If an insured is making a claim under a disability insurance policy that he or she is unable to perform the duties of their occupation, does the policy require a showing that the claimant is unable to perform all of the job duties or is a showing of an inability to perform any material job duty sufficient.  That was the question presented in Chaudhry v. Provident Life and Acc.Ins.Co., 2014 WL 3511529 (N.D.Ill. July 16, 2014), which involved a claim submitted by a psychiatrist who sought total disability benefits when a vision impairment significantly limited him from practicing in his field.  There were a number of complicating issues, including the doctor’s guilty plea to one count of Medicare fraud, which caused the insurer to question his claimed pre-disability income.  However, the major issue in the case turned on whether Dr. Chaudhry needed to show he could not perform any aspect of his prior practice.  Judge Amy St. Eve of the U.S. District Court for the Northern District of Illinois, analyzed the issue in the plaintiff’s favor.

The defendant maintained “that the Court should read the Total Disability and Residual Disability provisions together as creating a continuum of coverage…[and that] Total Disability provisions take effect only when the insured cannot perform even a single one of his ‘substantial and material’ duties.”  The court disagreed, finding Total Disability exists “if the insured cannot perform even a single one of his ‘substantial and material’ duties.”

The court found McFarland v. General American Life Insurance Co., 149 F.3d 583 (7th Cir. 1998) instructive in its analysis of this issue. The court gave the example of a baseball player, explaining:

[I]f a shortstop, whose principal duties include running, hitting, catching, and throwing, were injured such that he could no longer throw, he would be totally disabled because he could no longer be employed as a shortstop. Even though the shortstop could still run, hit and catch (a significant portion of his duties), throwing is an essential function for a shortstop and thus the inability to throw means that he is unable to perform “the material and substantial duties” of his occupation….

Id.  The court further determined “that a person purchasing the Policy at issue here would reasonably expect that if he could no longer perform an essential duty of his regular occupation, resulting in his inability to serve in that occupation, he would qualify for Total Disability benefits under the Policy.”  Thus, if the insured was unable “to perform even one essential duty of his occupation, if that inability completely precludes him from serving in his occupation, satisfies the definition of Total Disability. The insured need not establish that he is unable to perform all of the substantial and material duties of his occupation to qualify for Total Disability benefits under those circumstances.”

Although the court acknowledged that Dym v. Provident Life and Accident Insurance Co., 19 F.Supp.2d 1147 (S.D.Cal. 1998) supported the defendant’s reading of the policy, the court was unpersuaded.  The court explained, “If the parties intended for the Total Disability provisions to apply only when the insured is unable to perform ‘all’ of his or her substantial and material duties, Provident Life easily could have included ‘all’ in the definition of Total Disability.” (citing Gross v. UnumProvident Life Ins. Co., 319 F.Supp.2d 1129, 1136 (C.D.Cal. 2004)).  The court added that if Dym’s reading of the policy was reasonable, that would mean the policy was ambiguous, and that the ambiguity would have to be construed in favor of the insured.  The court also relied on Dowdle v. National Life Ins. Co., 407 F.3d 967, 972 (8th Cir. 2005) (holding that the insured was totally disabled under similar policy language where he could no longer perform “the most important substantial and material duty of [his] occupation as an orthopedic surgeon”).  Hence, the most widely accepted reading of the total disability provision of the policy requires that the insured need only show an inability to perform a single material job duty.

Related Articles