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Holden Business Forms Co.7/8/2005
Before WILLIAMS, DREW and MOORE, JJ.
LSU Health Sciences Center-Shreveport (LSUHSC-S) and Dr. Anthony Tran appealed a judgment ordering them to repay payments received for medical treatment of $72,918.43 and $23,219.15, respectively. The trial court based the judgment on a health policy exclusion for injury sustained while performing an illegal act. Assurecare, Inc., the administrator of Holden Business Forms Co., Inc.'s self-insured medical plan, paid for treatment of an employee 's husband injured in a motorcycle crash. LSUHSC-S and the doctor urged that a provision excluding coverage for injury suffered while performing an illegal act was inapplicable; alternatively, if the exclusion applied, then the insurer was in the best position to evaluate whether the policy exclusion applied. Moreover, the payments, made for services rendered, were not gratuitous.
We affirm.
FACTUAL AND PROCEDURAL BACKGROUND
Holden Business Forms Co., Inc. employed Candy Hughes, the wife of Jimmy Hughes, a covered dependent on Holden's self-insured medical plan. On May 8, 1998, Jimmy Hughes was severely injured in a motorcycle accident. Two blood samples were drawn. The first had a blood alcohol content (BAC) of .212. The second sample had a BAC of .13. LSUHSC-S and Tran treated Hughes for about a month, and his medical bills were paid by Assurecare, Inc., the administrator of Holden's medical plan. The policy excluded coverage for illness or injury "caused, or contributed to, by engagement in an illegal occupation or commissions or attempt to commit a misdemeanor and/or felony."
According to Holden, despite its diligent efforts, it was unable to obtain a copy of the accident report until months after the accident when Holden learned Hughes was drunk at the time of the crash. Holden filed suit for a refund of its medical payments based upon its policy exclusion for payments for injury caused while committing a felony or misdemeanor (DWI). Hughes was never convicted of any crime in connection with this accident, as he died in a 2002 fire. The criminal charges were nolle prossed in 2003 with the notation, "Defendant is deceased."
A summary judgment in favor of Holden was reversed by this court in Holden Business Forms Co., Inc. v. LSUHSC-S, et al, 35,694 (La. App. 2d Cir. 2/27/02), 811 So. 2d 1102. This court found that affidavits supporting the summary judgment were not based upon personal knowledge. The matter was remanded for further proceedings.
At the July 14, 2004, bench trial, the record of the prior appeal and a number of depositions were placed into evidence. The state trooper investigating at the scene noticed the heavy smell of alcohol on Hughes' breath as he lay in the ditch next to his motorcycle. The trooper described Hughes' companion as "profoundly drunk." Another trooper went to LSUHSC-S to have blood collected from Hughes. The state police crime lab analyzed that sample taken at 9:18 p.m. and found the blood alcohol level to be .13. A sample drawn a bit earlier and analyzed at LSUHSC-S found Hughes' blood alcohol level to be .212.
Hughes was treated at LSUHSC-S from May 8 until May 23, 1998. LSUHSC-S and the doctor filed their claims on June 9, 1998, and Assurecare paid the claims on July 28, 1998. The CEO of Assurecare stated that at the time the claims for Hughes' medical treatment were paid, Assurecare had no knowledge of the blood alcohol levels. According to Assurecare's CEO, Holden requested a copy of the police report but did not receive a copy until December 1998 and did not get information about Hughes driving under the influence until after the claims were paid. In January 1999, Assurecare learned about the
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