A Florida District Court held that Reliance Standard wrongfully denied an OB/GYN’s long-term disability benefits for a claimant suffering from chronic arm and hand weakness. The court held that Reliance Standard abused its discretion when it (1) defined the physician’s duties as those in the national economy and not his own occupation, (2) determined the physician could perform his occupation when the medical evidence proved otherwise, and (3) found the physician’s continued employment meant he could do his own occupation. Therefore, the court ordered Reliance Standard pay the doctor long-term disability benefits, plus prejudgment interest.
Due to severe weakness in his dominant hand and arm, Dr. Smith was instructed by several attending physicians to stop working in his occupation as an OB/GYN. Specifically, he was diagnosed with a brachial plexus traction injury and had to use a sling. According to Dr. Smith and his employer, Tenet Health Systems, the material duties of his occupation required patient care, surgery, and deliveries. The deliveries required use of forceps, manual dexterity, pulling, tugging, and lifting. Dr. Smith filed a claim for long term disability benefits.
Reliance Standard denied his benefits. Its reasoning, in part, was that the policy did not define Dr. Smith’s job at a particular employer but, rather, how it is performed in the national economy.
Reliance Standard claimed Dr. Smith’s physicians’ evaluations did not exclude him from being able to perform each and every material duty of his regular occupation. Specifically, Reliance Standard claimed Dr. Smith could perform routine patient examinations and consultations. The insurance company also pointed to the fact that Dr. Smith had started part-time work as an OB/GYN at another facility.
Dr. Smith appealed this decision. Reliance Standard denied his appeal. Thus, Dr. Smith filed a lawsuit against Reliance and was victorious before the court.
The Court’s Review
The court found that Reliance Standard’s decision to define Dr. Smith’s occupation by the national economy standard was wrong and cited to prior decisions on the policy’s exact language. Because Dr. Smith’s policy language had the qualifier “his/her” in the definition, the court held the occupation had to be directly connected to him. The court also found that Reliance Standard failed to consider Dr. Smith’s “material duties”, as reported by him and his employer which supported that his part-time position as an OB/GYN was different than his own occupation because the record was void of the material duties for the part-time position. Finally, the court noted that numerous attending physicians opined Dr. Smith was unable to perform his occupation based on the restrictions and limitations imposed on him due to his condition. Simply put, the court found that Reliance Standard ignored a large amount medical records supporting Dr. Smith’s total disability.
Ultimately, the court held that Reliance Standard’s decision to deny Dr. Smith his long-term disability benefits was not supported by the evidence. It found that Reliance Standard ignored medical records supporting disability, used the wrong occupational definition, and misinterpreted the doctor’s continued employment to deny benefits. As such, Dr. Smith was awarded his unpaid benefits.
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