Disability Policies

Accidental Death And Dismemberment Policy

November 19, 2017 | Mark S. Humphreys

Abilene Texas lawyers who handle accidental death and dismemberment policy claims that are governed by ERISA, need to read this 2017, 5th Circuit Court of Appeals opinion. It is styled, Robert Ramirez v. United Of Omaha Life Insurance Company.

Ramirez traveled to West Texas and contracted a fungal infection that resulted in the removal of one of his eyes. He made a claim through the accidental death and dismemberment plan he had through his employer. The plan is governed as an ERISA plan. United of Omaha denied the claim, stating the infection that caused the removal of Ramirez’s eye was not the result of an “Accident” as that term is defined in the policy. United of Omaha was granted summary judgment by the District Court and this appeal followed.

The facts are undisputed. Following a trip to West Texas, Ramirez came in contact with a fungus and eventually was diagnosed with a condition known as coccidioidomycosis.

Disability Claims – Illness Versus Accident

November 16, 2017 | Mark S. Humphreys

Lawyers who handle disability insurance claims know that the policy has to be read.

In a definition of “total disability” in an individual accident and sickness policy or hospital, medical, and dental service corporation subscriber contract, the inability to perform duties may not be based solely on an individual’s inability to perform “any occupational duty,” but the insurer may specify the requirement of the inability of the insured to perform all of the substantial and material duties pertaining to his or her regular occupation, or words of similar import, according to the Texas Administrative Code, Section 3.3012(b)

The policy may further provide coverage for “partial disability,” which is typically defined as the insured’s inability to perform one or more but not all of the essential duties of his or her employment or occupation.

Disability Insurance Coverage Issues

October 29, 2017 | Mark S. Humphreys

In a definition of “total disability in an individual accident and sickness policy or hospital, medical, and dental service corporation subscriber contract, the inability to perform duties may not be based solely on an individual’s inability to perform “any occupational duty,” but the insurer may specify the requirement of the inability of the insured to perform all of the substantial and material duties pertaining to his or her regular occupation, or words of similar import. This is found in the 28 Texas Administrative Code, Section 3.3012(b).

The policy may further provide coverage for “partial disability,” which is typically defined as the insured’s inability to perform one or more but not all of the essential duties of his or her employment or occupation.

Disability policies normally require that any claimed disability occur while the policy is in effect or within a specified time after any claimed accident or injury.

Disability Policy Language

October 28, 2017 | Mark S. Humphreys

As in all insurance policies, the language used in the policy will be used in enforcing and interpreting the policy.

In the 2003, Texas Supreme Court opinion, Provident Life and Accident Insurance Co. v. Knott, the court read the policies in question defining the term “total disability” to mean that the insured must, in order to be considered totally disabled under the policies, be unable to “perform all of the important daily duties of his occupation.” The then held that the trial court’s granting of summary judgment in favor of the insurance company was appropriate given that the insured, a gynecologist seeking benefits for total disability under those policies was able to see patients, perform surgery, consult with other physicians and perform administrative duties.

A long term disability policy that defined disability in part as the inability to perform “each of the material duties” of the insured’s regular occupation required only that the insured be unable to perform any single material duty of her occupation in order to be considered disabled, not that she be unable to perform all duties of that occupation. This was in the 2002, U.S. 5th Circuit opinion, Lain v. UNUM Life Insurance Co. of America. No concrete evidence disability insurer’s determination of non-disability for insured who suffered recurring severe chest pains, while overwhelming evidence supported disability claim, warranting benefit award under ERISA civil enforcement provision: the insured’s time at home doing research on her medical condition did not equate to ability to practice law, as insurer contended; insurer focused on certain “normal” test results to support its finding, but test results were primarily abnormal and also could not clinically measure insured’s pain; and insurer’s reliance on insured’s failure to seek psychiatric care prior to ceasing employment was misguided since her disability was physical.

Private Disability Claims

October 26, 2017 | Mark S. Humphreys

It needs to be noted at the beginning here. Private disability claims are different from government disability claims and also from disability claims that are governed by ERISA.

This posting deals those disability claims that are from private policies or policies other than government or ERISA.

Disability policies will usually specify an amount that will be paid in the event a claimant becomes disabled (as that term is defined in the policy) and a maximum length of time for which such benefits will be paid. As an example the policy may pay $500 per month for up to 10 years.

Disability Policies And Lawsuits

July 7, 2016 | Mark S. Humphreys

Attorneys who litigate disability claims need to read this case from the Southern District of Texas, Houston Division. It is styled, Larry Frederick v. American Heritage Life Insurance Company. This case will help an attorney understand some of the burdens put on the insurance company.

In October 2012, Frederick was severely injured in a vehicular accident. One month later, he submitted a claim for benefits under an accident insurance policy he purchased from AHLIC several months earlier. AHLIC initially denied payment under the policy, but later paid the claim after reversal on administrative appeal. Frederick now sues claiming that AHLIC violated the Texas Insurance Code by unreasonably delaying payment of the benefits.

In its answer to Frederick’s first amended complaint, AHLIC raises several affirmative defenses, including a pre-existing condition exclusion in the policy, ratification by Frederick, nonpayment of the policy premium, and failure to prove loss.

