Conventional Distinctions between Injury and Illness Prevail

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.