Court: Louisiana Court of Appeal; May 30, 2012; Louisiana; State Appellate Court
Kenneth N. Hawkins appeals a summary judgment favoring UNUM Life Insurance Company regarding the payment timing of two long-term disability policies. Hawkins, a Louisiana attorney, sustained neck and lower back injuries from an automobile accident on October 3, 1998. Following the accident, he received conservative treatment but continued practicing law until closing his practice in May 1999. Hawkins held two policies from UNUM: a policy effective November 1, 1994 (the '94 policy) and another effective July 20, 1998 (the '98 policy). UNUM requested an independent medical examination (IME) by Dr. Jack E. Hurst, who concluded Hawkins was not disabled. However, subsequent medical evaluations revealed a herniated disc, leading to surgery by Dr. Cobb on November 2, 1999. Dr. Corzatt later assessed that recovery would typically take three to six months and suggested Hawkins could potentially return to part-time work. Hawkins also underwent lumbar fusion in July 2000. The policies stipulate a thirty-day notification period following the onset of disability and a ninety-day period for proof of claim. The definition of 'disability' under the '94 policy indicates that it applies when the insured cannot perform the essential duties of their occupation, while 'partial disability' allows for some work capacity under specified conditions. The calculation for partial disability benefits is based on the difference between pre-disability income and current earnings, adjusted per policy terms.
The '98 policy distinguishes between 'partial disability' and 'residual disability,' with the latter defined as the insured's inability to perform significant duties of their occupation or to do so for the required time due to Injury or Sickness. For residual disability benefits, the insured must be under regular care from a licensed physician, and benefits are not available if income loss is less than 20%. Income loss is assessed by comparing the insured's income from the 24 months prior to the disability with income during the claimed residual disability months. A decline of less than 20% results in no benefits, while a decline over 80% qualifies for 100% benefits. Hawkins filed for benefits in August 1999 and later sued UNUM on December 23, 1999, for failing to pay total disability benefits, seeking double indemnity penalties and attorney fees. During the litigation, UNUM paid Hawkins $30,400 for total disability from January 31 to July 2, 2000, and $78,000 from January 2, 2004, to March 2, 2006, but indicated the latter payment was for residual disability benefits at 100% for a previous period. The case progressed slowly until UNUM filed a motion for summary judgment in March 2007. Hawkins had previously filed a motion for summary judgment in 2000, which was denied, and then re-urged it in 2011. The trial court ultimately granted summary judgment in favor of UNUM and denied Hawkins’ motion, leading to Hawkins’ appeal. In his appeal, Hawkins argues that the trial court erred in denying his motion, failing to refer the matter to trial, and granting UNUM’s motion. The appellate court reviews summary judgments de novo, adhering to the standards set forth in La. Code Civ. P. arts. 966 and 967, where the burden lies with the mover to demonstrate a lack of factual support for essential elements of the opposing party’s claims.
If the adverse party does not provide sufficient factual support to meet their evidentiary burden at trial, there is no genuine issue of material fact. In this case, UNUM's motion for summary judgment argued that Hawkins' claims should be dismissed due to reasonable suspicion that he was only partially disabled, necessitating a comparison of his pre- and post-disability income. Although UNUM claimed it did not receive Hawkins' 1999 tax returns until 2005, it paid him benefits for total disability for a period in 2000 without these returns. Hawkins contended he had submitted his 1997 and 1998 tax returns, asserting that the policies specified benefits should be based on income from the calendar year preceding his disability. He argued that UNUM's delay in payment was arbitrary and violated La.R.S. 22:1821 since the 1999 returns were not relevant for determining his benefits.
The court found that genuine issues of material fact existed regarding the timing of UNUM's payments and whether Hawkins was owed additional benefits. Particularly concerning was the payment made in 2000, as it occurred shortly after Hawkins' cervical surgery, despite UNUM’s own medical examiner indicating he would be disabled post-surgery. The payments recorded did not cover the entire period of disability as predicted by the examiner. Consequently, the court concluded that summary judgment was inappropriate, impacting both UNUM's and Hawkins' motions for summary judgment. The judgment in favor of UNUM was reversed, with all costs of the proceedings assigned to UNUM, while the dissenting opinion noted additional reasoning.
