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Parties Involved:
Eric Berg
Appellant
New York Life Insurance Company
Appellee
Unum Life Insurance Company of America
Appellee

Document Text:

In the 

United States Court of Appeals 

For the Seventh Circuit ____________________

No. 15‐1410

ERIC BERG,

Plaintiff‐Appellant,

v.

NEW YORK LIFE INSURANCE COMPANY and UNUM LIFE

INSURANCE COMPANY OF AMERICA,

Defendants‐Appellees.

____________________

Appeal from the United States District Court for the

Northern District of Illinois, Eastern Division.

No. 11 C 7939 — Milton I. Shadur, Judge.

____________________

ARGUED NOVEMBER 6, 2015 — DECIDED JULY 27, 2016

____________________

Before WOOD, Chief Judge, and POSNER and EASTERBROOK,

Circuit Judges.

WOOD, Chief Judge. Eric Berg brought this breach of con‐

tract action when New York Life, through its administrator

Unum, refused to pay him disability benefits. At bottom, this

case turns on the meaning of one phrase: “requires and re‐

ceives regular care by a Physician.” Does the clause contain a

temporal element? The insurers say yes, and the district court

Case: 15-1410 Document: 39 Filed: 07/27/2016 Pages: 9
2 No. 15‐1410

agreed, granting them summary judgment. But it certainly

says nothing about timing on its face, and we can find no

other sign that such a requirement was meant to be engrafted

onto the phrase. Applying the basic principle that the lan‐

guage must be construed against the insurers, we reverse the

judgment of the district court.

I

Born in 1959, Eric Berg was a long‐time pit broker at the

Chicago Mercantile Exchange. In 1991 and 1994, Berg bought

two disability‐income insurance policies underwritten by

New York Life. In 2005, he started to experience a tremor in

his arms and hands. The tremor interfered with his ability to

write quickly and legibly, and in September 2007, the tremor

forced him to leave his job. In February 2010, a neurologist

diagnosed Berg with an “essential tremor,” and Berg applied

for total disability benefits.

Although New York Life and Unum approved Berg’s

claim on July 2, 2010, they designated his disability onset date

as February 3, 2010, rather than September 2007. Then, in

April 2012, Unum discontinued Berg’s total‐disability bene‐

fits. It asserted that he was eligible only for residual‐disability

benefits because when he applied, his regular occupation was

that of an “unemployed person.” Berg sued, seeking benefits

dating from September 2007 and a designation of “total disa‐

bility” for the purpose of future benefits. The district court

granted summary judgment to the defendants. Berg ap‐

pealed.  

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No. 15‐1410 3

II

We review the district court’s decision to grant summary

judgment de novo, construing the facts in the light most favor‐

able to the non‐moving party—here, Berg. See Jaburek v. Foxx,

813 F.3d 626, 630 (7th Cir. 2016). Summary judgment is appro‐

priate only when there is no dispute of material fact and the

moving party is entitled to judgment as a matter of law. FED.

R. CIV. P. 56(a).

A

Before turning to the merits, we address the insurers’ no‐

tice defenses, which are dispositive if well taken. Berg does

not contest that his Notice of Claim and Proof of Loss submis‐

sions were untimely. Country Mut. Ins. Co. v. Livorsi Marine,

Inc., 856 N.E.2d 338, 343 (Ill. 2006). He asserts, however, that

the insurers waived these defenses.

In their answer to Berg’s first amended complaint, the in‐

surers raised the argument that Berg failed to comply with the

policies’ Notice of Claim or Proof of Disability or Loss provi‐

sions. They reiterated this point in their response to Berg’s

oddly styled “motion to narrow the issues” under Federal

Rule of Civil Procedure 16. This is not a use of Rule 16 that we

recognize. Rule 16, entitled “Pretrial Conferences; Schedul‐

ing; Management,” guides (not surprisingly) case manage‐

ment—it is not a tool for resolving dispositive motions,

whether under Rule 12(b) or Rule 56. Perhaps that is why the

district court’s rulings were silent on the insurers’ notice de‐

fenses. No matter: at that point, the insurers appear to have

abandoned this tack. In their summary judgment motion, the

insurers expressly relied upon the district court’s reasoning in

its previous opinions, but they did not bring up notice. We

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4 No. 15‐1410

agree with Berg, therefore, that the notice defenses are

waived. See D.S. v. E. Porter Cnty. Sch. Corp., 799 F.3d 793, 800

(7th Cir. 2015) (arguments not raised in motion for summary

judgment are waived).

B

On to the main event: interpreting the insurance policies.

The parties agree that Illinois law governs here. Our primary

goal in interpreting an insurance policy “is to give effect to the

intent of the parties as expressed in the agreement.” DeSaga v.

