Heard v. Sexton

A jury question remains as to whether insurance agent is liable for negligent misrepresentation since the insured relied on the agent's statement that only rheumatic heart conditions were excluded from coverage, while the insurer denied the insured's claim for quadruple-bypass surgery.

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Appellant-plaintiff Clifford Hugh Heard brought suit against his insurance agent, appellee-defendant Rupert Sexton “defendant”, and Sexton’s employer, appellee-defendant Sexton-Moore Agency, Inc.1 “Sexton-Moore”, seeking to recover damages for negligent failure to procure the health insurance coverage plaintiff desired. The superior court granted defendant’s motion for summary judgment, and plaintiff appeals.

It is undisputed in the record that plaintiff went to defendant’s offices to discuss replacing his existing health insurance coverage. Defendant reviewed plaintiff’s existing health coverage and determined it to be similar to a policy available through the Continental General Insurance Company “Continental General” which capped payable lifetime benefits at $2,000,000, four times the lifetime benefits cap provided by the health insurance policy which was then in force on plaintiff. With defendant’s assistance, plaintiff thereafter applied for the Continental General health insurance recommended by defendant and submitted to a physical examination. Subsequently, Continental General issued plaintiff its health policy substandard as burdened by two elimination endorsements. The first of these denied coverage to plaintiff for “loss caused by or resulting from: rheumatic heart disease and/or complication therefrom.” The second endorsement the “HLP endorsement”, applicable for 180 days after issuance, excluded coverage under the policy for “hyperlipoproteinemia2 and/or complications therefrom.” Plaintiff went to defendant after reading the policy concerned as to meaning and effect of the elimination endorsements, but signed the policy upon defendant’s explanation of the policy based upon a telephone call to representatives of Continental General. Plaintiff later required quadruple bypass surgery and brought the instant action upon Continental General’s refusal to provide coverage for plaintiff’s surgery3 as excluded under the HLP elimination endorsement issued as part of the health policy he had been provided by Continental General.

Heard v. Sexton

A jury question remains as to whether insurance agent is liable for negligent misrepresentation since the insured relied on the agent's statement that only rheumatic heart conditions were excluded from coverage, while the insurer denied the insured's claim for quadruple-bypass surgery.

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