In ERISA cases, insurance companies frequently construe terms to justify denying a claim. However, insurers run into problems when they use interpretations that are unreasonable. For example, in cases involving accidental bodily injury, Unum has taken the position that the actions which caused the injury must be accidental, as opposed to the injury itself being accidental. If an insured engages in an intentional act that results in an injury, Unum will contend there is no coverage. The interpretation of “accidental bodily injury” is broader when one looks at whether the resulting injury was expected or anticipated. A recent case explored this issue. Chapman v. UNUM Life Ins. Co. of Am., 20-CV-1155 (NEB/BRT) (D. Minn. Aug. 18, 2021).
Facts of the Case:
An endodontist suffered from degenerative arthritis in her hands.
When she first started having problems she did not go to a doctor but iced her hands or put heating pads on them and took ibuprofen. They got worse.
She consulted a physician in 2012 to make sure she was not suffering from a rheumatological disease. She was.
About four years later, she sought treatment from a physician who diagnosed her with degenerative joint disease and treated her with injections. They helped a little.
She repeated the injections over the next few years.
Eventually, she claimed disability through her Unum policy, which was governed by ERISA.
The policy provided disability benefits up to age 65 for sickness, but for life, for an injury.
Unum agreed that Dr. Chapman was disabled. Using one of its regular doctors to support that opinion, Unum contended that there was no accidental injury just a sickness – arthritis.
The plaintiff argued that she had a repetitive stress injury caused by her use of tools as an endodontist. Unum disagreed. Dr. Chapman filed a lawsuit.
Unum claimed that the words “accident” and “injury” should be read together as “accidental injury” to support its argument that Dr. Chapman knew that she was engaging in actions that harmed her hands.
Thus, the actions which led to the injury were not accidental but intended, so there was no coverage.
The plaintiff submitted that “accident” and “injury” had independent meanings. Not every accident results in an injury, and not every injury is caused by an accident.
Further, “accidental” modified “injury.” It was the injury itself that was not expected, not the means which resulted in the injury.
The court agreed with Dr. Chapman.
It noted that disabilities caused by repetitive trauma are often termed “repetitive stress injuries” not “repetitive stress sicknesses.” It relied on a Georgia decision, which answers a question for the Eleventh Circuit, Provident Life and Accident Ins. Co. v. Hallum, 276 Ga. 147 (Ga. 2003).
That court found accidental bodily injury “… in the context of this policy, means a bodily injury that was unexpected, but could have arisen from a conscious or voluntary act. By using ‘accidental' to modify ‘bodily injuries,' as opposed to modifying the cause or means of any injuries, the Provident Life policy places the focus of the coverage on the injuries, not the means that caused the injury.” Id at 148.
A reasonable person would expect that a repetitive stress injury would be covered by the definition of accidental bodily injury, and thus, the degenerative arthritis was an injury under the policy.
Relying on that case, the court found for Dr. Chapman on the issue of lifetime benefits.
Having won the case, Dr. Chapman requested that the court award attorney's fees as provided by the ERISA statute.
Though not required by the Supreme Court, the court considered the five basic attorney's fees factors. One of the key factors is bad faith or culpable conduct. The court noted that “First, although there is no evidence in the record of bad faith, Unum's position before the Court contradicts its position in the administrative proceeding, and it also appears to have taken a position that no repetitive stress injury can be an “injury” under the Policy, a reading inconsistent with the Policy's language.” The court also found evidence of the other four factors, and thus was inclined to award fees. It permitted briefing as to the reasonableness of the fees and costs.
An interesting case. Antics like this one by insurance companies are just one reason why having an experienced ERISA attorney on your client's case is crucial to its success. Contact us today if your client has an ERISA long term disability, short term disability, life insurance, or retirement benefits claim.