benefit amount shown -in the Schedule under Section E for any one sickness. PREMIUM AND BENEFIT INCREASES For the first ten years the policy is in force, the premiums and benefits will increase each Policy Anniversary Year shown in the Schedule of Premiums and Benefits for the plan selected. All benefits payable under this policy shall be calculated based on the scheduled benefits Jor .the . Policy Anniversary Year in which the sickness occurred. Benefits are not payable based on any, other" date. In the event your policy lapses due to non-payment of premium, you may policy in accordance with the Reinstatement provision and the calculation of your Policy Anniversary Year will be subject to the definition of Policy Anniversary Y-ear. Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 17 of 24 PAYABLE IN ADDITION TO OTHER INSURANCE . . Benefits provided by this policy are payable in addition to those provided by any other insurance policy. EXCEPTIONS This policy will not pay for losses resulting from: bodily injuries; from mental or emotional disorders; or from normal pregnancy or childbirth. PRE-EXISTING CONDITIONS LIMITATION . Loss caused by a Pre-existing Condition is not covered unless such loss begins after 12 months from the issue date. DEFINITIONS "Ambulatory Surgical Center'' means a public or private .institution which. complies with each of the following: (1) employs a medical staff of Physicians; (2):consists of permanent equipped and operated primarily for performing surgical procedures; (3). offers continuous Physician and registered . nursingservices when a patient is in the .facility; (4) does not provide services or accommodations for patients to stay overnight; and (5) operates pursuant to law. "Covered. Sickness" means a bodily illness or disease you incur, including complications of pregnancy, but not including conditions caused by a bodily injury or Pre-existing Condition. A Pre-:-existing Condition will be considered a Covered Sickness if loss caused by such condition begins after 12 months from the issue date .. "Emergency Care Facility" is an institution which meets the following requirements: (1) operates pursuant to law; (2) has a staff of at least one licensed Physician and one registered nurse available at all times; and, (3) has facilities for diagnosis and treatment of emergencies. "Hospital" is an institution which meets all of the following requirements: (a) operates pursuant to law;. (b) operates primarily for the care and treatment of sick or injured persons as inpatients; (c) provides 24 hour nursing service; (.d) has facilities available for diagnosis and surgery either on its own premises or in facilities available to the.Hospital on a pre-arranged basis; (e) has a staff of at least one licensed Physician available at all times. "Hospital" does not include a nursing home or convalescent care facility, whether such facility is independent or associated with a Hospital. "lnpatienf' means Hospital confinement which the Hospital classifies as Inpatient. It does not mean confinement on an outpatient basis. "Intensive Care Unif' means that part of a Hospital (other than a patienfs room, operating room or recovery room) where patients receive continual nursing care and which is commonly known as the intensive care or cardiac care unit. "Physician" means a licensed practitioner of the healing arts acting within the scope of his or her license. It does not include the Insured or a member of his or her family . . "Policy Anniversary Year" means each continuous 12 month period the policy is in force beginning from the issue date of the policy. Any amount of time accrued between the last Policy Anniversary Year and the.reinstatement date which .does not equal a continuous 12 month period the policy is in force will not be taken into account in the calculation of a Policy Anniversary Year. "Pre-existing Condition" means a bodily illness or disease which was diagnosed or treated by a Physician within the 12 months preceding the issue date of the policy . . "Totally Disabled" means the inability to perform all of the substantial and material duties of your business or occupation (usual activities if not employed). If you are able to perform any of the substantial and materialduties of your business or occupation (usual activities if not employed), you are -not Totally Disabled. You must be under the care of a Physician. - 3- Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 18 of 24 . 