Insurance policies often have different terms of coverage for disabilities caused by “accidental injuries” and “sickness” so it is important that your claim is correctly classified. A recent case by an endodontist disabled by advanced degenerative arthritis in her hands illustrates the tactics used by insurers to limit coverage. Chapman v. Unum Life Ins. Co. of Am. Unum asserted that her claim was based on sickness, which limits disability benefits to age 65. Dr. Chapman claimed that she was entitled to lifetime benefits under the “accidental injury” clause in her policy on evidence that her arthritis condition was caused by repetitive stress injuries to her hands from work, causing micro traumas evidenced in x rays.
Secondly, Unum claimed that even if the condition was caused by injuries, it was not an accident, imputing knowledge to Dr. Chapman that she was highly likely to suffer this injury by her work. The court disagreed, explaining, that it “strains credulity to conclude that any endodontist views the possibility of disabling arthritis simply by practicing endodontia as highly likely. If this were the case, the dental field would be suffering a severe shortage of endodontists.”
The court considered the reasonable expectation of the insured:
“Finally, as a matter of logic and common sense, disabilities caused by repetitive trauma, are often termed repetitive stress injuries not repetitive stress sicknesses. An ordinary plan participant would likely expect that an insurer would cover a repetitive stress injury under Provident’s definition of an accidental bodily injury.”
This important analysis applies to many professions commonly exposed to repetitive stress to the body in the workplace. If you are disabled due to a condition that originates or is worsened by repetitive exposure to the causative agent (constant use of hands, heavy lifting objects) read your policy carefully and determine if your claim is based on sickness or accidental injury because this may impact the maximum duration of your claim.