The Court concludes that the policy must be interpreted to provide benefits to age 65 for the type of disability suffered by Akins.
The policy clearly provides for benefits to age 65 for all disabilities that are the "result of" physical injury, not merely for physical disabilities. Similarly, the policy limits benefits to 24 months for disabilities "caused by . . . a mental or nervous disease or disorder," not for mental disabilities caused by physical injury.
Ambiguities in an insurance contract must be resolved against the insurer, the drafter of the policy. Continental Casualty Co. v. Beelar, 132 U.S. App. D.C. 1, 405 F.2d 377, 387 (D.C.Cir. 1968). If there are several reasonable interpretations of a policy, the Court should generally adopt the one favoring coverage. Id. See also Carley Capital Group v. Fireman's Fund Insurance Co., 278 U.S. App. D.C. 143, 877 F.2d 78, 81 (D.C.Cir. 1989) (interpreting Pennsylvania law).
The policy provisions, from Mutual's side, are at best ambiguous. They appear to cover mental disabilities caused by physical injury. Certainly that is a reasonable interpretation of the policy. Therefore, the policy must be read to cover Akins' disability to age 65. The stabbing -- a physical injury -- triggered Akins' mental disability. See Prince v. United States Insurance Co., 42 Misc. 2d 410, 248 N.Y.S.2d 336 (N.Y.Sup.Ct. 1964), aff'd, 23 A.D. 2d 723, 257 N.Y.S.2d 891 (1965), aff'd, 17 N.Y. 2d 742, 270 N.Y.S.2d 209, 217 N. E. 2d 33 (1966).
For the foregoing reasons Akins is entitled to summary judgment against Mutual on his contract claim. In light of Mutual's liability on the contract, WMATA is entitled to summary judgment on Akins' contract claim against it.
Akins' complaint sought damages amounting to the total benefits he would have received had he been paid under the policy from January 1986 until his 65 birthday in 1994. However, the Court concludes that the proper remedy must be partly equitable in nature.
Under the terms of the policy, Akins must periodically be reexamined at Mutual's request to determine if he is still disabled. The possibility that he might overcome his disability or die before 1994 requires that Mutual be directed to restore Akins to the benefit rolls, as of January 1986, not pay him a lump sum for future coverage.
Only benefits from January 1986 to the present, plus interest, must be paid now. Mutual may not avoid liability for these past benefits by arguing that Akins was not disabled for all or part of the period, because Akins cannot be expected to reconstruct his past, and Mutual's erroneous interpretation is responsible for the present situation. Mutual's obligation to pay future benefits, however, is dependent upon Akins' continued disability. A requirement by Mutual that Akins obtain a prompt medical examination, like that required of other beneficiaries, to determine continued eligibility is not unreasonable.
Considering the unusual circumstances of this case, the parties shall bear their own costs.
Akins and Mutual are directed promptly to submit a joint Form of Judgment to the Court fixing the amounts Mutual owes Akins and the schedule for payment.
A separate Order accompanies this Memorandum.
ORDER -- January 26, 1990, Filed
Upon consideration of the cross-motions for summary judgment and the oppositions thereto, and for the reasons stated in the accompanying Memorandum, it is hereby
ORDERED that plaintiff Mark Akins' Motion for Summary Judgment is denied as to the claims in Count I and II of the complaint and granted as to the claim in Count III; and it is further
ORDERED defendant Washington Metropolitan Area Transit Authority's ("WMATA") Motion for Summary Judgment is granted; and it is further
ORDERED that defendant Mutual Benefit Life Insurance Company's ("Mutual") Motion for Summary Judgment is granted as to Count II and denied as to Count III; and it is further
ORDERED that Mutual shall immediately restore Akins to the rolls of persons covered pursuant to his Mutual long-term disability insurance policy; and it is further
ORDERED that Mutual shall pay Akins a lump sum equalling the benefits that would have been provided Akins had he remained on the benefit rolls to the present time plus interest; and it is further
ORDERED that the parties shall bear their own costs; and it is further
ORDERED that Akins and Mutual shall promptly submit a joint Form of Judgment to the Court fixing the amounts owed and the schedule for payment.