A Michigan Dentist wins lawsuit for total disability benefits against Provident Life and Accident Company and Paul Revere Life Insurance Company (referred to as the “insurance companies”).
Background
Before suffering a spinal injury, Dr. Leonor worked as a dentist and owned his own practice. Dr. Leonor estimated he spent two-thirds of his time performing dental procedures and one-third of his time managing dental practices and other businesses he owned.
In March of 2009, Dr. Leonor underwent neck surgery. After his surgery, he was no longer physically able to perform dental procedures. However, he was able to keep managing and operating the businesses he owned. Dr. Leonor also purchased additional dental practices as investments.
No longer able to perform dental procedures, Dr. Leonor filed a claim for total disability benefits.
Total Disability was defined under the policy as follows:
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Total Disability means that because of Injury or Sickness:
- You are unable to perform the important duties of Your Occupation; and
- You are under the regular and personal care of a physicians
The insurance companies initially awarded Dr. Leonor his total disability benefits. However, after learning of the extent of his managerial duties, the insurance companies terminated his benefits. They argued that Dr. Leonor was still engaging in some of his important job duties and thus not totally disabled.
In short, the insurance companies argued that to be found disabled, Dr. Leonor must be unable to perform all the duties of his occupation. Because he continued to be able to perform the managerial duties of his job, the insurance companies argued he was not totally disabled.
Dr. Leonor appealed the termination of benefits and argued that because he was unable to perform most of his occupational duties, he was totally disabled under the policy.
The Court’s Review of Dr. Leonor’s Claim
The dispute before the court was whether the definition of total disability required Dr. Leonor to be:
- Unable to perform all of his occupational duties; or
- Unable to perform most of his occupational duties
The court found that the definition of total disability is ambiguous. Under the law, ambiguities in disability insurance contracts are to be construed against the insurance companies and in favor of the claimants. Dr. Leonor would prevail on this fact alone.
Still, the court conducted an analysis of the language at issue and concluded that to prove total disability, Dr. Leonor need only establish that he cannot perform most of his job duties. The court found that because Dr. Leonor’s injury made it so he could not perform duties that occupied two-thirds of his time, it followed that he could not perform the important duties of his previous occupation.
The court did not care that Dr. Leonor continued to earn a high salary from managerial duties following his injury. Nor did the court care that there was a partial disability benefit available to Dr. Leonor under the policy. The simple fact was Dr. Leonor could not perform the important duties of his occupation and was thus entitled to benefits.
Help from an Attorney with Expertise in Disability Insurance
Disability insurance law is complicated. If your claim for disability benefits was denied or being delayed by an insurance company, it is important to get help from a lawyer with expertise in disability law.
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