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Gibbons v. Mony Life Insurance Co.

United States District Court, N.D. Illinois, Eastern Division

September 22, 2016




         Clifford Gibbons alleges that he has not received certain benefits owed to him under his disability insurance policy. He has sued MONY Life Insurance Company, the issuer of the policy, and Disability Management Services, Inc. (DMS), the policy's administrator. In a prior order, the Court dismissed as time-barred Gibbons' claims for negligence and reformation. His remaining claims against both defendants are for breach of contract and for a declaratory judgment regarding his entitlement to certain benefits. He also asserts a claim against DMS for intentional infliction of emotional distress based on DMS' allegedly abusive conduct following Gibbons' benefits request.

         Gibbons became disabled as a result of two heart attacks he suffered in 2013, and a pivotal issue in connection with the breach of contract and declaratory judgment claims is whether the disability resulting from Gibbons' heart attacks is "due to" an "injury, " as opposed to a "sickness, " under the terms of his insurance policy. Gibbons concedes that his remaining claims cannot succeed if the Court determines that his disability was due to sickness. Before the parties engage in extensive discovery regarding those claims, Gibbons has moved for partial summary judgment on the issue to allow the Court to address this threshold legal question. For the reasons discussed below, the Court concludes that, under the terms of his policy, Gibbons' disability was due to "sickness." The Court thus denies Gibbons' motion for summary judgment.


         Gibbons' primary disability insurance policy provides benefits through age 65, but pursuant to an attachment or "rider" to the policy entitled "Lifetime Benefit Period Extension, " his benefits continue beyond age 65 and throughout his lifetime if certain conditions are met. In particular, the rider provides:

Lifetime Benefit - We will extend the Benefit Period of this Policy and pay to you the monthly income benefit under this rider if, while this Policy is in force:
(a) an Incapacity, as defined in this Policy, due to Injury commences prior to your Age 65, or
(b) an Incapacity, as defined in this Policy due to Sickness commences prior to your Age 60, and continues uninterrupted from its Onset Date. These monthly payments will begin at the later of (1) your Age 65, (2) the end of the Excluded Period satisfied by such Incapacity, and (3) the end of this Policy's Benefit Period, and continue for your lifetime or until the Incapacity is interrupted or ends.

Ex. A to Pl.'s Compl. at 12. Under the policy, an "Incapacity" exists when the insured is "not able to perform the substantial and material duties of [his] Regular Occupation" and is under a physician's regular care. Id. at 5. The term "Injury" is defined as "accidental bodily injury sustained while this Policy is in force." Id. And the term "Sickness" is defined as "sickness or disease which first manifests itself while this Policy is in force."


         It is undisputed that Gibbons became disabled-that his "Incapacity commenced, " to use the rider's terms-in April 2013 when he had a heart attack at age 62. What is in dispute is whether his incapacity is properly classified as being "due to injury" or instead due to "sickness." If the incapacity was due to sickness, as defendants contend, then Gibbons is not entitled to the lifetime benefit extension, because he became disabled after age 60. But if the incapacity was due to injury, as Gibbons contends, then he does qualify for lifetime benefits, because the disabling injury occurred prior to age 65.

         In arguing that Gibbons' disabling heart attack was due to sickness (and not injury), defendants point out that Gibbons' heart surgeon diagnosed him with coronary artery disease and that his disability was thus clearly the result of a diagnosable disease or "sickness" under the terms of his policy. For his part, Gibbons asserts that work-related stress, not coronary artery disease, induced the heart attack. To obviate (at the parties' request) the need for extensive discovery at this juncture regarding the underlying cause of Gibbons' heart attack, the Court asked the parties to assume for purposes of argument that Gibbons was correct on the causation issue and limit the scope of their briefing on Gibbons' summary judgment motion to the following question: whether an insured who is disabled by a heart attack that is indisputably induced by stress is, under the terms of Gibbons' policy, disabled due to injury or due to sickness?

         In ruling on Gibbons' motion, as just indicated, the Court assumes the truth of his assertions concerning the work-related stressors that he says induced his heart attack. In particular, Gibbons points to three "significant and unusually stressful events" that contributed to a stressful work environment in the spring of 2013, prior to his first heart attack. Pl.'s Resp. to Defs.' Stmt. of Add'l Mat. Facts ¶ 21 (citing Ex. B to Defs.' Stmt. of Add'l Mat. Facts ¶ 13). At that time, Gibbons was working as president of Gibbons & Company, a Washington, D.C. lobbying firm. He explains that the shutdown of the Federal government and Congress' failure to pass routine appropriations bills in the spring of 2013 adversely affected government funding for one of the firm's significant clients. As a result, Gibbons had to work "around the clock" in a highly stressful environment to assist this particular client with fundraising. Id. During the same time period, a foreign government froze the assets and bank accounts and confiscated the products of another of Gibbons' major clients. This development required Gibbons to meet with senior United States government officials and foreign ambassadors to attempt to retrieve the hundreds of millions of dollars at stake for the client. Also during that time, a third client faced problems with business operations related to regional trade in another foreign country, a problem which Gibbons says would require quick implementation of strategies to resolve. It was in the midst of these three concurrent crises that Gibbons suffered his first heart attack in April 2013.

         Following his heart attack, Gibbons underwent heart surgery, including the implantation of two heart stents, and he remained in the hospital's intensive care unit for three days following the surgery. Gibbons returned to work, and to his "relentless work schedule, " immediately after leaving the hospital, and he then suffered a second heart attack in June 2013. Id. In April 2015, DMS issued a letter to Gibbons advising him that, under the terms of his policy, his heart attack constituted a "sickness" and not an "injury, " and that as a result he was not entitled to lifetime benefits under the policy. As ...

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