In our previous post, we looked how one California court analyzed the interpretation of “total disability” as applied to a gynecologist’s claim for disability benefits. In this post, we look at another California case, Gross v. UnumProvident Life Ins. Co., which has similar facts and addresses substantially the same issue: whether an orthopedic surgeon is “totally disabled” as defined by the disability insurance policy. Here, however, the California court engages in a much more fact-intensive analysis.
In Gross v. UnumProvident Life Ins. Co. an orthopedic surgeon, whose complications from diabetes rendered him unable to continue performing surgeries, sued his insurer, Paul Revere Life Insurance Company, after it denied his claim for disability benefits. Paul Revere denied his disability insurance claim because it determined he was not “totally disabled” as defined by his disability insurance policy. The Paul Revere disability insurance policy defined total disability as follows:
“Total Disability” means that because of Injury or Sickness:
a. You are unable to perform the important duties of your occupation; and
b. You are under the regular and personal care of a Physician.
Thus, to determine whether the disabled orthopedic surgeon was “unable to perform the important duties of [his] occupation,” the California court engaged in a factual analysis of the three major duties the orthopedic surgeon performed pre-disability: (1) surgical duties; (2) medical-legal duties; and (3) in-office orthopedic duties. For each of the three categories, the California court asked “first, whether they were important duties of his occupation at the time he became disabled, and second, whether he is unable to perform them post-disability.”
1. Surgical duties
It was uncontested here that, as a result of his disabling condition, the orthopedic surgeon was no longer able to perform surgeries. However, the facts demonstrated that the surgeon only spent about 5-8 hours per week, 13% of his pre-disability time, performing surgery. Because the amount of practice time dedicated to surgical duties was limited, Paul Revere argued that surgical duties did not constitute an “important duty” to satisfy the disability insurance policy’s definition of total disability. The California court agreed: “Plaintiff’s inability to perform his surgical duties, standing alone, is insufficient to render him totally disabled.” Therefore, it proceeded with the analysis of the other two duties.
2. Medical-legal duties
Paul Revere argued that the orthopedic surgeon was not totally disabled because he was still able to perform his medical-legal work post-injury, and that this was an important duty. The facts demonstrated that the orthopedic surgeon dedicated approximately 15-25% of his work time performing Independent Medical Examinations (IMEs) and other medical-legal related work; he continued doing this work after filing for disability benefits. Although the surgeon spent a considerable portion of his time performing medical-legal duties, the California court found persuasive the fact that only 1.6% of the orthopedic surgeon’s patients were medical-legal related and the amount of income earned from the IMEs was very little. Consequently, the California court concluded that medical-legal duties did not constitute an “important duty” under the disability insurance policy.
3. In-Office Patient Care
Thus, “whether Plaintiff remains able to perform in-office patient care is the crucial issue in determining whether Plaintiff is totally disabled.” Here, the California court found a triable issue of fact as to whether the disabled orthopedic surgeon could still perform his in-office care duties. Therefore, the issue would need to be determined by a jury.
However, in order to provide guidance to the parties, the California court explicated the legal backdrop under which the analysis should proceed. It explained that “one is unable to perform an important or material and substantial duty if she is unable to perform that duty ‘in the usual or customary way.’” (citing Erreca). Moreover, since the disability insurance policy was an own occupation policy, meaning that coverage would be provided if the orthopedic surgeon was unable to perform the duties within his own occupation as opposed to any occupation, “usual or customary way” would be determined by examining the ordinary practices of the orthopedic surgeon in his office pre-disability.
This case provides an illustration of the legal analysis a court will undertake to determine whether or not a disability claimant is totally disabled under California law. As the case demonstrates, what constitutes a material or substantial duty may turn on the amount of time and effort a disabled doctor put toward a particular duty’s accomplishment pre-disability; the financial aspect of an occupational duty, although not dispositive, may also come into play to determine materiality.
Significantly, much of the data the California court relied upon to determine the issue of materiality was provided by the disabled orthopedic surgeon when he first filed his claim for disability benefits. Therefore, it is important to understand and fill out all of this information accurately when you file for disability benefits. Even small mistakes can have a devastating impact on your chances of recovery because they could alter the way your disabling condition is defined by a disability insurer or a court. For this reason, you should meet with an experienced disability insurance attorney to discuss the best way to present your occupational history on your disability insurance claim as this information may ultimately be relied upon by a court to determine your eligibility for benefits.