Heller v. Equitable Life Assurance Society of the United States

United States Court of Appeals for the Seventh Circuit

833 F.2d 1253 (7th Cir. 1987)

An insurance policy that requires an insured to be under a physician’s care does not also require the insured to undergo surgical treatment for the condition that causes the disability in order to receive benefits.

Relevant Facts

Stanley Heller is a doctor specializing in invasive cardiology (the plaintiff). The plaintiff was issued a disability-income policy from Equitable Life Assurance Society of the United States (the defendant) in 1983. The policy provided $7,000 per month to the plaintiff in the event he became totally disabled. “Total disability” was defined in the policy as “the complete inability of the Insured, because of injury or sickness, to engage in the Insured's regular occupation, … provided, however, the total disability will not be considered to exist for any period during which the Insured is not under the regular care and attendance of a physician.” That same year, the plaintiff developed carpel tunnel syndrome and as a result, could not continue practicing invasive cardiology. Subsequently, the plaintiff applied for benefits under his disability-income policy with the defendant. The defendant paid the policy out until 1985, when they ceased payments on the grounds that the plaintiff refused to undergo recommended surgery to fix his carpel tunnel syndrome. The defendant reasoned that the plaintiff’s refusal meant that he was no longer under a physician’s care and was therefore no longer “totally disabled” under the policy. The plaintiff sued, seeking a declaratory judgment under a theory of breach of contract. The trial court found for the plaintiff, holding that he was entitled to receive the monthly disability-income payments under the policy. The defendant appealed.

Issue

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Holding & Reasoning

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Concurrence

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Dissent

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Last updated:

December 20, 2020

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Procedural History

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Citations

833 F.2d 1253 (7th Cir. 1987)