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Physician Totally Disabled Due to Sickness Cannot Reclassify Disability Based on Later Sustained Injury

Physician Totally Disabled Due to Sickness Cannot Reclassify Disability Based on Later Sustained Injury

ERISA and Life Insurance News
(February 6, 2012)

Dr. Laun, a surgeon, was covered by a disability income insurance policy issued by AXA Equitable. The policy provided benefits for two types of total disability: (1) "accident total disability," defined as total disability resulting from injury, and (2) "sickness total disability," defined as total disability caused or contributed to by sickness or by medical or surgical treatment of any sickness or disease.

The policy provided lifetime benefits for accident total disability, but provided benefits only to age 65 for sickness total disability.

In 2003, Dr. Laun was diagnosed with bilateral basal osteoarthritis of his thumbs, a degenerative joint condition that caused pain in the base of his thumbs after he performed surgery. In November 2003, Dr. Laun stopped performing surgery and submitted a claim for total disability caused by sickness. His claim was approved.

While recovering from surgery to correct the condition in his thumbs, Dr. Laun fell and sprained his wrist. Dr. Laun wrote to AXA Equitable, describing his wrist injury and requesting that the status of his claim be changed to accident total disability, for which lifetime benefits could be paid.

An independent physician consultant determined that Dr. Laun’s disability was due 35% to his wrist injury and 65% to his thumb condition and the subsequent surgery. AXA Equitable concluded that Dr. Laun was not eligible for reclassification because, at the time of his accident, he was already receiving total disability benefits for a sickness from which he had not recovered.

Dr. Laun sued, and Equitable moved for summary judgment, arguing that the disability could not be reclassified because it was caused and contributed to by his thumb illness, and because Dr. Laun was not engaged in his occupation when he reportedly became disabled due to his wrist injury. The trial court granted AXA Equitable’s motion for summary judgment.

On appeal, Dr. Laun argued that his disability should have been reclassified because the policy did not state that reclassification was prohibited, because his wrist bothered him more than his thumbs, and because he had hoped to return to his surgical practice until he injured his wrist.

The Georgia Court of Appeals held that Dr. Laun was not entitled to accident disability benefits, because the policy unambiguously provided that "total disability caused or contributed to by sickness or disease will not be considered accident total disability," but must be considered sickness disability.

Dr. Laun contended that an issue of fact existed as to whether his disability resulted solely from his wrist injury. However, Dr. Laun’s testimony showed that, while he perceived his wrist injury to be "more disabling" than his thumb condition, this characterization implied that his thumbs still contributed to his disability. Thus, the court of appeals affirmed the trial court’s grant of summary judgment.

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