Georgia Court Rules For Gynecologist Finding Provident Life and Accident Insurance Company Incorrectly Applied its Policy Terms

A Georgia Court ruled in favor of a gynecologist and found Provident Life and Accident Insurance Company (“Provident”) incorrectly applied its policy terms.

Background

Dr. Gladstone was a board certified gynecologist. Before his disability, Dr. Gladstone was responsible for both office-based gynecological services and hospital-based gynecological surgeries. He estimates that he spent about 60% of his work week in the office and 40% of his work week devoted to hospital surgeries.

In 2001, Dr. Gladstone was diagnosed with carpal tunnel syndrome, making it impossible for him to perform surgeries. However, he was able to continue performing his office duties. Unable to perform surgery, one of the material and substantial duties of his occupation, Dr. Gladstone filed a claim for total disability benefits with Provident.

Dr. Gladstone’s Claim for Disability Benefits

The Provident policy provided for total disability benefits and residual (or partial) disability benefits. The definitions of total and residual disability are as follows:

  • Total disability: the insured not able to perform the substantial and material duties of his or her occupation
  • Residual Disability: the insured is unable to perform one or more of his his or her substantial daily business duties

Provident decided that Dr. Gladstone was not totally disabled because he was able to perform some of his occupation duties (i.e. the office visits). Accordingly, Provident argued he was only residually disabled. Believing he was entitled total disability benefits, Dr. Gladstone filed a lawsuit against Provident.

Court’s Review of Dr. Gladstone’s Case

The dispute before the court was whether the definition of total disability required Dr. Gladstone be unable to perform all or most of his occupational duties.

Provident argued that in order for Dr. Gladstone to be eligible for total disability benefits, he must prove that he is unable to perform all of his occupational duties. Dr. Gladstone argued that to meet the definition of his total disability unable to perform most of his occupational duties.

The court ultimately ruled in favor of Dr. Gladstone and agreed that to be totally disabled he must be unable to perform most or the vast majority of the substantial duties of occupation. Importantly, the court was not persuaded by Provident’s argument that the existence of a partial disability benefit meant that total disability benefits would only be available to those who are incapable of performing all of one’s material and substantial duties.

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