4. UNIFORM PROVISIONS {1) ENTIRE CONTRACT; CHANGES: This-policy with the application and attached papers, if any, is the entir& contract between the Insured and Combined. No change in this policy will be effective until approved by an executive officer of Combined .. This approval must be noted on or attached to this policy. No agent may change this policy or waive any of .its provisions. (2) TIME LIMIT ON CERTAIN DEFENSES: (a) Misstatements in the Application: .After two years from the issue date only fraudulent misstatements in the application may be used to void the policy or deny any claim for loss incurred or disability that starts after the two year period. (b). Pre-existing Conditions: No claim for loss incurred or disability that starts after one year from the-issue date will be reduced or denied because a .sickness or physical condition not excluded by name or specific .description before the date of loss had existed before the issue date. (3) GRACE PERIOD:This policy has a 31 day grace period. This means that if a renewal premium is not paid on or befo-re the date it is due, it may be paid during the following.31 days. During the grace period, the policy will stay in force. (4) REINSTATEMENT: If the renewal premium is not paid before the grace period ends, the policy will lapse. Later acceptance of the premium by Combined (or by an agent authorized to accept payment) without requiring an application for reinstatement will reinstate this policy. If Combined or its agent requires an. application the Insured will be given a cond.itional receipt for the premium .. If the application is approved, the policy will be reinstated as of the approval date. Lacking such approval, the policy will be r-einstated on the 45th day after the date of the conditional receipt unless Combined has previously written the Insured of its .disapproval. On your reinstatement date you will begin a new Policy Anniversary Year. Any amount of time accrued prior to reinstatement which does not equal a continuous 12 month period. the policy is in force, will not be taken into account in the calculation of a Policy Anniversary Year. The reinstated policy will cover only loss that results from sickness that starts more than 1 0 days after the date of reinstatement. lnall other respects the rights of the Insured and Combined will remain the same, subject to any provisions noted on or attached to the reinstated policy. (5) NOTICE OF CLAIM: Written notice of claim must be given within 30 days after a covered loss starts or as soon as reasonably possible. The notice can be given to Combined at its Home Office, Chicago, Illinois or to Combined's agent. Notice should include the name of the Insured and the policy number. (6) CLAIM FORMS: When Combined receives the notice of claim, it will send the claimant forms for filing proof of loss. If these forms are not given to the claimant within 15 days, the claimant will meet the proof of loss requirements by giving Combined a written statement of the nature and extent of the loss within the time limit stated in the Proofs of Loss Section. (7) PROOFS OF LOSS: If the policy provides for periodic payment for a continuing loss, written proof of loss must be given to Combined within 90 days after the end of each period for which Combined is liable. For any other loss, written proof must be given within 90 days after such loss. If it was not reasonably possible to give written proof in the time required, Combined shall not reduce or deny the claim for this reason if the proof is filed as soon as reasonably possible. In any event, the proof required must be given no later than 1 year from the time specified unless the claimant was legally incapacitated. (8) TIME .OF PAYMENT OF CLAIMS: After receiving written proof of loss, Combined will pay monthly all benefits then due the Insured for disability. Benefits for any other loss covered by this policy will be paid as soon as Combined receives proper written proof. (.9) PAYMENT OF C.LAIMS: Benefits will be paid to. the Insured. Any other benefits unpaid at death may be paid, at Combined's option, either to the Insured's beneficiary. or estate. Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 19 of 24 . {H)). -.PHYSICAL EXAMINATIONS: Combined at its-expense Insured . examined as .often as reasonably necessary while a .claim is pendinQ; (1t} LEGAL ACTIONS: No Jegal action may be brought to recover on: :policy Within eodays after- written.proof.of Joss has been given as required by .tt)is policy., NOS(JCb _actiqn:may;:be brought- after 'the. expiration of 3 years from the time written proof of loss is . . {12) CONFORMITY WITH STATE STATUTES: Any-provision of date, is in conflict with the laws of the state in which the Insured resides on that date is amended to . col!form to the minimum requirements of such Jaws. (13). MISSTATEMENT OF AGE: .If your age has been misstated, any amount payable wiiJ. be that which the premium paid would have purchased at the correct age. But, if the misstatement-of age caused this policy.to be issued to you beyond the age set by Combined for issue of. this policy, then liability is limited to a. return of all premiums paid. If the misstatement of age caused this. policy to be continued or.renewed beyondthe date setfor the policy to terminate, then Combined's liability for loss occurring after that date is limited to a return of the premiums. paid after that date. . (14) CHANGE OF BENEFICIARY: The Insured can change the beneficiary at any time by giving Combined written notice satisfactory to Combined which is received by Combined at its home office during the Insured's lifetime. Unless irrevocably designated, the beneficiary's consent is not required. GENERAL PROVISIONS A. TERM: This policy is issued for the term shown in the It begins and ends at 12:01 A.M., Standard Time, at the place where you reside. It is effective on the date issued. It continues in force so long as the applicable scheduled premium is paid on or before the due date or within the grace period. B. PAYMENT OF PREMIUM: This policy is issued in consideration of the initial premium and the statements in the application. If payment of the initial premium is made by check or draft not honored the policy shall be void. C. YOUR RIGHT TO CANCEL: You may cancel this policy at any time by writing Combined. Coverage will end on the date the notice. is received or on a later date you specify. Combined will return any unearned premium. Cancellation will not affect any claim beginning before the date of cancellation. D. TERMINATION: This policy shall terminate on the policy anniversary after you reach age 75 .. If Combined accepts any premium after that date, the policy continues in force while premium is accepted. However, if a misstatement of age caused this policy to be continued or renewed beyond .thedate set for the policy to terminate, then Combined's liability for Joss occurring after that date is limited to a return of all premium paid after that date. E. REFUND OF UNEARNED PREMIUM: Upon the death of the Insured, the proceeds payable shall include premiums paid .for the policy for any period beyond the end of the policy month in which death occurred. This poliCy is issued by COMBINED INSURANCE COMPANY OF AMERICA. It shall not be . binding on Combined unless countersigned by our authorized agent. Chairman and Chief Executive Officer -5- Corporate Secretary Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 20 of 24 Plan Selected: D Plan II . Policy .. Anniversary Year At Issue "1 2 3 4 5 6 7 8 9 10 and over Polley Anniversary Year At Issue 1 2 3 4 5 6 7 8 9 10 and over SCHEDULE OF PREMIUMS AND BENEFITS PLAN II Premiums Annual .. Monthly :IS$U&Age . lssueAge . 0-19 20-34. 35"54 . 55-64. . 2D-34- 35,-54 55-64 $264.00 :$396.00 $660.00 $. 858;00 $22.00 $33.00 $55.00 $ 71.50 $415.80 $693:oo $ 900:90 $23.10 $34.65 . $57.75 $.75.08. $290.40 $435.60 '$726.00 $ 943.80 $24.20 $36.30. $60.50. $ 78.65 $303.60 $455.40 $759.00' $ 986.70 $25.30' $37.95 $63.25 $ 82.23 $316.80 $475.20 $792;00 $1,029.60 $2.6.40 '$39.60 $66.00 $ 85.80. $330.00 $495.00 $1,072,50 $27.50 $41.25 $68.75 . $ 89.38 $343.20 $514.80 $858.00 $1,115.40 $28.60 $42.90 $71.50 $ 92.95 $356.40 $534.60 $891.00 $1-,158.30 $29.70 $44.55 $74.25 $ 96.53 $369.60 $554.40 $924.00 $1,201.20 $30.80 $46.20 $77.00 $100.10 $382.80 $574.20 $957.00 $1,244.10 $31.90 $47.85 $79.75 $103.68 $396.00 $594.00 $990.00 $1,287.00 $33.00 $49.50 $82.50 $107.25 Benefits SECTION A SECTIONB SECTION C SECTION D SECTIONE Dally Dally Recovery Outpatient DaiJy Intensive Following Hospital Surgery Emergency Confinement (for up Hospital Care to 4 times Section A Major Minor Room(Per Income Income Confinement) (Per Sickness) Sickness)
