IRENE HICKMAN, and the class of similarly situated persons, Plaintiffs - Appellants, v. GEM INSURANCE COMPANY, INC., a Utah corporation, formerly known as Gem State Mutual of Utah, Inc., Defendant - Appellee, 299 F.3d 1208

Summary

The class members alleged that the insurer was liable for violating the terms of the insurance policies, and equitable relief was requested under for the insurer's failure to follow the claims procedure and notice requirements of the Employee Retirement Income Security Act, 29 U.S.C.S. § 1001 et seq. The hospital insurance contracts that the class members entered into with the insurer stated that unless otherwise negotiated, the insurer would pay the lesser of the billed charges or the "usual and customary" charges, and that the room and board charge would be limited to an "average semi-private room rate." The class members claimed that the language was ambiguous and subject to clarification by evidence of industry practices. The appellate court found that the district court correctly found that the term "average" did not render the contract ambiguous. The insurer's definition of "usual and customary" clearly gave notice that limitations would be as determined by the insurer's company....