The language in a disability policy is important to read and understand. The Courts will do so very closely.
This is illustrated in a 2017, opinion from the U.S. 5th Circuit. It is styled, David M. Cox v. Provident Life & Accident Insurance Company. It is a summary judgement case that was decided by the lower court in favor of Provident. This Court reversed the lower court finding.
Cox had a disability policy with Provident. The Policies provided coverage for disability caused by injury or sickness and contain provisions tying the period of benefit payments to the cause of the insured’s disability. If the insured is rendered disabled at the age of 60 as a result of an accident or injury, the Policies provide for lifetime benefit payments. By contrast, if the insured is rendered disabled at the age of 60 as a result of sickness, the Policies provide that benefit payments will be paid only until age 65. The greater of the two applicable benefits periods applies when the disability results from a combination of the two.
Cox, at age 60, in December 2010, injured his left knee when he fell into a hole while walking his dog. An MRI revealed joint effusion, a peripheral tear of the medial meniscus, a MCL sprain, and degenerative thinning of the articular cartilage. The tear was surgically repaired.
Cox filed a claim and benefits were paid until he was able to return to work without restrictions in March 2011. In July 2011, another surgery was performed and the claim was re-0pended. A subsequent MRI revealed “severe” arthritis. Over the next few years, a series of examinations and procedures were performed.
In March 2014, Cox was informed that his ongoing claim for disability was being administered under the “sickness” provisions of the policy because Provident considered the degenerative arthritis under the “sickness” provision of the policy and not due to the December 2010 injury.
This lawsuit was eventually filed by Cox seeking full benefits.
This Court said the lower court erred by ruling as a matter of law that arthritis was a sickness and the disability was due to the injury of 2010. This was a battle of medical experts and the lower court should have let a jury decide this as a fact issue.