Opinion ID: 163688
Heading Depth: 1
Heading Rank: 1

Heading: facts

Text: In 1971 Reiner, a self-employed court reporter, obtained group disability insurance made available to members of the National Court Reporters Association (NCRA). During the twenty-eight year period Reiner paid premiums for disability insurance through NCRA, the group was insured by a number of different -2- carriers. Effective August 1, 1998, USLIC replaced Allianz Life and issued NCRA a new group disability policy. USLIC’s policy contains the following provisions relevant to this appeal: ELIGIBILITY ELIGIBLE CLASSES All persons who: • are members in good standing with the National Court Reporters Association; • are actively at work on a full-time basis; and • were insured under the prior plan [defined elsewhere in the policy] on July 31, 1998. .... DATE INSURANCE ENDS A person’s insurance will end at the earliest of: .... 3. the date the person ceases full-time employment for reasons other than total disability. Jt. App., Vol. I at 112. DEFINITIONS ACTIVE WORK or ACTIVELY AT WORK means that a person performs, in his customary manner, each duty of his occupation for full pay. This must be done at the person’s customary place of employment or business or any place to which such employment or business requires the person to travel. -3- FULL-TIME means active work on a regular work schedule that must be at least 30 hours a week. Id. at 111. USLIC also issued a certificate of insurance in connection with the policy. It contains the above definitions and the above-quoted provision regarding when insurance ends, but it does not include the provision denominated “Eligible Classes.” Id. at 130. Reiner did not receive a copy of this certificate of insurance until November 1999, after his claimed onset of disability. Id., Vol. II at 487. An insurance certificate issued in 1991 by Allianz Life, however, contains substantially similar provisions conditioning coverage on the insured’s continuing to work thirty hours per week at his customary place of employment or at a location where he is required to travel. Id., Vol. I at 21-22. Reiner acknowledges receiving a copy of this certificate at some time prior to 1994, and an addendum to the certificate in 1994. Id. Vol. I at 277; Vol. II at 487. USLIC’s policy provides for two forms of disability benefit. First, if the insured becomes totally disabled, he is entitled to a long-term disability benefit of $150 per month for a period of twelve months. Second, if after payment of such benefits for twelve consecutive months, the insured is suffering a disability involving the loss of sight, speech, hearing, or use of hands, the insured is entitled to an additional benefit. -4- After injuring his hand, Mr. Reiner made a claim for benefits. He was quickly approved for the $150 per month disability payments. But after he made a further claim for the $50,000 permanent disability benefit for loss of use of his hand, USLIC required him to undergo an independent medical examination. Based on his comments to the physician and other information that he submitted, USLIC determined that he had not met the thirty-hour-per-week requirement for full-time employment during the time the policy was in effect, and was therefore not entitled to the additional disability benefit. This action followed.