ERISA Disability Claims

May 29, 2016 | Mark S. Humphreys

This 5th Circuit Court of Appeals opinion is a must read for ERISA attorneys. The case is styled, Burell v. Prudential Insurance. The facts will be given here. The case needs to be read to understand how the Court affirmed the findings of the lower Court in denying benefits to Burell.

In 1985, Burell began working as an entry-level technician for Methodist Healthcare Systems (“MHS”). After 26 years, he ended his career as Director of Biomedical Services for all San Antonio MHS facilities. As an employee of MHS, Burell participated in the company’s insurance plan (“the Plan”), which is provided through HCA Management Services, L.P. Prudential acts as both administrator and insurer of the Plan. In order to qualify for long-term disability benefits, a claimant must meet the following definition of “disabled”: the claimant must (1) be “unable to perform the material and substantial duties of [his or her] regular occupation due to [his or her] sickness or injury “; (2) be “under the regular care of a doctor “; and (3) suffer “a 20% or more loss in [his or her] monthly earnings due to that sickness or injury.”

Burell was diagnosed with multiple sclerosis (“MS”) in 2008. Citing worsening symptoms of MS, in September 2011, Burell went on medical leave and filed for long-term disability benefits with Prudential, claiming that he qualified for benefits under the Plan due to MS, headaches, depression, and anxiety. In January 2012, he stopped working altogether, ending his employment with MHS. In support of his claim, Burell submitted medical records from his treating physicians and a psychiatrist. Prudential hired Heidi Garcia, a registered nurse, and Dr. Alan Neuren, who is board certified in neurology, to review Burell’s claim. Dr. Neuren found that Burell’s diagnosis of MS was unsupported by his medical records. He also found it unlikely that Burell suffered any cognitive impairments, opining that job stress is “likely the source of his complaints as opposed to a neurological disorder.” Garcia focused her review on Burell’s claim of depression and anxiety, ultimately finding that any cognitive symptoms he was experiencing were not sufficient to prevent him from working. Based on their reports and the medical records submitted, Prudential denied Burell’s claim for long-term disability benefits.

Coverages In Disability Policies

May 19, 2015 | Mark S. Humphreys

Arlington insurance attorneys who handle disability policy claims would want to read this 1978, Beaumont Court of Appeals case. It is styled, Lone Star Life Insurance Company v. Griffin.

Griffin testified that as he was returning to his home from his farm, he passed by his drugstore. As was his custom, he entered the store to see if everything was normal (having been burglarized several times in the past). He smelled smoke which he found to be coming from the rear of his building. He testified that he emptied his fire extinguisher but his efforts were futile; that he was trying to get out of the building when an aerosol can exploded in his face; that he lost consciousness while upon the floor of the store near a door, and regained consciousness later in a hospital in Jasper.

Dr. Lee Popejoy testified as to his treatment of Griffin beginning at about two in the morning following the fire. He told of finding external burns on several parts of Griffin’s body but the most serious injury was to his lungs from the inhalation of smoke and fumes. Griffin was hospitalized for several weeks and testified that he was unable to do any work for several months thereafter.

Policy Definition Of Total Disability

May 17, 2015 | Mark S. Humphreys

Arlington lawyers handling insurance disability claims need to know all the places to look to find law helpful to their client. This includes not only the Texas Insurance Code, but also the Texas Administrative Code.

But first, a case helpful to disability case understanding is a 1970, El Paso Court of Appeals case styled, Travelers Insurance Company v. Solomon.

Solomon received a jury verdict in his favor against Travelers for anticipatory breach of an insurance contract. The contract was an accidental disability policy issued by Travelers. Under the policy Travelers agreed to pay the sum of $200.00 per month during the period of any total disability sustained by Soloman which commenced within 30 days after he received accidental injuries. The policy defines ‘total disability’ as meaning an inability of the insured to perform any and every duty pertaining to his occupation during the first 24 months of any period of disability; thereafter, the term is defined to mean complete inability of the insured to engage in any and every occupation or employment for wage or profit.

Disability Policy Claim Denial

September 9, 2014 | Mark S. Humphreys

Dallas insurance lawyers who handle disability policy’s need to be aware of an opinion from the United States District Court, Houston Division. The style of the case is, Fernandez v. Mutual of Omaha Ins. Co. Here is the relevant information.

The cross-motions for summary judgment in this disability insurance dispute raise one legal issue: whether the statute of limitations bars the plaintiff’s causes of action. The answer depends on when the limitations periods began to run. If the defendant insurer’s July 27, 2009 letter to the plaintiff insured legally denied the claim, then, as the plaintiff concedes in his brief, all his causes of action are barred. If, as the plaintiff contends, the July 27, 2009 letter did not legally deny the claim, the causes of action alleged did not accrue until the policy terminated when he became 65, and the action is timely filed.

Based on the undisputed facts in the summary-judgment record, the July 27, 2009 letter repeating an earlier letter stating that the plaintiff’s benefits claim was “inactive,” legally denied the claim. The statutory and extracontractual claims had to be brought by July 27, 2011. The breach of contract claim, subject to a three-year contractual-limitations period, had to be brought by July 27, 2012. Fernandez filed this suit on September 30, 2013, well after all limitations periods had expired.