100.00 1,000.00 $100.00 $500.00 105.00 $ 1,050.00 $105.00 $525.00 $52.50 $105.00 $ $ 1 '100.00 $.110.00 $550.00 $55.00 $110.00 $ 115.00 $ 1,150.00 $115.00 $575.00 $57.50 $115.00 $. 120.00 $ 1,200.00 $120.00 $600.00 $60.00 $120.00 $ 125.00 $ 1',250.00 $125.00 $625.00 $62.50 $125.00 $ 130.00. $ 1,300.00 $130.00 $650.00 $65.00 $130.00 $ 135:00 '$ 1,350.00 $135.00 $675.00 $67.50 $135.00 $ 140.00 $ 1',400.00 $140.00 $700.00 $70.00 $140.00 $ 145.00 $ 1,450.00 $145.00 $725.00 $72.50 $145.00 $ 150.00 $ 1,500.00 $150.00 $750.00 $7s;oo $150.00 AU--benefits payable under this policy shall be calculated based on the scheduled benefits for the Policy Anniversary Year in which the sickness occurred. .not payable based, on any other date.ln .the event- your policy taps.es due to. ncm-payment of premium; you may relnstate. your policy in accordance-with the Reinstatement provision-and the-calculation of your Policy Anniversary Year Will be subject -to the definition of Policy Anniversary Year.
-6- Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 21 of 24 Plan Selected: o Plan I (12a29) Policy Anniversary Year At Issue ' 1 2 . SCHEDULE OF PREMIUMS AND BENEFITS PLANI . Premiums Annual Monthly Issue Age Issue Age 0-19 . '20-34 35-54 55-64 0-1.9 35-54 55-64 $:132.00 $198.00 $330.00 . $429.00 $11.00 $16.50 $2750 $35.75 $138.60 $207.9.0 $346;50 $450.45 '$11.55 $17.33 $28.88 $37.54 $145.20 $217.80' $363.00. $471.90 $12.10. $18.15 $30.25 $39.33 3 . $151.80 $227.70 $379.50 $493.3S $12.65 $18.98 $31.63 $41.11 4 $158.40 $237.60 $396.00 $514.80 $13.20 $19.80 $33.00 $42.90 5 . $1.65.00 $247.50. '$412.50 $536.25 $13.75 $20.63 $34.38 $44.69 6 $171.60 $257.40 $429.00 $557.70 $14'.30 $21.45 $35.75 $46.48 7 $178.20 $267.30 $445.50 $579.15 $14.85 $22.28 $37.13 $48.26 8 $184.80 $277.20 $462.00 $600.60 $15.40 $23.10 $38.50 $50.05 9 $191.40 $287.10 $478.50 $622.05 $15.95 $23.93 $39.88 $51.84 10 and over $198.00 $297.00 $495.00 $643.50 $16.50 $24.75 $41.25 $53.63 Benefits SECTION A SECTIONB SECTION C SECTION D SECTION E Policy Daily Daily Recovery Income Outpatient Anniversary Dally Intensive Following Hospital Surgery Emergency .confinement (for up Year Hospital Care to 4 times Section A Major Minor Room(Per Income Income Confinement) (Per Sickness) Sickness) At Issue
50.00 $ 500.00 $50.00 1 52.50 $ 525.00 $52.50 $262.50 $26.25 $52.50 2 $ 55.00 $ 550.00 $55.00 $275.00 $27.50 $55.00 3 $ 57.50 $ 575.00 $57.50 $287.50 $28.75 $57.50 4 $ 60.00 $ 600.00 $60.00 $300.00 $30.00 $60.00 5 $ 62.50 $ 625.00. $62.50 $312.50 $31.25 $62.50 6 $ 65.00 $ 55o.oo $65.00 $325.00 $32.50 $65.00 7 $' $ 675.00 $67.50 $337.50 $33.75 $67.50 8 $ 70.00 $ 700.00 $70.00 $350.00 $35.00 $70.00 9 $ 72.50 $ 725.00 $72.50 $362.50 $36.25 $72.50 10and over $ 75.00 $ 750.00 $75.00 $375.00 . $37:50 $75.00 All benefits payable under this policy shall be calculated based on the scheduled benefits for the Policy Anniversary Year ln which the sick_ness occurred. Benefits are not payable based on any.other date; In the event your policy .lapses due to non-payment of premium, you may reinstate your poJicy in accordance w:itll the :Reinstatement provision and the calculation of your Policy Anniversary Year will be subject to the definition of Policy Anniversary Year. (12815-SI) -7- Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 22 of 24 . COMBINED.INSURANCE COMPANY OF AMERICA Chicago; Illinois 60640 . LIMITED BENEFIT HEALTH COVERAGE SICKNEss HOSPITAL CONFINEMENT INDEMNITY POL1CV Plan Selected: WITH SCHEDULED ANNUAL INCREASES 0 . D . . . IN PREMIUMS AND BENEFITS . Plan II . Plan I .OUTliNE OF COVERAGE {12830) (12829) For Policy Form No. 12815-AR (1}Read Your. Policy Carefully. This outline of coverage provides a very brief description of some important .features of your This is not the insurance contract and only the actual. pqlicy provisions will control. The policy itself sets forth. in detail,. the. rigbtsand obligations of both you and your insur.ance eompany; It is, therefore, important that you READ YOUR POLICY CAREFULLY! . . (2) Lim Heel Coverage. Policies :of this category are designed to-provide, the. person insured, limited or supplemental (3) Description of Benefits. This is a Sickness Only .Policy and Does Not Pay Benefits for Loss From Accidents. For the first :I'Oyears the premiums and benefits- increase each Polley Anniversary All benefits . . payable- under this policy shall be calculated based on . the scheduled benefits. for the Policy Anniversary Year in which the sickness occurred. Benefits are not payable based on any other date. .Benefit at Section A. Plan II Plan I Issue/Policy Year Daily Hospital Income. $ 100.00 