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Astros call CIGNA off base on denial of disability claim

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Astros call CIGNA off base on denial of disability claim

HOUSTON—The injured right shoulder of baseball player Jeff Bagwell has become a sore subject for his baseball team and its insurer.

The first baseman's injury is at the center of a dispute between the Houston Astros baseball team and CIGNA Corp. related to an insurance policy purchased by the team to cover the Astros if Mr. Bagwell were to become totally disabled.

The team filed a claim for approximately $15.6 million in January, saying an injury to Mr. Bagwell's right shoulder has left him totally disabled. But CIGNA denied the claim last month, a decision the Astros plan to challenge in court unless the insurer reverses its position, according to the team's lawyer.

A key part of the dispute arises from the fact that Mr. Bagwell, who had surgery on the shoulder in June 2005, played at the end of the regular baseball season and in the baseball playoffs in September and October 2005.

"It really makes no sense that Mr. Bagwell was healthy enough to start game one of the World Series and then somehow became totally disabled in the off season," said Ty Buthod, a partner with Houston-based Baker Botts L.L.P. who represents Connecticut General Life Insurance Co., the legal entity of Philadelphia-based CIGNA.

According to the Astros, though, the fact that Mr. Bagwell played in the World Series has no bearing on the legitimacy of its claim because Mr. Bagwell was diagnosed as being totally disabled on Jan. 12, after being examined by Dr. James Andrews, a prominent sports medicine orthopedic surgeon at the Alabama Sports Medicine & Orthopedic Center in Birmingham, Ala.

"That is ludicrous on its face, in our opinion," said Wayne Fisher, a partner with Houston-based Fisher, Boyd, Brown, Boudreaux & Huguenard L.L.P., who represents the team. "As a result of the examination, Dr. Andrews concluded that Jeff Bagwell was totally disabled from playing baseball and so advised Mr. Bagwell and the Astros."

After the team received Dr. Andrews' diagnosis, it filed an insurance claim and provided information on the examination to the insurer. But CIGNA took the position that there was no new injury or accident that led to Mr. Bagwell becoming totally disabled and denied the claim on March 13.

"The company couldn't find any accident or injury or change in Mr. Bagwell's condition from the end of the 2005 season to the time he was said to be totally disabled," Mr. Buthod said.

According to the Astros, the policy wording requires the claim to be paid because it provides for coverage for any bodily injury, sickness or disease that leads to Mr. Bagwell's total disablement. The insurance policy provides that if Mr. Bagwell were to become totally disabled during the off season, the Astros would be eligible for benefits, Mr. Fisher said. "The policy doesn't require--as we read it--any new accidental injury," he said.

The Astros purchased the policy in January 2001. The policy expired on Jan. 31 of this year.

Under this insurance policy, there is no formal appeals process, but the insurer would consider any more information on Mr. Bagwell's condition during the policy's effective period that the Astros can produce, Mr. Buthod said. "We will certainly consider anything else the Astros want to send us," he said. "As far as we're concerned, the matter is over. Whether the Astros want to file suit is their decision."

Mr. Fisher said he was planning to ask the insurer to reconsider last week and would probably give the company several weeks to do so. But if the insurer does not change its position, the Astros will file a lawsuit to force it to pay the claim, he said.

Mr. Bagwell was participating in a rehabilitation program supervised by the team's physician during spring training, but the Astros announced on March 25 that he decided not to continue his rehabilitation and training for the upcoming 2006 season because of his shoulder injury and will instead pursue surgical options to remove bone spurs in his right shoulder. The club placed the 37-year-old player on the 15-day disabled list with right shoulder arthritis and bone spurs.

Mr. Bagwell is the team's all-time leader in home runs, with 449 home runs and 1,529 runs batted in during his 15-season Major League career, encompassing 2,150 career games. Mr. Bagwell won Rookie of the Year honors in 1991 and the Most Valuable Player award in 1994.