199 F.3d 399 (7th Cir. 1999), 99-1031, Winter v. Minnesota Mutual Life Inc
|Citation:||199 F.3d 399|
|Party Name:||DOUGLAS S. WINTER, Plaintiff-Appellant, v. MINNESOTA MUTUAL LIFE INSURANCE COMPANY, Defendant-Appellee.|
|Case Date:||December 03, 1999|
|Court:||United States Courts of Appeals, Court of Appeals for the Seventh Circuit|
Argued September 17, 1999
Appeal from the United States District Court for the Northern District of Illinois, Eastern Division. No. 97 C 2256--James B. Zagel, Judge.
[Copyrighted Material Omitted]
Before BAUER, FLAUM and RIPPLE, Circuit Judges.
RIPPLE, Circuit Judge.
Douglas Winter brought this action against Minnesota Mutual Life Insurance Company1 ("Minnesota Life") for disability benefits under his insurance policy. Mr. Winter had worked as a trader in the "pit" of the Chicago Board of Options Exchange ("CBOE"), but became disabled due to headaches and stomach pains, for which Minnesota Life paid him disability benefits. After several months, Minnesota Life discontinued Mr. Winter's benefits because it claimed it had insufficient evidence of his disability. Pursuant to a request for information by Minnesota Life, one of Mr. Winter's doctors stated that Mr. Winter's condition precluded employment while another doctor replied that Mr. Winter reported chronic headaches that interfered with his ability to work. However, Minnesota Life still denied coverage. During this time Mr. Winter began trading stocks and options by computer.
Several months later, Mr. Winter visited a specialist for a throat condition and notified Minnesota Life that he was disabled from pit trading due to his throat problem. Minnesota Life denied Mr. Winter benefits and stated that his throat problem did not prevent him from computer trading and that he was not disabled.
Minnesota Life argues that Mr. Winter's regular occupation is that which he was doing at the time of his sickness: computer trader. Because his throat problem does not affect his computer trading, Minnesota Life maintains that he is not disabled. Conversely, Mr. Winter argues that his regular occupation is the one listed in his policy: pit trader. He argues that his throat problem prevents his work as a pit trader and that he is therefore disabled. Alternatively, he claims that his sickness continued past the date determined by Minnesota Life and, therefore, he should recover his benefits.
The district court granted summary judgment for Minnesota Life and found that Mr. Winter's regular occupation was the occupation he was engaged in at the time of his sickness. Because at that time he was computer trading, which a throat condition does not affect, the court determined that Mr. Winter was not disabled. The court did not address whether Mr. Winter's stomach and head pains continued past the date determined by Minnesota Life.
We believe the term "regular occupation," as defined in Mr. Winter's insurance policy, is unambiguous and is the occupation Mr. Winter was employed in at the time of his sickness. However, we also believe Mr. Winter presented a triable issue of fact on the issue of the continuation of his disability. Mr. Winter may be able to convince the trier of fact that his stomach and head pains continued past the date determined by Minnesota Life, thus allowing him benefits for a continuing or recurrent disability. Therefore, we reverse the district court decision and remand for reconsideration in light of our following opinion.
Mr. Winter obtained a disability insurance policy with Minnesota Life in 1983. In his application for the policy, Mr. Winter listed his occupation as a stock options trader.2 He kept that occupation for
the next 12 years. As a stock options trader, he traded options in the pit at the CBOE. In the pit, he used his voice and hands to make trades.
At the outset of our consideration of this case, we set forth the provisions of the disability insurance policy3 that determine the scope of Minnesota Life's obligations to its insured, Mr. Winter.4
The policy explains that "[w]henever we use the word 'disability' or 'disabled' in this policy we mean that due to sickness or injury you are unable to perform the substantial and material duties of your regular occupation."5 R.19, Ex.1 at 5. The policy defines "sickness" as "a disease or illness which is treated or diagnosed while this policy is in force." R.19, Ex.1 at 6. The policy also defines the words "regular occupation." It states that "[w]henever we use the words 'regular occupation' in this policy, we mean your occupation or profession, including your specialty as listed in the Specialty Endorsement attached to this policy." R.19, Ex.1 at 8.
