Sickness or Injury?
Why Does it Matter?

Some disability insurance policies have different rules for a sickness versus injury.  These differences can prove quite significant when it comes to your maximum benefit period.

While the difference between an injury and sickness may, initially, seem clear-cut, if you have certain disabling conditions (such as degenerative disc disease or carpal tunnel syndrome) whether you have a disabling sickness versus injury can be a very nuanced determination. For example, when a particular event causes a slowly progressive disease to become suddenly disabling to the point a dentist or doctor can no longer work in his or her occupation, the final determination may have to be made by a court.

This is what happened in a recent case before the Arizona District Court.[1] Dr. Wood was an anesthesiologist who practiced in Page, Arizona within the Banner health system. Dr. Wood suffered from degenerative disc disease in his lumbar and cervical spine, but continued to practice (a common phenomenon among physicians and dentists called presenteeism). In 2015, he and a team of nurses lifted a patient from the operating table to a hospital bed—a routine maneuver that he had done thousands of times before. This time, however, the maneuver resulted in intense radiating pain in his spine and he found himself unable to work. Dr. Wood then filed a claim with his insurer, Provident, due to the disabling back condition.

While Dr. Wood felt his disability was caused by an accident, making him eligible for lifetime benefits under the terms of his policy, Provident classified his disability as a result of sickness, and maintained he was only eligible for 48 months of benefits. Dr. Wood sued Provident and the court had to determine what “injury” meant.

Fortunately for Dr. Wood, in this case, the Arizona judge determined that the policy had a vague definition of “injury” and ruled the provision should be interpreted in Dr. Wood’s favor. The court turned to precedent set by the Arizona Court of Appeals, finding that Arizona does not distinguish between ‘accidental means’ and ‘accidental results.’”[2] The court also noted the Arizona Supreme Court’s findings that “accident” must be read in light of common speech, usage, and understanding of the average man.[3]  In the end, the court found that, under Arizona law, Dr. Wood became disabled when performing the lifting maneuver and he was eligible receive lifetime benefits.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are unsure of how your policy interprets sickness versus injury, an experienced disability insurance attorney can help you interpret this language and apply it to your particular situation.

[1] See Wood v. Provident Life & Accident Ins. Co., 2018 WL 2416190  (D. Ariz. May 29, 2018).

[2] Id. quoting Central Nat. Life Ins. Co. v. Peterson, 529. P.2d 1213  (Ariz. App. 1975).

[3] Id. quoting Knight v. Metro Life Ins. Co., 437 P.2d 416 (Ariz. 1968).

 

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