Educators Mutual Insurance Ass'n v. Evans

2011 UT App 171, 258 P.3d 598, 683 Utah Adv. Rep. 24, 2011 Utah App. LEXIS 171
CourtCourt of Appeals of Utah
DecidedJune 3, 2011
DocketNo. 20090527-CA
StatusPublished
Cited by1 cases

This text of 2011 UT App 171 (Educators Mutual Insurance Ass'n v. Evans) is published on Counsel Stack Legal Research, covering Court of Appeals of Utah primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Educators Mutual Insurance Ass'n v. Evans, 2011 UT App 171, 258 P.3d 598, 683 Utah Adv. Rep. 24, 2011 Utah App. LEXIS 171 (Utah Ct. App. 2011).

Opinion

OPINION

VOROS, Judge:

111 Joel Evans is a military veteran and a Salt Lake City police officer. After being injured as a police officer, Evans applied for disability benefits from Salt Lake City Corporation (the City). The City administered its disability benefits through Educators Mutual Insurance Association (Educators). Various disputes arose concerning the amount and duration of these benefits and whether they should be offset by federal benefits Evans was receiving. The trial court granted summary judgment against Evans, who appeals. We affirm in part and reverse in part.

BACKGROUND

1 2 Evans is a peacetime and Gulf War era veteran. He served in the Army from May 25, 1981, to August 28, 1981, and in the first Gulf War from November 21, 1990, to May 30, 1991. He began receiving disability benefits from the Department of Veterans Affairs (VA benefits) in June 1999. These benefits were based on multiple service-related health problems.

{3 Upon returning from the Gulf War, Evans resumed his duties as a Salt Lake City police officer until he became further disabled in 2001. In October 2001, Evans applied for disability benefits under the City's disability program, which was administered by Educators. When he applied for disability benefits from Educators, he listed multiple disabling conditions, including some that overlapped with those for which he was receiving VA benefits.

14 Educators awarded Evans disability benefits, but with several Hmitations. First, Evans was awarded a monthly disability benefit of two-thirds of his regular base monthly income, rather than 100%. The Group Long-Term Disability Plan (the Plan) allowed a benefit of 100% of a person's salary only if the person was disabled from injuries occurring on the job. Educators determined that at least some of Evans's injuries stemmed from his service in the Gulf War, rather than his service as a Salt Lake City police officer. Second, Evans was awarded disability benefits for only twenty-four months. The Plan allowed benefits up to twenty-four months "[ilf a covered employee is disabled from performing the duties of the occupation he performed before disability." It allowed benefits for a longer period only "lilf a covered employee is disabled from performing any and all occupations." Educators determined that Evans, though disabled from his regular occupation, was not disabled from "any and all occupations." Educators did, however, state that after twenty-four months Evans could request that benefits be extended if he was at that time totally disabled from "any and all occupations." Third, Evans was required to participate in a vocational rehabilitation program. Fourth, Evans's monthly benefit was to be offset by any amount he might receive in VA benefits. Educators informed Evans that "[aleceptance of the benefit indicates acceptance of the diagnosis" and that if he disagreed with any of the decisions made on his claim, he must write to Educators within thirty days.

[602]*60215 Evans's then-counsel timely wrote to Educators, challenging some of the decisions made on his claim. His letter outlined three objections: (1) he asserted that Evans's disability benefit should not be limited to two-thirds of his salary; (2) he asserted that Evans's disability benefit should not be offset by the VA benefits; and (8) he asserted that negotiating the benefit checks should not be deemed acceptance of the limited benefit. This letter said nothing about the twenty-four-month time limit.

T6 Educators' counsel responded, stating that he had reviewed Evans's concerns and had obtained an independent medical opinion from a physician with expertise in disability issues. Educators maintained its position, first, that it was entitled to offset Evans's award by his VA benefits, and second, that Evans was not entitled to 100% of his salary because his "current disability is not caused by on-duty injuries, either individually or in total." This letter stated that if Evans wished to appeal the decision to Educators' Claims Review Committee, he should "kindly notify [Educators' counsel] within sixty days of the date of this letter."

I 7 Shortly thereafter, Educators sent Evans a second letter indicating that it had received information from the Department of Veterans Affairs that Evans was currently receiving disability benefits. Educators asserted that Evans had therefore received an overpayment from Educators because his benefits were supposed to have been offset by his VA benefits Educators requested that Evans repay Educators the amount of the overpayment, which it stated was $11,568.40.

T8 Evans timely requested review of "the entire decision of Educators denying Evans's claims," as outlined in his previous letter. Educators' Claims Review Committee rejected Evans's appeal. It affirmed that his disability payments would be offset by his VA benefits. And it concluded that his disability benefits would be paid at two-thirds of his salary because his disability was "a combination of many things," including injuries incurred prior to his police service, injuries secondary to his police service, and conditions unrelated to his police service. The letter also informed Evans that he had the right to appeal to Educators' Board of Directors (the Board) and that any such appeal must be made in writing within thirty days.

19 Fifty-eight days later, Evans's then-counsel wrote a letter requesting an appeal to the Board. The Board denied his appeal as untimely. Counsel then wrote a letter to Educators accepting responsibility for missing the deadline and stating that he had miscalculated the due date. Counsel asked Educators to waive the deadline and allow Evans to proceed with his appeal. Educators denied this request.

I 10 Some months later, Educators notified Evans that his disability benefits were about to expire because the twenty-four months had passed. Evans, through new counsel, requested an extension of benefits on the ground that his physical condition rendered him permanently "incapable of engaging in any occupation or employment for wage or profit." Educators agreed to review the file and stated that its review would take approximately thirty days. In addition, Educators directed that "[dJuring this time Mr. Evans will need to request all new current medical information from all doctors that are treating him for his disability at this time and who can substantiate that he is totally disabled from any and all occupations."

{11 Evans responded by submitting two one-page documents. First, he submitted a one-page report from his treating physician indicating that Evans could not work at his regular work, nor could he work eight hours per day. Evans also submitted a one-page letter from himself, stating "I remain totally disabled and remain eligible for [benefits]. Both submissions were made within thirty days of Educators' letter. Evans submitted no other information at this time.

{12 Many months later, Educators sued Evans, alleging breach of contract and seeking $8,510.78 in overpayments.1 Evans counterclaimed against Educators and filed a third-party complaint against the City. He [603]*603alleged that the City and its agent, Educators, had breached the contract and violated Utah law by awarding him disability payments of only two-thirds of his salary, by offsetting his disability benefits by his VA benefits, and by terminating his benefits after twenty-four months. Shortly thereafter, Evans sent Educators another letter from his doctor indicating that Evans was disabled from all occupations.

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Related

EDUCATORS MUT. INS. ASS'N v. Evans
2011 UT App 171 (Court of Appeals of Utah, 2011)

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Bluebook (online)
2011 UT App 171, 258 P.3d 598, 683 Utah Adv. Rep. 24, 2011 Utah App. LEXIS 171, Counsel Stack Legal Research, https://law.counselstack.com/opinion/educators-mutual-insurance-assn-v-evans-utahctapp-2011.