The policy further provides that if Mr. Winter becomes disabled, but enters a different occupation while still disabled, he will continue to receive the benefits from his original occupation. The policy states:
What if you engage in a different occupation while you are still disabled?
If you work on a part-time or full-time basis in a different occupation while you are still disabled, you will continue to be eligible to receive the full monthly income benefit, regardless of your earnings in that new occupation.
R.19, Ex.1 at 7. Similarly, the policy explains:
What if you engage in your regular occupation while you are still disabled?
If you work in your regular occupation while you are still disabled, you will be eligible to receive a benefit, if you are unable, due to your continuing disability, to earn from your regular occupation more than 50% of your prior average earned income.
R.19, Ex.1 at 7.
Finally, the policy states that if the insured has a recurrent disability he can relate the second period of disability back to the first and recover benefits under the terms of the initial disability. Under the policy, "[a] recurrent disability is a period of disability which results from the same or related cause or causes as a previous period of disability." R.19, Ex.1 at 10. The benefits to be paid for a recurrent disability are listed in the policy as follows:
What benefits will be paid for a recurrent disability?
If, following a period of disability, you return to or are able to return to your regular occupation for a continuous period of six months or more, any recurrent disability will be considered a new disability. However, if you engage in your regular occupation for less than six months, any recurrent disability
shall be considered a continuation of the preceding period of disability.
R.19, Ex.1 at 10.
Beginning in 1991, Mr. Winter experienced almost daily headaches. His general physician, Dr. Rosenbaum, referred him to Dr. Heller, a neurologist. Dr. Heller could not pinpoint the exact cause of the pain, but stated that it was consistent with muscle contraction or tension headaches and recommended a mild treatment for Mr. Winter. Notably, Dr. Heller also observed and documented Mr. Winter's mild hoarseness, probably due to Mr. Winter's occupation. From 1991 through 1995, Dr. Heller treated Mr. Winter several times per year for his headaches.
In 1993, Mr. Winter began experiencing stomach pains in addition to his headaches. In 1994, again on referral from Dr. Rosenbaum, Mr. Winter visited Dr. Sparberg, a gastroenterologist. This physician noted that Mr. Winter's stomach pains prevented him from sleeping on his stomach, that the pain worsened when he was nervous, and that his stomach felt better on the weekends.
On March 8, 1995, Mr. Winter stopped working in the pit at the CBOE because of his head and stomach pains. He informed Minnesota Life of his ailments and of his inability to perform at his job. Minnesota Life then requested doctors' reports, to which Drs. Rosenbaum, Heller, and Sparberg replied.
On the form supplied by Minnesota Life, the general physician, Dr. Rosenbaum, listed Mr. Winter's disability as head pain and abdominal pain. His report stated, in truncated and somewhat confusing fashion, that the disability was possibly related to Mr. Winter's employment, that Mr. Winter was not disabled from his regular work, but that he was disabled from other gainful work. Also, Dr. Rosenbaum wrote that he did not expect a change in Mr. Winter's condition in the future because Mr. Winter's stress and job would not change.
The neurologist, Dr. Heller, reported Mr. Winter's disability as headaches, "mental fogginess," and fatigue. He attributed this condition to Mr. Winter's employment and also remarked that Mr. Winter believed his symptoms related directly to his work activities.
Finally, the gastroenterologist, Dr. Sparberg, described Mr. Winter's disability as a spastic stomach. Based on one visit with Mr. Winter in 1994, he marked Mr. Winter as disabled from his regular work, but with the expectation of improvement in his condition within 4-6 months. He also explained that Mr. Winter's stress- induced abdominal pain was not "amicable" to Mr. Winter's regular work.
Based on these physicians' reports, Minnesota Life allowed Mr. Winter's claim and related the claim back to the date he had stopped working in March. However, in an October 5, 1995 letter, Minnesota Life informed Mr. Winter that it would not continue his benefits past August 31, 1995, and stated that the information provided to Minnesota Life did not substantiate his disability beyond those periods already paid, March 8 to August 31. Minnesota Life advised Mr. Winter that it would request information about Mr. Winter's condition from Drs. Rosenbaum and Heller and further apprised Mr. Winter that his claim remained open pending the physicians' replies.
The general physician, Dr. Rosenbaum, responded to Minnesota Life's request and stated that...
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