GE Benefit Denial Overturned For Plaintiff with Permanent Loss of Function of His Foot
Author: Attorney Gregory Dell
In Stockman v. GE Life, Disability and Medical Plan et al., the plaintiff severely injured his foot and totally lost the function of it for 12 months. He then applied for benefits under the GE Life policy claiming he suffered a “total and permanent” loss of the use of his foot. MetLife, Plan Administrator for GE, denied his claim on the grounds that the loss was not total and permanent. Both the Ohio district court and appellate courts disagreed with MetLife. The appellate court concluded: “If Stockman’s injury, which has resulted in the ‘permanent’ loss of the use of his foot in the way that a foot should be used does not qualify him to receive benefits, we are unsure of a situation, absent actual severance, where a claimant would qualify.”
Brief History of the Case
In 2009, Steven Stockman severely injured his foot when he fell off a second story ladder. Subsequently, he underwent seven separate surgical procedures and contracted several infections that required extensive treatment. After 12 months of total loss of the use of his foot, he applied for benefits under the policy that covered accidental dismemberment with the definition of dismemberment being the “permanent and total loss of function of the hand or foot as a result of an accident after the loss has continued for at least 12 consecutive months.” The plan denied him benefits and after he exhausted his administrative appeals, he filed a lawsuit under the provisions of ERISA.
MetLife did not dispute the fact that Stockman had lost the function of his foot for 12 consecutive months as required by the plan, but argued the loss of function was not total and permanent since, after the expiration of the 12 months, he was able to walk with a cane. In court, the resolution of the case depended on the definition of the word “permanent”.
MetLife argued that “permanent” means there will never be any improvement, and since the condition of Stockman’s foot had improved after the 12 month eligibility period to the extent that he could occasionally walk without a cane, his injury was not permanent. Stockman argued that the dictionary definition of permanent should be used which describes something as permanent when it is “enduring without fundamental or marked change.”
The Court’s Final Decision
The district court agreed with Stockman and stated that the “mere fact that his foot is still attached to his body” is not enough to decide the foot is functional. The appellate court agreed with the district court and concluded that if MetLife’s definition of permanent were followed, it would be superfluous. No claimant whose foot had not been severed would ever be able to collect benefits. That court agreed with the district court’s conclusion that Stockman was entitled to benefits since “the plan allowed for benefits when a person has suffered an injury that, for all intents and purposes, has resulted in the loss of the use of the foot to the point where it no longer serves the purpose it was intended to serve and will never be able to serve that purpose.” Since Stockman’s medical records supported that definition, the district court determined he was entitled to benefits and the Court of Appeals for the Sixth Circuit agreed.
This case was not handled by our office, but it may provide claimants guidance in their pursuit of compensation under the accidental dismemberment clause of an insurance policy. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.