Collins v. Unum Life Insurance Company of America is a case with an unfortunate result for plaintiff Daniel Collins who fractured his ankle when he fell in the employee parking lot. Initially surgery was performed and various screws put in place to hold the tibia and fibula together and securing the medial malleolus. For about three months, he had no complaints and the fracture appeared to be healing appropriately.

Then, he began having complaints about pain. About six months after the fall, he developed a Charcot ankle, which is misalignment of the ankle joint. His treating physician noted that he suffered from pain due to the fracture “among other issues.” He had more surgery, but continued to have pain. A breakdown of the tibia indicated that he might need a “limb-salvage procedure.”

After numerous problems and more surgeries, approximately one year after the fracture, surgeons amputated Collins leg just below his knew. The pre and post-surgical diagnoses included, among other things, Charcot neuroarthropathy with ankle deformity, ankle fracture and diabetes mellitus. A few months after the amputation, Collins applied for dismemberment benefits under his employee benefit plan and his claim was denied. Unum based its denial on its determination that “Plaintiff’s diabetes partly contributed to the need to amputate Plaintiff’s foot.” Plaintiff’s administrative appeal was denied and he filed this ERISA lawsuit.

Unum’s Accidental Dismemberment Exclusion

The Unum policy which provided plaintiff dismemberment coverage specifically had an exception and did not provide coverage for dismemberment that was “caused by, contributed to by, or resulting from…disease of the body.” The policy also gave discretion and authority to Unum to process and interpret claims under the policy.

The District Court Upholds Unum’s Denial Based on a Sufficient Record Showing the Diabetes Was A Contributing Factor to the Need for Amputation

Plaintiff’s medical history showed that he was responsible for not controlling his diabetes. As a result, he had ankle problems both before and after his fall. A board-certified pathologist, who reviewed plaintiff’s medical records at the request of Unum, determined, with a reasonable degree of medical certainty, that “both the underlying illness and the injury were necessary for the development of the joint pathology that led to the amputation.” In evaluating these facts, the court held that “Unum’s decision to deny Plaintiff’s benefits application was not arbitrary and capricious based on the policy’s bodily disease exclusion.”

This case was not handled by our firm, but we believe it can be instructive to those struggling to obtain benefits under their insurance’s dismemberment coverage. If you have questions about this case, or any matter relevant to your dismemberment or disability coverage, contact one of our experienced attorneys at Dell and Schaefer for a free consultation.