Rich v. Principal Life Insurance

875 N.E.2d 1082, 226 Ill. 2d 359, 314 Ill. Dec. 795, 2007 Ill. LEXIS 1157
CourtIllinois Supreme Court
DecidedSeptember 20, 2007
Docket103754
StatusPublished
Cited by139 cases

This text of 875 N.E.2d 1082 (Rich v. Principal Life Insurance) is published on Counsel Stack Legal Research, covering Illinois Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Rich v. Principal Life Insurance, 875 N.E.2d 1082, 226 Ill. 2d 359, 314 Ill. Dec. 795, 2007 Ill. LEXIS 1157 (Ill. 2007).

Opinion

JUSTICE FREEMAN

delivered the judgment of the court, with opinion.

Chief Justice Thomas and Justices Fitzgerald, Kilbride, Garman, Karmeier, and Burke concurred in the judgment and opinion.

OPINION

Plaintiff, David Rich, brought an action in the circuit court of Winnebago County against defendant, Principal Life Insurance Company, for breach of an insurance contract. Defendant filed a counterclaim against plaintiff seeking a declaratory judgment. Plaintiff and defendant filed cross-motions for summary judgment in the declaratory judgment action. The circuit court entered summary judgment in favor of plaintiff. The appellate court reversed and entered summary judgment in favor of defendant. No. 2 — 05—1197 (unpublished order under Supreme Court Rule 23). We allowed plaintiffs petition for leave to appeal (210 Ill. 2d R. 315(a)), and now affirm the judgment of the appellate court.

I. BACKGROUND

The pertinent and undisputed facts are as follows. On March 20, 1980, Bankers Life Company, now known as defendant, Principal Life Insurance Company, issued a disability insurance policy to plaintiff. The policy provides that defendant will pay monthly benefits “if Total Disability (as that term is defined in this policy) of the Insured commences while the Policy is in force.” The policy defines “total disability” as “the complete inability of the Insured due to Injury or Sickness to perform any and every duty pertaining to an occupation (as defined herein) for remuneration or profit.” The policy defines the terms “Sickness” and “Injury” as follows:

“INJURY means accidental bodily injury sustained by the Insured while this Policy is in force. Injury which is a direct or indirect result of physical or mental infirmity, illness or disease of any kind, or medical or surgical treatment therefor or Injury which results in Total Disability which commences more than 90 days after the date the Injury is sustained will be deemed to be Sickness.” 1

In the benefit and premium schedule, the policy prescribes lifetime benefits if the disability resulted from an “injury,” but limits the benefit period to five years if the disability resulted from a “sickness.”

On January 19, 1999, plaintiff was loading 50-pound tires onto a truck at work. A tire bounced back and struck his right wrist. Plaintiff continued working despite pain and swelling in the wrist. The next day, a medical examination with X-rays revealed only a contusion and strain. However, plaintiff continued to experience pain and swelling in his right wrist. On March 3, 1999, plaintiff received an MRI. On March 3 and 18, based on the MRI, various physicians diagnosed plaintiff as having a tear of the right scapholunate ligament with segmental instability. Dr. Robert Schenck confirmed this diagnosis and recommended surgery. Plaintiff was fully employed from January 19, 1999, through May 17, 1999.

On May 18, 1999, Dr. Schenck performed surgery on plaintiffs right wrist. Exploration of the wrist revealed a complete, irreparable rupture of the scapholunate ligament. Consequently, Dr. Schenck performed a scapholunate fusion, inserting pins to attach a bone graft from the distal radius. On August 23, 1999, Dr. Schenck removed the cast from plaintiffs right hand and wrist. Dr. Schenck observed swelling on the dorsal aspect of plaintiffs hand and drainage at the fusion site. Dr. Schenck removed the pins and prescribed oral antibiotics to prevent infection from spreading to the bone. On August 25, 1999, plaintiff returned to Dr. Schenk with complaints of abnormal redness and swelling near the site where the pins had been removed. Cultures from the pin-removal site revealed a “rare growth of staphylococcus species.” As a result, Dr. Schenck directed plaintiff to continue taking his antibiotics.

On August 25, 1999, plaintiff applied for benefits under his disability insurance policy by submitting to defendant a verified disability claim notice. Plaintiff identified his injury as the torn ligament in his right wrist, which he incurred while loading tires at work on January 19, 1999. Plaintiff stated that his total disability commenced on May 18, 1999, the date of his wrist surgery. Plaintiff explained: “I was put on disability because of an infection in my wrist that was operated on.”

In a letter dated September 8, 1999, defendant acknowledged receipt of plaintiffs disability claim notice. Defendant advised plaintiff: “The Maximum Benefit Period is five years. For disabilities as a direct result within 90 days of an accident/injury, your benefit is extended to your lifetime.” Also, defendant requested an attending physician’s statement to further process plaintiffs claim. Plaintiff thereafter submitted the statement, prepared by Dr. Schenck, who verified that he “told the patient [plaintiff] to restrict employment activities,” and that the restrictions began on May 18, 1999. In a letter dated October 1, 1999, relying on the verified information that plaintiff provided, defendant determined that plaintiff was totally disabled as of May 18, 1999, and awarded him benefits under the policy beginning on June 17, 1999, after the policy’s 30-day elimination period.

Dr. Schenck continued to treat plaintiff on a monthly basis for hand and wrist pain. On January 31, 2000, plaintiff complained again of swelling and redness. X-rays revealed that plaintiff suffered from osteomyelitis in the proximal scaphoid and adjacent lunate bones. A biopsy of plaintiffs wrist revealed a rare growth of staphylococcus species and mold. As a result, Dr. Schenck referred plaintiff to Dr. David Simon, an infectious disease specialist, who ordered a six-week course of intravenous antibiotics. On March 30, 2000, Dr. Schenck operated a second time on plaintiffs right wrist and discovered that the lunate and adjacent portions of his scaphoid bones were necrotic. Dr. Schenck excised most of the necrotic bone and advised plaintiff that if the scaphoid failed to fuse, he would eventually need a total wrist fusion. On October 22, 2001, plaintiff underwent wrist fusion surgery and an ulnar head replacement on his right wrist.

The record shows that defendant administered plaintiffs claim as having a five-year benefit period. In a July 12, 2001, letter to plaintiff, in which defendant approved plaintiffs continued benefits, defendant noted: “Benefits will continue until June 16, 2004, which is when your benefits will exhaust, as long as you continue to be Disabled per the provisions of your policy and provide Proof of Loss that you are satisfying this policy requirement.”

On August 28, 2002, plaintiff requested that defendant reconsider its determination that he was ineligible for lifetime benefits. Defendant responded in a letter dated August 30, 2002. Defendant explained that it was correctly administering plaintiffs claim as a “sickness” under the policy, based on the verified facts that plaintiff gave in his claim forms. Citing the policy provision defining “sickness,” defendant noted the policy’s 90-day injury limitation. Defendant informed plaintiff that, according to the information in his claim file, plaintiff did not become disabled from the January 19, 1999, injury until May 18, 1999, or 120 days after he sustained the injury.

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Cite This Page — Counsel Stack

Bluebook (online)
875 N.E.2d 1082, 226 Ill. 2d 359, 314 Ill. Dec. 795, 2007 Ill. LEXIS 1157, Counsel Stack Legal Research, https://law.counselstack.com/opinion/rich-v-principal-life-insurance-ill-2007.