Disability Insurance Policies

A lot of people in Grand Prairie, Arlington, Mansfield, Irving, Fort Worth, Dallas, Hurst, Euless, Bedford, and other places in Texas will have a disability policy. What they need to understand is the conditions under which the policy pays benefits.
The Texas, 14th Court of Appeals, issued an opinion recently styled, “Chester Humphrey v. AIG Life Insurance Company, in which a disability policy was at issue. Here is some background.
Chester Humphrey, sought total disability benefits from his employer’s insurance company, AIG, following an on-the-job injury. Because AIG denied Humphrey’s claim, he sued.
AIG moved for summary judgment, asserting there was no evidence that AIG breached the terms of the policy because Humphrey could not establish any coverage obligation under the terms of the policy. The trial court granted the summary judgment to AIG, specifically holding that Humphrey failed to present legally sufficient evidence to controvert AIG’s motion.
Humphrey was employed as a truck driver in 2001. In June 2001, he injured his back while attempting to lift a tarp to cover a load on his truck. He sought medical attention a few days after the incident; a physician examined him and prescribed medication and physical therapy. His pain did not resolve and he later received an MRI, which showed he had “multiple herniated disks” in his back.
At the time of his injury, the AIG policy provided a “weekly accident indemnity” when a covered employee, such as Humphrey, suffered an injury that totally and continuously disabled and prevented him from performing his job duties. After the injury, Humphrey sought and received weekly accident disability payments through the AIG policy.
Pursuant to the policy terms, these benefits expired in June 2003. AIG informed Humphrey he could seek “continuous total disability benefits” if he could provide “due proof” that, inter alia, he was totally disabled and that such total disability “resulted solely and directly” from the June 2001, on-the-job injury.
In response to the motion for summary judgment, Humphrey filed affidavits from himself and his wife which stated he was fine before the on-the-job injury and had no prior problems.
The trial court, in its summary judgment order, specifically ruled Humphrey failed to present at least “a scintilla of evidence that Plaintiff’s total disability resulted solely and directly from the injury.” The court refused to consider the unqualified lay opinions of Humphrey and his wife.
In Humphrey’s response, he asserted that the trial court should not have granted AIG summary judgment because he did not need to provide expert testimony to establish that his total disability resulted “solely and directly” from his injury.
In discussing the case, the court pointed out that according to the Texas Supreme Court, “Generally, expert testimony is necessary to establish causation of medical conditions that are ‘outside the common knowledge and experience of jurors.'” However, under limited circumstances, non-expert evidence may sufficiently support a causation finding that links an event with one’s physical condition. This exception applies only in certain cases in which general experience and common sense enable a layman to determine the causal relationship with reasonable probability. In such cases, “lay testimony establishing a sequence of events which provides a strong, logically traceable condition between the event and the condition is sufficient proof of causation.”
Here, however, Humphrey’s medical issues are neither common nor basic. The record reflected that Humphrey suffered from multilevel disc herniation at the L1-L2 and L2-L3 levels, with additional non-contiguous “posterocentral spondylitic subligamentous herniation” at the L5-S1 level, and additional disc bulges at several other levels. According to one of Humphrey’s treating physicians, these disc herniations have resulted in lumbar radiculopathy.
Further, although some of Humphrey’s disc complaints are located in the lumbar region, they are not readily traceable to the lifting injury alone because Humphrey has had previous spinal fusion surgery. The record also reflects that Humphrey is morbidly obese and suffers from edema and cellulitis of the lower extremities, which renders him unable to walk without assistance. He produced a letter from another physician who opined Humphrey is totally and permanently disabled. But the physician linked that condition to a “combination” of several medical ailments unrelated to his 2001 back injury: “Because [Humphrey] suffers from Congestive Heart Failure, Hypertension, Morbid Obesity, Lumbar Radiculopathy and Diabetes Mellitus, I feel that he is totally and permanently disabled and cannot return to any type of gainful employment.”
In sum, given (1) the complex nature of Humphrey’s purported back injury; (2) the combination of medical ailments unrelated to his 2001 back injury that were identified by his doctor as contributing to Humphrey’s permanent disability; and (3) his prior spinal fusion surgery, the court concluded that the task of evaluating whether his “total disability” was caused “solely and directly” by his 2001 back injury – as required by the terms of the policy at issue here – is not within the general experience and common sense of a layman.
This court concluded that expert testimony was necessary in this summary judgment proceeding and such expert testimony was not provided, thus AIG prevailed.