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Conventional Distinctions Between Injury and Illness Prevail
(October 2009) By Tamiya N. Wilkes, Associate.
For more information, contact Paul Farquharson
410-576-4742.
Charles McDevitt v. Reliance Standard Life Insurance Co.,
Civil No. JFM-08-3431 (D. Md. October 13, 2009).
Charles McDevitt was diagnosed with metal fume fever as
result of exposure to fumes while at his workplace. McDevitt’s metal fume fever
developed into increasing symptoms of fever and respiratory distress, causing
him to be hospitalized for a substantial period of time over three and a half
months until he returned to work. During that three and half month period,
McDevitt was covered by a short-term disability plan ("the Plan"), issued by
Reliance Standard Life Insurance Companty ("Reliance"). Nevertheless, Reliance
denied coverage to McDevitt, alleging that his illness fell within the Plan’s
"sickness" and "injury" exclusions. Specifically, Reliance alleged that its
injury exclusion, which excludes injuries that occur out of or in the course of
employment, is sufficiently broad to include a "sickness" that is not covered by
the Plan.
McDevitt filed suit against Reliance in the United States
District Court for the District of Maryland, pursuant to the Employee Retirement
Income Security Act of 1974, 29 U.S.C. § 1001 et seq. ("ERISA"). ERISA provides
individuals with a right to bring a civil action against an insurance company to
recover benefits due under the terms of an insurance plan, or to enforce their
rights under the terms of a plan. 29 U.S.C. § 1132(a)(1)(B). McDevitt alleged
that Reliance’s refusal to award him disability benefits, violated the terms of
the Plan.
The terms of the Plan gave reliance discretion to determine
eligibility, therefore the U.S. District Court for the District of Maryland
reviewed Reliance’s decision to deny coverage to McDevitt, under the "abuse of
discretion standard." In other words, Reliance’s decision to deny coverage to
McDevitt would only be upheld by the Court if the Court found that the decision
was reasonable. According to the Court, "reasonableness requires a deliberate
principled reasoning process and a decision supported by substantial evidence."
The Court held that neither the Plan’s "sickness" nor
"injury" exclusions applied to McDevitt and that he was "naturally and
literally" entitled to coverage. The Court further explained that McDevitt
suffered from a sickness, not an injury, that was not covered by a Worker’s
Compensation Act; therefore, it did not fall within the Plan’s sickness
exclusion and the injury exclusion did not apply to McDevitt at all. Although
Reliance attempted to explain that the Plan defined injury as a bodily injury
resulting directly from an accident and that McDevitt’s sickness was a bodily
injury that resulted from a work accident, the Court did not accept this
argument. The Court stated that Webster’s New World Dictionary defines "injury"
as "physical harm," or "a wound or other specific damage" which "connote
tangible change to an external body part or internal organ caused by invasion or
impact." The Court found that "the terms of insurance policies must be
construed… in the context of the language used by ordinary persons whose
contractual relationships the policies are intended to govern;" therefore,
conventional distinctions between the terms injury and illness prevailed.
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