Lee v. Unum Life Ins. Co. of America

900 So. 2d 1021, 2004 La.App. 4 Cir. 1483, 2005 La. App. LEXIS 1011, 2005 WL 896461
CourtLouisiana Court of Appeal
DecidedMarch 30, 2005
Docket2004-CA-1483
StatusPublished
Cited by3 cases

This text of 900 So. 2d 1021 (Lee v. Unum Life Ins. Co. of America) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Lee v. Unum Life Ins. Co. of America, 900 So. 2d 1021, 2004 La.App. 4 Cir. 1483, 2005 La. App. LEXIS 1011, 2005 WL 896461 (La. Ct. App. 2005).

Opinion

900 So.2d 1021 (2005)

Stella LEE
v.
UNUM LIFE INSURANCE COMPANY OF AMERICA.

No. 2004-CA-1483.

Court of Appeal of Louisiana, Fourth Circuit.

March 30, 2005.

*1022 Bonnie L. Zakotnik, New Orleans, LA, for Plaintiff/Appellee.

Lauren A. Welch, Retha E. Karnes, McCranie Sistrunk Anzelmo Hardy Maxwell & McDaniel, Metairie, LA, for Defendant/Appellant.

(Court composed of Chief Judge JOAN BERNARD ARMSTRONG, Judge MAX N. TOBIAS, JR., and Judge ROLAND L. BELSOME).

MAX N. TOBIAS, JR., Judge.

This case arises out of a coverage dispute over disability benefits between a school bus driver who was injured in an automobile accident and the insurance company providing group coverage through her employer.

Stella Lee ("Lee") was employed as a school bus driver for the Orleans Parish School Board ("OPSB") for twenty-five years. On 17 May 2001, a third party driver, who was cited for running a stop sign, struck the school bus Lee was driving. Lee was not cited for any violations following the accident. In the accident Lee sustained injuries, as a result of which she was unable to work from 17 May 2001 until 14 November 2001. During that period, *1023 Lee received workers' compensation benefits.

In 1999, Lee applied to become a beneficiary under a disability policy issued by Unum Life Insurance Company of America ("UNUM") to the OPSB.[1] She received two documents from OPSB regarding the UNUM policy plan: a two-page handout and a pamphlet describing coverage available under the plan. The pamphlet states, in part, that

UNUM's Disability Insurance Can Help
• It replaces a portion of your income.
• It helps provide financial security when you are disabled, whether for a short time or a longer time.
• It is available to you at affordable group rates, conveniently payroll deducted by your employer.

(Emphasis in original.) It does not mention any limitations or exclusions from coverage. The handout, however, lists a number of "exclusions" including "any occupational injury or sickness under STD."

Under the policy, short-term disability ("STD") is defined as when

due to sickness or injury: [insured is] unable to perform the material and substantial duties of [his/her] regular occupation; and [he/she is] not working in any occupation. [Emphasis in original.]

The UNUM policy provides an exclusion to coverage that states, in pertinent part, that the STD plan:

does not cover any disabilities caused by, contributed to by, or resulting from your:
-occupational sickness or injury, however, UNUM will cover disabilities due to occupational sickness or injuries for partners or sole proprietors who cannot be covered by a workers' compensation law. . . . [Emphasis in original.]

The exclusion defines "occupational sickness or injury" as "a sickness or injury that was caused by or aggravated by any employment for pay or profit." [Emphasis supplied.]

As a result of the 17 May accident, Lee filed for STD benefits under the UNUM policy, but coverage was denied by UNUM on the grounds that her injury was not covered, insofar as it met the definition of an "occupational sickness or injury." Lee appealed the denial of coverage on 9 August 2001, but was again denied on 28 August 2001.

Lee filed suit against UNUM on 3 July 2002, alleging that UNUM improperly denied her claim, insofar as the only written material received by Lee describing the policy consisted of a single pamphlet from UNUM and a two-page document on UNUM letterhead, the relevant portions being noted above.

The handout, entitled

Orleans Parish School Board

SHORT TERM/LONG TERM DISABILITY PROGRAM

provides a "brief description of the group disability (STD/LTD[2]) insurance being made available to you by UNUM Life Insurance Company of America." The second page of the document contains a section entitled "Exclusions" and provides the following:

*1024 Benefits would not be paid for loss resulting from war, declared or undeclared, or any act of war; active participation in a riot; intentionally self-inflicted injuries; loss of a professional, occupational license or certification; commission of a crime for which you have been convicted under state or federal law; any period of disability during which you are incarcerated; any occupational injury or sickness under STD; or, any pre-existing condition for which you receive treatment in the 3 months prior to your effective date which causes a disability within the first 12 months after your effective date under LTD. [Emphasis supplied.]

Both UNUM and Lee filed motions for summary judgment, which were heard on 28 March 2003. UNUM asserted in its motion that by the terms of the policy issued to Lee, she was not entitled to any short-term disability benefits, because her injuries were sustained while she was working. Lee maintained, however, that her injuries were not "caused by" her employment, but rather were caused by the actions of a third party tortfeasor, and not excludable under the policy by its clear language. She further argued that even if the policy were found to be ambiguous, she would be entitled to benefits, because any ambiguities in the exclusionary language should be construed against UNUM under Louisiana law. Lee finally asserted that she was entitled to statutory penalties and attorneys' fees from UNUM for arbitrarily refusing to pay her benefits.

In support of her motion for summary judgment, Lee filed a list of uncontested material facts,[3] an affidavit attesting to the veracity of the uncontested material facts, a photocopy of the pamphlet and hand-out briefly describing disability coverage given to school board employees, a copy of her pay statement for the period 17 May to 30 May 2001, photocopied excerpts from the policy defining exclusions and "gross disability payment," as well as a copy of UNUM's opinion letter denying Lee's claim for benefits. UNUM's motion was supported by a copy of its file detailing Lee's claims as well as a copy of the policy.[4] No verification of the policy was attached.

On 8 April 2003, the trial court granted Lee's motion for summary judgment and denied UNUM's cross-motion for summary judgment without issuing written reasons. UNUM sought supervisory review of the decision, but this court and the Supreme Court declined to review the decision. Lee v. Unum Life Ins. Co. of America, 03-0954, unpub. (La.App. 4 Cir. 7/18/03), writ denied, 03-2307 (La.11/21/03), 860 So.2d 549.

On 17 February 2004, Lee filed a second motion for summary judgment seeking calculation of an award for her STD benefits, an award for LTD benefits, as well as an award for penalties and attorneys' fees pursuant to La. R.S. 22:658, and costs; the *1025 motion was heard on 26 March 2004. In support of her second motion for summary judgment, Lee filed a second statement of uncontested material facts, which asserted that she was out of work from 17 May through 23 November 2001;[5]

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900 So. 2d 1021, 2004 La.App. 4 Cir. 1483, 2005 La. App. LEXIS 1011, 2005 WL 896461, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lee-v-unum-life-ins-co-of-america-lactapp-2005.