A Georgia OBGYN wins his lawsuit against Berkshire Life Insurance Company of America for total disability benefits.
Background
Before his disability, Dr. Pomerance was a board-certified obstetrician/gynecologist (“Ob/Gyn”). As an OBGYN, Dr. Pomerance was required to:
- Deliver babies (including C-sections)
- Surgeries
- Hold office visits
- Make hospital rounds
- And perform minor biopsies
- Assist with emergency room coverage
In September of 1995, Dr. Pomerance was diagnosed with a chronic knee condition. This condition made it difficult for Dr. Pomerance to stand for extended periods of time making it impossible for him to deliver babies, perform surgeries, or assist with emergency room coverage. He was however able to continue performing general office visits and provide nonsurgical care.
No longer able to perform all of his job duties, Dr. Pomerance filed a claim for disability benefits with Berkshire Life Insurance Company. The 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 is unable to perform the material and substantial duties of his occupation
- Residual Disability: the insured is unable to perform one or more important daily business or professional duties
Berkshire treated Dr. Pomerance’s claim as a claim for residual disability benefits given he was able to perform some of his job duties. At first, Dr. Pomerance did not object to this classification because there was no difference in his monthly benefit check. However, when he increased his work activities (more office visits) and his income increased, his residual disability benefit decreased. At this point, Dr. Pomerance argued to Berkshire that he should be receiving total disability benefits and not residual disability benefits. He argued he was totally disabled because he could not perform all of the material and substantial duties of his occupation.
Berkshire refused to acknowledge total disability. Thus, Dr. Pomerance filed a lawsuit against Berkshire.
Court’s Review of Dr. Pomerance’s Case
The dispute before the court was whether the definition of total disability required Dr. Pomerance to be:
- Unable to perform all of his occupational duties; or
- Unable to perform most of his occupational duties
The trial court ruled against Dr. Pomerance. However, the Court of Appeals of Georgia overruled the trial court and ruled in favor of Dr. Pomerance.
To be disabled Dr. Pomerance must be unable to perform the material and substantial duties of his occupation. The court found that the definition of total disability was unclear. Specifically, the court focused on the term “substantial,” and argued it could mean:
- Important or essential (qualitative); or
- Considerable in quantity or significantly great in amount (quantitative)
The court ultimately held that substantial meant great in amount or a majority. Thus, to be disabled Dr. Pomerance must be unable to perform a majority of job duties. Because of this, the court found that Berkshire incorrectly required that Dr. Pomerance be unable to perform all of his occupational duties and ruled in favor of Dr. Pomerance.
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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