per day At Issue Benefit paid when confined in a Hospital overnight. $ 50.00per day Benefit payable for up to your lifetime. $ 1 05.00 per day $ 52.50 per day 1 $ 110.00 per day $ 55.00 per day 2 $ 115.00 per day $ 57.50 per day 3 $ 120.00 per day $ 60.00 per day 4 . $ 125.00 per day $ 62.50 per day 5 $ 130.00 per day $ 65.00 per day 6 $ 135.00 per day $ 67.50 per day 7 $ 140.00 per day $ 70.00 per day 8 $ 145.00 per day $ 72.50 per day 9 $ 150.00 per day $ 75.00 per day 10 and over Section B. Daily Intensive Care Income. $ 500.00 per day Additional benefit paid when confined in an Intensive $ 1 ,000.00 per day At Issue Care Unit during a Hospital stay for which benefits are $ 1,050.00 per day $ 525.00 per day 1 payable under Section A. $ 1,100.00 per day $ 550.00 per day 2 $ 1,150.00 per day $ 575.00 per day 3 $ 1,200.00 per day $ 600.00 per day 4 $ 1 ,250.00 per day $ 625.00 per day 5 $ 1 ,300.00 per day $ 650.00 per day 6 $ 1,350.00 per day $ 675.00 per day 7 $ 1 ,400.00 per day $ .700.00 per day 8 $ .1,450.00 per day $ 725.00 per day 9 $ 1 ,500.00 per day $ 750.00 per day 10 and over Section c. Recovery Income Following Hospital Confinement. $ .100.00 per day $ 50.00 per day Benefit paid if total disability continues after a Hospital At Issue . stay for which benefits are payable under Section A. $. 105.00 per day $ 52.50 per .day 1 Benefit paid up to four times the number of days of $ 110.00 per day $ 55.00 per day 2 Hospitar stay. $ 115.00 per day $ 57.50 per day 3 $ 120.00 per day $ 60.00 per day 4 $ 125.00 per day $ 62.50 per day 5 $ 130.00 per day $. 65.00 per day 6 $ 135.00 per day $ 67.50 per day 7 $ 140.00 per day $ 70.00 per day 8 $ 145.00:per day $ 72.50 per day 9 $ 150.00 per day $. 75.00 per day 10 and over Benefit at Form No. 012815-AR {Continued on Reverse Side) Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 23 of 24 Section o. Outpatient Surgery Recovery Benefit paid for recovery from Major or Mfnor- Outpatient ~ u r g e r y . performed by a Physician. .Classified as "Major'' when performed in a Hospital operating room on an outpatient basis or in an Ambulatory Surgical Center. Classified as "Minor'' when performed in an Emergency Care Facility, emergency room,. Physician's office, clinic, or any other location not classified. Section E. Emergency Room Benefit paid for emergency room treatment at a Hospital emergency room, a Hospital affiliated. Emergency Care Facility or a 24 hour Emergency Care Facility. flm.ll Major Minor PER SICKNESS $ 500.00 $ 50.00 . $ 525.00 $ 52.50 $ 550.00 $ 55.00 $ 575.00 $ 57.50 $ 600.00 $ 60.00 $ 625.00 $ 62.50 $ 675.00 $ 65.00 $ 700.00 . $ 67.50 $ 725..00 $ 70.00 $ 725.00 $ 72.50 $ 750.00 $ 75.00 PER SICKNESS $ 100.00 $ '105.00 $ 110.00 $ 115.00 $ 120.00 $ 125.00 $ 130.00 $ 135.00 $ 140.00 $ 145.00 $ 150.00 .eJiml Major Minor PER SICKNESS $ 250.00 . $ 25.00 . $ 262.50 $ 26.25 $ 275.00 $ 27.50 $ 287:50 $ 28:75 $. 300.00 $ 30.00 $ 312.50 $ 31.25 $ 325.00 $ 32.50 .. $ 337.50 $ 33.75 $ 350.00 $ 35.00 $ 362.50 $ 36.25 $ 375.00 $ 37.50 PER SICKNESS $ 50.00 $ 52.50 $ 55.00 $.57.50 $ 60.00 $ 62.50 $ 65.00 $ 67.50 $ 70.00 $ 72.50 $ 75.00 Issue/Policy . Anniversary Year At Issue 1 2 3 4 5 6 7 8 9 10 and over. At Issue 1 2 3 4 5 6 7 8 9 10 and over If your policy lapses and is reinstated, in accordance with the reinstatement provision, your reinstatement date will begin your new Policy Anniversary Year. Any amount of time accrued between the last Policy Anniversary Year and the reinstatement date which does not equal a continuous 12 month period the policy is in force will not be taken into account in the calculation of a Policy Anniversary Year. (4) Exceptions. For the first year the policy does not cover sickness for which medical advice or treatment was received within the 12 months before the issue date. The policy does not cover loss resulting from bodily injuries received in an accident; from mental or emotional disorders; or from normal pregnancy or childbirth. (5) Renewability. You have the right to renew the policy until the first premium due date after your 75th birthday. For the first ten years the premiums and benefits will increase each Policy Anniversary Year as outlined in the policy. Combined cannot change the premiums shown in the Schedule of Premiums and Benefits. THIS POLICY IS NOT A MEDtCARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company. Form No. 012815-AR Case 3:12-cv-00254-SWW Document 1 Filed 11/08/12 Page 24 of 24