Whether you live in Grand Prairie, Fort Worth, Dallas, Weatherford, Arlington, Mansfield, Irving, or anywhere else in the state of Texas, too many times when making a claim for insurance benefits, you are forced to hire an attorney. An experienced Insurance Law Attorney is valuable for recovering monies due under an insurance policy and a disability insurance policy in particular.
An example of the above in noted in a 1966 case that was decided by the Houston Court of Appeals. The style of the case is Continental Casualty Company v. Walter Earl Vaughn. Here are a lot of facts in this case.
The evidence showed that on April 10, 1962, Vaughn wrote Continental a letter stating he had sustained a back injury on March 30, 1962, and that he was in Leggett Memorial Hospital, and did not know how long he would be hospitalized or unable to work. Vaughn returned a standard claim form he had been sent, reporting that he had “a back injury in the nature of a ruptured disc that occurred on March 30, 1962 while loading a load of tubing on a truck in Houston.” The same report contained a statement by Vaughn’s doctor saying Vaughn had a ruptured intervertebral disc between Lumbar 4 and Lumbar 5; that the accident occurred on March 30, 1962; that Vaughn first consulted the doctor on April 1, 1962; and that Vaughn was to have a spinal fusion. Continental sent a one month’s indemnity and a thirty days’ hospital indemnity. The indemnity continued for another month after another claim form was filed.
Continental then sent an inquiry to the hospital to examine the record of Vaughn. In response Continental received a history stating “patient was lifting a pipe and felt sudden pain in lower back with radiation to left leg.” Another report showed Vaughn was injured “while unloading my truck with a load of tubing. I picked up a joint of tubing, rupturing a disc in my back. It happened about 4 p.m.”
Continental did not question that Vaughn had injured his back. Continental questioned “Was it an accidental injury?” Its definition of “injury” according to its representative was “an abnormal, localized condition of the body that is not caused by an existing illness or disease process”: whereas the policy defined “injury” as a “bodily injury caused by an accident and resulting directly and independently of all other causes, in loss ….”
On July 13, 1962, a Continental representative wrote Vaughn explaining that his description of how his disability occurred indicated that such disability was not the result of an accident, and that benefits were, therefore, not payable. Thus, Continental denied liability on the basis that what had happened to Vaughn could not be considered an accident.
Continental took the position that the occurrence in question was not an accident since Vaughn in lifting the pipe was doing what he intended to do, and hence any bodily injury sustained by him was not the result of an accident.
To make matters worse, Continental was telling Vaughn to return the money that he had already received.
The disability policy is this case, which was in 1962, paid benefits of $100 per month for the rest of Vaughn’s life.
This case went to trial and a jury found in favor of Vaughn. The jury awarded $29,200 on the policy and attorney’s fees of $8,850. The trial judge reduced the $29,200 to $14,246. This was based on the present current value of the award. The court also awarded 12% penalty on 43 past due accrued monthly installments and 6% interest thereon.
It is worth noting that today, 2011, the Texas Insurance Code, Section 542.060 requires an 18% penalty rather than the 12% that existed when this case was decided. Further, the present law allowing for more ways of financially punishing the insurance company for conduct that is committed “knowingly” or “intentionally” as those terms are defined in the insurance code. Per section 541.152, the “trier of fact may award an amount not to exceed three times the amount of actual damages.”
Updated: