Insurer Says Condition was a Sickness,
Not an Injury

posted in: Case Studies | 0

Claimant, a chiropractor suffered from a herniated L5-S1 with radiculopathy, stenosis of the cervical spine, left knee chondromalacia and tear, and neck pain that all began after trying to assist a heavy-set patient to return to an upright position. Claimant did not seek medical attention following the accident and there was no record of the incident anywhere in his medical files. Following the accident, claimant tried to continue to work over the next six months but he could only manage one day a week. When the claimant applied for total disability benefits, the insurer informed him that because there was no record in any of his files of any “injury” because it appeared that his condition was the result of degenerative disc disease – an “illness”. The importance of this distinction was that like many policies, this client’s differentiated between disabilities caused by sickness and disabilities caused by injury. When the policy makes such a distinction, the disabilities caused by sickness will only be paid until age 65, while disabilities which result from injuries will be paid for life. As the claimant neared his 65th birthday, it appeared that the insurer was going to terminate benefits at age 65 on the grounds that there was “absolutely no way to prove that the claimant’s disabilities were the result of anything other than disease and degeneration”.

Result: Settlement in excess of $1,575,000

Back and Spinal Injuries - Long Term Disability Claims