QUEEN'S BENCH DIVISION
Strand London WC2 |
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B e f o r e :
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SIMON ANTHONY EARL |
Claimant |
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and |
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CANTOR FITZGERALD INTERNATIONAL |
Defendant |
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Mr. David Foskett Q.C. and Mr. Gordon Wignall instructed by Olswang appeared for the defendant.
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Crown Copyright ©
The Hon. Mr. Justice Moore-Bick
The Rules governing the Scheme
"GENERAL RULES
2. DEFINITIONS
"Incapacitated Member" means . . . . . . . . . .
A. (b) In respect of a member who is not required to hold a licence as above, Incapacitated Member shall mean that the Member while in Service and before Terminal Date is totally unable by reason of sickness or accident to follow his Occupation and is not following any occupation except as provided under the reduced benefit provision of General Rule 6(b).
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"Member" means a person who has been admitted to membership of the Scheme and remains for the time being in membership in accordance with these Rules.
"Occupation" means the occupation of a Member immediately prior to incapacity.
"Service" means continuous active service with the Employer and includes any period while benefit is payable . . . . . . . . . . . .
3. ADMISSION TO MEMBERSHIP
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(d) An employee who is to be included in the Scheme shall furnish such information (including proof of age) in such form and at such times as the Principal Employer and/or the Insurer may request. Any misrepresentation including mis-statement of age may affect any entitlement to benefits under the Scheme.
4. EVIDENCE OF HEALTH
(a) When an employee becomes a Member or becomes eligible to be covered under the Scheme for an increased amount of benefit, commencement of or increase in his benefit shall be subject to such evidence of active employment in his usual occupation and/or of insurability, including evidence of health, as the Insurer shall specify. If the employee is not actively employed and working the normal basic hours in his usual basic occupation because of illness or injury the benefit or increase therein will become effective only when he returns to such occupation with the approval of his medical adviser and any evidence of health and insurability requirements of the Insurer are fulfilled.
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6. DESCRIPTION OF BENEFIT
(a) If a member becomes a totally Incapacitated Member the benefit under Special Rule C shall become payable to him on completion of the Deferred Period and shall continue to be paid for so long as he remains an Incapacitated Member subject always to the terms and provisions of these Rules.
(b) If after becoming an Incapacitated Member within base A(b) . . . . . and having completed the Deferred Period a Member with medical consent either adopts or has adopted a different and less well paid occupation or returns or has returned to his Occupation or any occupation on a part-time basis, or partially follows his Occupation at a lesser rate of pay, or is undertaking any work either on an unpaid basis or for less than the market rate of pay, then provided that in all other respects he remains an Incapacitated Member benefit in respect of him under Special Rule C shall commence or continue to be payable as appropriate, but for a reduced amount.
7. NOTIFICATION OF OTHER EMPLOYMENT
During any period when benefit is being paid in respect of an Incapacitated Member the Employer must be notified within 31 days by the Incapacitated Member if he undertakes any work, gainful or otherwise or there is a change in any other circumstances affecting the benefit of the Incapacitated Member.
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11 PAYMENT OF BENEFIT
(a) Benefit will be paid by equal monthly instalments in arrears until the Member ceases to be an Incapacitated Member or he reaches Terminal Date or until the death of the Member, whichever shall first occur.
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(c) payments of benefit made to a Member under the Scheme who is in Service are a continuance of salary or earnings and although benefits are insured by the Employer they are not insurance benefits to the Member. . . . . . . . . . . .
(d) The Employer shall not be under any obligation to make any payment to an Incapacitated Member or any other person unless the Employer has first received such sum from the Insurer or the Principal Employer as applicable.
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13 CESSATION OF SERVICE AND MEMBERSHIP
(a) A Member shall cease to be a Member at whichever is the earliest of
(i) his Terminal Date
(ii) the date on which he ceases to be in Service, and
(iii) his death.
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15 LEGAL LIABILITY AND RIGHTS OF EMPLOYER
Nothing in these rules is intended to create any legal relation between the Insurer and any Member it being (as respects the Employer and the Members) the purpose of these Rules to establish the terms of the Scheme as between the Employer and the Members.
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SPECIAL RULES
A. DEFINITIONS
"Deferred Period" means the first 26 weeks of any continuous period during which the Member is an Incapacitated Member.
"Terminal Date" means the 60th anniversary of birth of a Member."
C. BASIC BENEFIT
Subject to the provisions of General Rules 4 and 10 the annual rate of basic benefit in respect of an Incapacitated Member shall be 75 per cent of his Remuneration, less the Social Security Pension."
Mr. Earl's medical history
(a) Back pain
(b) Alcohol abuse
(c) Depression
(d) Under-confident personality
The Breakdown
The nature of the scheme
"UNUM will pay benefits as specified . . . . . . . . on production of proof satisfactory to [UNUM] of the insured's entitlement to such benefits."
A dispute arose between UNUM and the insured as to whether he was fit to return to work. UNUM contended that the policy only required it to pay on proof satisfactory to itself of the insured's entitlement to benefit and that provided it acted bona fide its decision was binding on the insured. Tuckey J. rejected that construction of the contract holding that the clause in question related only to vouching the claim.
The Rules
"Active service"
"Totally unable . . . . . . . . to follow his Occupation"
"Sickness"
"In my view the word "sickness" is very commonly used to denote a body in imperfect health, whether that condition arises from disease or accident. If I ask myself what the parties to the arbitration in which this award was made were thinking about, and what language they were familiar with when they used the word "sickness", I answer that they were considering the case of a workman who for some reason was prevented from being on duty and deciding what he should receive as wages during that period." (My emphasis).
In my view the same considerations apply in the present case. At various points in his judgment Scrutton L.J. refers to "bodily" health, but I do not think he was seeking to draw a distinction between physical and mental health and I can see nothing to suggest that the parties in the present case intended to limit themselves to physical as opposed to mental illness. Such a distinction would be quite contrary to the objectives of the scheme. In my judgment, therefore, the scheme was intended to apply to all cases where a member is prevented by illness of any kind from carrying out his existing employment.
Self-induced sickness
Continuing incapacity
Termination of the contract
Damages