Do I Qualify For Total Disability Insurance Benefits In Texas?

Since 1922, disability claimants in the state of Texas have been arguing with disability insurance companies as to whether they are entitled to “total disability” benefits. In most private disability insurance policies, “total disability” is defined as the inability to perform the substantial and material duties of your own occupation. The answer to whether a claimant is entitled to receive total disability benefits is a fact specific question that requires an understanding of the definition of “total disability” in Texas and a detailed analysis of the exact work duties the claimant was performing during the time period immediately before he or she became disabled.

Let’s take a look at a lawsuit brought by an OBGYN against Provident Life and Accident Company (also known as UNUM) in which the Texas appellate court explained and interpreted the definition of “total disability” after this doctor’s claim for total disability was denied by UNUM.

OBGYN Doctor Sues Provident Life Seeking Total Disability Benefits

An OBGYN, Dr. K, was involved in a plane crash that resulted in a fracture to his spine and kept him out of work for two months. Dr. K returned to work in a full time capacity but there were various medical procedures that he could no longer perform. Unum denied his claim for total disability benefits by claiming that he could perform some of his pre-disability duties and he did not satisfy the 90 day elimination period by returning to work in 60 days.

The exact duties of what Dr. K. was able to do pre-accident versus post-accident were not discussed in the Texas Appellate court’s decision. Dr. K’s initial lawsuit was dismissed as the Judge agreed with Unum that Dr. K was not eligible for total disability. Dr. K appealed and his Texas disability insurance lawyer argued that a jury must be able to decide if he is totally disabled based upon the facts of his case and not a Judge. The appellate court agreed with Dr. K. and issued a detailed written opinion explaining how Texas courts and insurance companies must interpret the definition of “total disability” in Texas.

The Texas Court Systems Interpretation of “Total Disability”

In a disability insurance dispute, Courts are called upon to interpret the terms of an insurance contract. In Dr. K’s case, his disability policy contained the following definition: “Total Disability means that due to Injuries or Sickness, you are unable to perform the duties of your occupation.” With respect to the dispute between Dr. K and Unum, the most important words are “the duties of your occupation.” Unum argued that Dr. K cannot be totally disabled under the policy unless he is unable to perform all the duties of his occupation. On the other hand, Dr. K contends that he is disabled if he is unable to perform any duty of his occupation.

The Texas Appellate court cited numerous disability cases going back to 1922 and explained that the construction of Dr. K’s definition of total disability in his disability policy is governed by a series of Texas Supreme Court cases dealing with total disability policies. We have quoted below the court’s historical explanation of these cases and the court’s reasoning for reversing the lower court’s dismissal of Dr. K’s lawsuit:

Commonwealth Bonding & Casualty Ins. Co. v. Bryant, 113 Tex. 21, 240 S.W. 893 (1922), involved an insurance policy which provided for the payment of weekly total disability benefits if the insured sustained injuries which would “wholly disable and prevent the insured from performing any and every kind of duty pertaining to his occupation.” The court refused to give a literal interpretation to the policy’s definition of total disability. Instead, the court ruled that the insured was totally disabled if he was substantially unable, in the exercise of ordinary care, to perform every material duty pertaining to his occupation.

In Great Southern Life Ins. Co. v. Johnson, 25 S.W.2d 1093, 1097 (Tex. Comm’n App.1931, holding approved), the insurance policy provided for total disability benefits if the insured was “wholly prevented from performing any work for compensation or profit or from following any gainful occupation.” The court further stated:

A policy requiring payment for total disability ordinarily is not one of indemnity against loss of income but against loss of capacity to work. Cooley’s Briefs on Insurance (2d Ed.) 5536.

“Total disability” is necessarily a relative matter, and must depend chiefly on the peculiar circumstances of each case and on the nature of the occupation or employment and the capabilities of the person injured. It does not mean absolute physical disability of the insured to transact any kind of business pertaining to his occupation, but exists if he is unable to do any substantial portion of the work connected therewith. – (Emphasis added)

“Thus, Johnson modified Bryant by deleting the requirement that every material duty be impacted. The court in Prudential Insurance Company of America v. Tate, 162 Tex. 369, 347 S.W.2d 556 (1961), reaffirmed the holdings in Johnson. As per the holdings in Johnson and Tate, Dr. K was totally disabled if he was unable to do any substantial portion of the work connected with his occupation.

The holdings in Johnson and Tate are based on policy grounds which reject the express definitions contained in each of the insurance policies that were at issue. It would appear that the holdings in these cases possibly conflict with the Texas Supreme Court’s current approach to construing insurance policies. In Trinity Universal Insurance Company v. Cowan, supra at 823, the court held that, when terms are defined in an insurance policy, those definitions control. We would note in this regard that, after the enactment of the ERISA in the 1970s, the vast majority of reported cases involving disability insurance have been litigated in the federal court system. Be that as it may, the holdings in Johnson and Tate speak directly to the meaning of total disability in an insurance context, and they have not been overruled.

Provident (Unum) argues that Johnson and Tate are distinguishable because the policies at issue in this case provide for the payment of partial disability benefits. We disagree with this assessment. The policies defined partial disability as the inability to perform “one or more, but not all” duties. Provident contends that, if one harmonizes the partial disability definition of “one or more, but not all” duties with the definition of total disability, the policies imply that all duties must be impacted in order to constitute total disability. Even if one assumes that the policies contain an implied requirement that all duties be impacted for the total disability provision to apply, Johnson and Tate are still controlling because those cases rejected express requirements that all duties be affected.

The determination of whether or not Dr. K was unable to do any substantial portion of the work connected with his occupation when his total disability benefits were terminated is inherently a fact question. See Prudential Insurance Company of America v. Tate, supra at 554. Dr. K testified to various procedures which he could not perform as a result of his disability. This testimony raises an issue of fact precluding dismissal as to the ground that Dr. K was not disabled when Provident denied his claims for total disability benefits.

Attorneys Dell & Schaefer have Helped Thousands to Collect Total Disability Benefits

Similar to the battle that Dr. K had with Unum, our law firm has handled this same exact situation on behalf of thousands of physicians and other professionals. The ultimate decision comes down to a jury and our disability attorneys have been through a jury trial with Unum and litigated countless cases dealing with the total vs. residual disability issues. The key is to collect your disability benefits without ending up in court. Every claim is fact specific and there are often things that a claimant can do in order to either strengthen their claim or position themselves to collect total disability benefits in the future. Dr. K did not understand his disability policy and he unfortunately waited many years to battle Unum. Time is of the essence with disability claims and it is always best to consult with a disability attorney in order to make sure that you are maximizing the terms of your disability insurance policy. Contact us for a free consultation to discuss your disability claim options.