W. Bend Mut. Ins. Co., 910 N.E.2d 159, 163 (Ill. App. Ct. 2009).

Where “the terms of an insurance policy are clear and unam‐

biguous, they must be given their plain and ordinary meaning

and enforced as written, unless to do so would violate public

policy.” Id. If a word is specifically defined in the policy, that

meaning controls. Am. Nat. Fire Ins. Co. v. Nat’l Union Fire Ins.

Co. of Pittsburgh, PA, 796 N.E.2d 1133, 1141 (Ill. App. Ct. 2003).

On the other hand, if the policy language is “susceptible to

more than one reasonable meaning,” an ambiguity exists and

it will be construed against the insurer. Gillen v. State Farm

Mut. Auto. Ins. Co., 830 N.E.2d 575, 582 (Ill. 2005).  

In determining whether a provision is ambiguous, we

read the policy in light of “the insured’s reasonable expecta‐

tions and the policy’s intended coverage.” Gen. Star Indemn.

Co. v. Lake Bluff Sch. Dist. No. 65, 819 N.E.2d 784, 793 (Ill. App.

Ct. 2004). A court should not “strain to find an ambiguity

where none exists.” Founders Ins. Co. v. Munoz, 930 N.E.2d 999,

1004 (Ill. 2010). Neither should it “adopt an interpretation

which rests on ‘gossamer distinctions’ that the average per‐

son, for whom the policy is written, cannot be expected to un‐

derstand.” Id. (quoting Canadian Radium & Uranium Corp. v.

Indem. Ins. Co. of N. Am., 104 N.E.2d 250, 255 (Ill. 1952)). “Any

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No. 15‐1410 5

provision in a policy that limits or excludes coverage must be

construed liberally in favor of the insured and against the in‐

surer,” DeSaga, 910 N.E.2d at 164, and must “be read narrowly

and will be applied only where its terms are clear, definite,

and specific.” Gillen, 830 N.E.2d at 582.  

1

The insurers argue that Berg did not meet the policy’s def‐

inition of “total disability” until he saw a physician on Febru‐

ary 3, 2010. They point out that under the policies, “Total Dis‐

ability means that the Insured can not [sic] do the substantial

and material duties of his or her regular job.” The definition

further stipulates that “[t]he cause of the total disability must

be an injury or a sickness.” Elsewhere in the policies, “Injury”

is defined as “an accidental bodily injury of the Insured.” In

the same provision, “Sickness” is defined as “an illness or dis‐

ease of the Insured.”

The Injury and Sickness provision sets out several require‐

ments. One is that “[t]he injury or sickness must be one which

requires and receives regular care by a Physician.” The insur‐

ers contend that because Berg did not receive “care by a Phy‐

sician” for his tremor until February 3, 2010, he did not have

an “illness or sickness” until that date. Because the “cause of

the total disability must be an injury or a sickness,” they con‐

tinue, Berg was not totally disabled for policy purposes until

February 3, 2010.

This syllogism might hold up in the rarified atmosphere

of formal logic, but it disintegrates when exposed to the cor‐

poreal world. To begin with the obvious, neither of these pro‐

visions contains any temporal element. There is no reason to

think that either of them demands that the injury or sickness

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6 No. 15‐1410

have required and received the care of a physician at any

point except when the insured makes the claim. Both are writ‐

ten in the present tense. If the insurers had wanted the defini‐

tions to have force at any moment before the one at which the

relevant claim was adjudicated, they could easily have in‐

cluded language to that effect. They didn’t.

The insurers’ reading is not even the most logical of the

reasonable ones available. First, while there is no temporal

language in the physician‐care requirement, there is in one of

the preceding requirements: that the injury or sickness “first

manifest itself[] while this policy is in force.” If the insurers’

reading were correct, this provision would be surplusage: an

injury or sickness cannot require and receive regular care by

a physician before it manifests itself. “We will not interpret an

insurance policy in such a way that any of its terms are ren‐

dered meaningless or superfluous.” Pekin Ins. Co. v. Wilson,

909 N.E.2d 379, 387 (Ill. App. Ct. 2009).

Moreover, the use of the word “one” in the proviso that

“[t]he injury or sickness must be one which requires and re‐

ceives regular care by a Physician” indicates that the require‐

ment applies to the kind of malady that qualifies as an “injury

or sickness” under the policy, not when it qualifies. The provi‐

sion is thus best read as a description of the class of conditions

that qualify under the policy—not a prerequisite for their on‐

set date.  

