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Court Says Doctor Still Performing Minor Surgeries Not Disabled

Disability Claim Denials

Under California law, an insured claiming coverage under an insurance policy has the burden of proving entitlement to such coverage.  See Royal Globe Ins. Co. v. Whitaker, 181 Cal.App.3d 532, 537, 226 Cal.Rptr. 435, 437 (1986).  Therefore, in the disability insurance context a claimant must demonstrate that his disabling condition is one covered under the disability insurance policy.  Disputes often arise when the parties to the contract disagree over the meaning of key terms in the policy, which may result in denied disability benefits.

In Dym v. Provident Life and Acc. Ins. Co., for example, a dispute arose between a disabled gynecologist and his disability insurance company, Provident Life, when Provident denied his disability claim on the basis that the doctor was not “totally disabled” as defined by the disability insurance policy and California law.  The policy defined total disability as follows:

Total Disability or totally disabled means that due to Injuries or Sickness:

1. you are not able to perform the substantial and material duties of your occupation; and

2. you are receiving care by a Physician which is appropriate for the condition causing the disability.

your occupation means the occupation (or occupations, if more than one) in which you are regularly engaged at the time you become disabled. If your occupation is limited to a recognized specialty within the scope of your degree and license, we will deem your specialty to be your occupation.

Prior to an automobile accident, the gynecologist routinely examined patients and scheduled and performed major surgeries as part of his occupation.  After the accident, the gynecologist filed for disability benefits with Provident Life, claiming he was totally disabled within the meaning of the policy because he could no longer perform most of these surgeries.  Provident Life, on the other hand, contended the doctor was not totally disabled because, although he could not perform most of the occupational surgeries, he was still capable of performing other minor surgeries, which he had, in fact, continued performing after the accident.  Thus, the issue for the court to decide was whether or not the gynecologist was “totally disabled” as defined by the policy.

The California court held that the gynecologist was not totally disabled within the meaning of the disability insurance policy, and therefore it permitted Provident Life’s denial of disability benefits.  Even though California courts construe ambiguous policy language against the disability insurer, here the court did not find a construction of “total disability” favorable to the disabled gynecologist – it reasoned that the meaning of “total disability” was not ambiguous.  Furthermore, the court was persuaded that because the gynecologist was capable of performing some surgeries, even though not the most significant ones, he was capable of performing “the substantial and material duties of [his] occupation.”

This case may have been decided differently had the disabled gynecologist not attempted to prematurely return to work post-injury.  Indeed, the court’s decision turned largely on the fact that the gynecologist continued performing surgeries after he became injured.  Unfortunately, many disabled doctors and other professionals prejudice their chances of recovery because they want to get back to work as soon as possible.  Often they ignore the advice of a treating physician so they can get back to doing what they love, despite being physically unfit for work.  Doing so, even if you are in fact totally disabled, may be fatal to your case.  Additionally, returning to work when you are unfit to practice is unsafe for patients and may be a violation of physician ethical duties.  For these reasons, it is important to consult with an experienced disability insurance lawyer prior to filing a claim with your disability insurance company for disability benefits.

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