Hunt v. Golden Rule Ins. Co., No. 10-2065 (1st Cir. 2011)Annotate this Case
The insured was treated as an outpatient for "mental or nervous disorder" in 2005-2007, allegedly incurring expenses of more than $125,000. In 2006 the company informed her that it had already paid $8,506 and would pay only $1,494 more toward the lifetime cap of $10,000. The district court held that the contract was not ambiguous and that the limit was not prohibited by New Hampshire law. The First Circuit affirmed. The policy limit for mental health benefits, stated as "the amount shown on page 3" is not ambiguous simply because that page refers to both the "Mental and Nervous Disorder Limit" of $10,000, and the "Maximum Benefit Limit Per Covered Person" of $1 million. A state law prohibiting unfair trade practices, including discrimination in insurance does not provide a private right of action until after the claimant obtains a favorable ruling from the insurance commissioner.