In any event, an alternate reading does not have to be the

best one: for ambiguity to exist, there need only be more than

one reasonable interpretation of the provision. Gillen, 830

N.E.2d at 582. Finding ambiguity in the possible temporal ef‐

fect of the provision is unavoidable given the commandments

that (1) the language must be read in light of “the insured’s

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No. 15‐1410 7

reasonable expectations and the policy’s intended coverage,”

Gen. Star, 819 N.E.2d at 793; (2) interpretations may not rest

on picky distinctions that the average person would not un‐

derstand, Munoz, 930 N.E.2d at 1004; and (3) “[a]ny provision

in a policy that limits or excludes coverage must be construed

liberally in favor of the insured and against the insurer,” De‐

Saga, 910 N.E.2d at 164, and must “be read narrowly and will

be applied only where its terms are clear, definite, and spe‐

cific.” Gillen, 830 N.E.2d at 582. Average insureds would pre‐

sume that their benefits will flow from the date that their mal‐

ady became severe enough to prevent them from working or

require medical care, not when they actually went to the doc‐

tor. The provisions at issue do nothing to put them on notice

that this is not the case.

Finally, construing the provisions as the insurers suggest

would create the kind of absurd results we must avoid. U.S.

Fire Ins. Co. v. Hartford Ins. Co., 726 N.E.2d 126, 128 (Ill. App.

Ct. 2000). Under their reading, the existence of an insured’s

“illness or injury” would depend entirely on the date the in‐

sured saw a physician for it; it would change arbitrarily with

no regard for the insured’s bodily condition or ability to work.

Hypochondriacs might find a doctor who spots an illness at

the earliest possible moment, while those who lack the re‐

sources to see doctors regularly might suffer for months or

years and yet not be considered to have an illness or injury.

A few examples illustrate this point. Say, for instance, that

an insured fell down the stairs to his basement, severing his

spinal cord and rendering him a paraplegic. He happens also

to be a doomsday prepper and thus has ample food and water

for an extended period of time. He survives in the basement

for six months until he is discovered. Finally, he is taken to a

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physician and his care begins. According to the insurers, his

injury did not exist, and he was not totally disabled, for those

six months. Or suppose that an insured’s hands were ampu‐

tated in an industrial accident. She would need immediate

care from a physician, but eventually, when there was nothing

more that a doctor could do for her, she would cease receiving

care from a physician. Would she not be totally disabled after

that point? Or what about a woman who discovers a lump in

her breast, but who cannot see a doctor for several months

and only then is told she has Stage 4 cancer? In each of these

cases, it is plain that the person is either disabled or ill without

regard to the timing of the visit to the physician.  

These hypotheticals show why it would have made no

sense to impose a requirement that a physician visit deter‐

mines the time when a disability commenced. Illinois courts

do not read insurance policies in such a counter‐intuitive way.

The insurers suggest there could be some way for these un‐

fortunate individuals to show cause for the late detection, but

this is just another effort to re‐write the policy. There is no

show‐cause exception to the “Injury and Sickness” provision;

it determines basic eligibility. Show‐cause provisions do exist

elsewhere in the policies, in the Notice of Claim and Proof of

Disability or Loss provisions. This is further evidence that the

provisions’ temporal effect is at least ambiguous, and there‐

fore must be construed against the insurers under Illinois law.

Gillen, 830 N.E.2d at 582. If Berg can prove that his essential

tremor prevented him from performing his pit broker duties

in September 2007, then he was disabled under the policies

starting at that time. The facts in the light most favorable to

Berg show just that.

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No. 15‐1410 9

2

Unlike the definitions of “total disability” and “injury and

sickness,” the policies’definition of “regularjob” does contain

a temporal element. “Regular Job” is defined as “[t]he occu‐

pation, or occupations if more than one, in which the Insured

is engaged when a disability starts.”  

The insurers’ argument hangs on the date when Berg be‐

came totally disabled—and thus on the outcome of our anal‐

ysis in the previous subsection. They assert that because Berg

first received care from a physician for his tremor on February

3, 2010, that was the first date on which he was totally disa‐

bled under the policy. They argue that because he was unem‐

ployed on that date, his “regular job” was that of “unem‐

ployed person.” But, as we have just shown, the evidence fa‐

vorable to Berg shows that he met the policies’ definition of

“total disability” when he left his job as a pit broker at the

Chicago Mercantile Exchange. If that is accepted by the trier

of fact, then his “regular job” under the policies was that of a

pit broker.  

III

Unum contends that it is not properly joined as a defend‐

ant to this action. But the defendants did not include this ar‐

gument in their motion for summary judgment, and it is

therefore waived. See D.S., 799 F.3d at 800. All that remains,

therefore, is to REVERSE the district court’s judgment and

REMAND for proceedings consistent with this opinion.  

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