Insurance Policy Interpretation

When it comes to interpreting an insurance policy, the Courts are suppose to read the relevant portions of a policy and see how the policy language tracks with whatever the facts are in a claim.  Many claims are denied due to the insurance company believing the policy says something or is interpreted in such a way as to allow the insurance company to deny the claim.

When an insurance company interprets the policy language in such a way as to allow the insurer to deny the claim and the insured interprets the language in such a way as to believe coverage exists, a lawsuit is going to result.  Insurance companies want these policy interpretations to be litigated in Federal Court because, most of the time, Federal Courts are much stricter in their interpretation than most State or County Courts.

The normal way to get a ruling in these policy interpretation cases is for the insurer or either party to file a motion for summary judgment.  In this motion the party asks the Court to rule as a matter of law what the policy is saying and how that is relevant to the facts of the claim.  This was an issue in a 2020 opinion from the Southern District of Texas, Galveston Division, styled, Louise Odom Hayes v. Blue Cross And Blue Shield Of Texas, Inc. And Health Care Service Corporation.

In this case the Court went over the motion for summary judgment standards.  The facts are discussed in the case but will not be discussed here.

Insurance lawsuits usually require for a plaintiff to prove the insurance company breached the insurance contract by not paying the claim.  The elements of breach of contract under Texas law, as stated in the 2016, 5th Circuit opinion, Crose v. Humana Ins. Co., are: “(1) the existence of a valid contract; (2) performance or tendered performance by the plaintiff; (3) breach of the contract by the defendant; and (4) damages to the plaintiff resulting from that breach.”

Summary judgment is required when the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.  A fact is ‘material’ if its resolution in favor of one party might affect the outcome of the lawsuit under governing law.  A genuine dispute of material fact exists when the evidence is such that a reasonable jury could return a verdict for the nonmoving party.

The moving party bears the initial responsibility of informing the district court of the basis for its motion, and identifying those portions of the record which it believes demonstrate the absence of a genuine issue of material fact.  Where the non-movant bears the burden of proof at trial, the movant may merely point to the absence of evidence and thereby shift to the non-movant the burden of demonstrating by competent summary judgment proof that there is an issue of material fact warranting trial.

If the moving party fails to meet its initial burden, the motion for summary judgment must be denied, regardless of the nonmovant’s response.  When the moving party has met its Rule 56(a) burden, the nonmoving party cannot survive a summary-judgment motion by resting on the mere allegations of its pleadings.  The nonmovant must identify specific evidence in the record and explain how that evidence supports that party’s claim.  This burden will not be satisfied by some metaphysical doubt as to the material facts, by conclusory allegations, by unsubstantiated assertions, or by only a scintilla of evidence.

In deciding a summary-judgment motion, the court draws all reasonable inferences in the light most favorable to the nonmoving party.  But if a party fails to properly support an assertion of fact or fails to properly address another party’s assertion of fact as required by Rule 56(c), the court may . . . consider the fact undisputed for purposes of the motion.

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