Dones v. Life Insurance Co. of North AmericaAnnotate this Case
While employed by Alameda County and on a medical leave of absence, Johnson enrolled online in supplemental life insurance coverage under a LINA group insurance policy. She remained on leave on the policy’s effective date and died six months later, without returning to work. When her beneficiary claimed benefits, LINA denied coverage based on a policy provision stating the insurance would not become effective if the employee was not in “active service” on the effective date. Johnson’s beneficiary sued for breach of contract, arguing that LINA and the county waived or were estopped from asserting the active service precondition.
The court of appeal affirmed the dismissal of Alameda County but reversed the dismissal of LINA. In determining the effect of preconditions to effective coverage, waiver and estoppel are questions of fact. There are factual questions as to what Johnson knew or should have known about the active service requirement and whether the conduct of LINA and the county supported a reasonable expectation that the supplemental insurance was in place and effective. It is not apparent that “active service” has a single unambiguous meaning such that Johnson necessarily must have known she was not in “active service” because she was on medical leave. If Johnson’s policy went into effect, LINA, not the county, is liable for improper denial of benefits.