How Can You Play by the Rules if You Don’t Know Them?

When filing a disability insurance claim, it’s critical that you consult with an experienced disability insurance attorney. While we have previously discussed the importance of understanding the specific definitions assigned to terms in a disability policy, the interpretation of a policy depends upon more than its internal definitions. State law may assign particular definitions or restrictions to ambiguous terms, or may invalidate certain types of clauses as against the state’s public policy. Insureds are often unaware of this substantive body of case law that shapes the interpretation of their policy—and ultimately determines their claim’s outcome. This means that a disability insurance policy’s benefits vary from state to state. An experienced disability insurance attorney is familiar with the laws of your state and how courts will interpret the language of your policy.

Two unrelated physician disability cases, one occurring in California and the other in Georgia, serve as an excellent example of how state laws vary. Both contained virtually identical facts as to the physician’s disability and the language of the insurance policies, yet the courts arrived at opposite outcomes. In each case, the physician indisputably suffers from carpal tunnel syndrome (CTS) that leaves him unable to practice medicine, with all parties agreeing that the CTS had developed over a career of repetitive hand motions.1 Each physician’s disability insurance policy provides for benefits lasting until age sixty-five for disability due to sickness, and lifetime benefits for disability due to injury.2 The question in both cases was: Is carpal tunnel syndrome a sickness or an injury? Both physicians’ policies defined “injury” as “accidental bodily injury occurring while this policy is in force.”3 However, the courts diverged as to whether carpal tunnel syndrome that had developed over a number of years was an “accidental bodily injury.”

The California court found that the physician had not suffered an “injury” under the policy because his carpal tunnel syndrome was not an “accidental bodily injury.”4 California case law has stated that an accidental bodily injury requires a sudden event causing an identifiable injury. In other words, California places the focus of “accidental” on the cause or means of the result, not on the result itself. Because the long development of the carpal tunnel syndrome did not manifest identifiable harm as it occurred, the U.S. District Court for the Central District of California, relying upon prior California court decisions, concluded that the physician had not experienced an accidental bodily injury under the policy. Therefore, the injury provision of the policy did not apply, and the California physician was entitled to his benefits under the sickness provision only until age sixty-five.

In Georgia, on the other hand, the Georgia Supreme Court decided that “accidental bodily injury” meant a bodily injury that was unexpected, but could have arisen from a voluntary act.5 Following prior Georgia court decisions, the court thus placed the focus of “accidental” on the result itself, not on its cause or means of the result6—the opposite of the California approach. It held that “an unexpected physical injury that disables the insured is covered as an ‘injury’ under this policy.”7 The court noted that, as here, a person could suffer a series of small traumas over an extended period that ultimately resulted in a bodily injury that was disabling, and such injuries were “accidental bodily injuries.”8 Applying this standard, the court held that the physician’s carpal tunnel syndrome was an accidental bodily injury under the policy. Therefore, the physician had experienced an “injury” within the policy’s terms, and the Georgia physician was entitled to his benefits under the injury provision for his lifetime.

The antipodal outcomes of these two cases illustrate the complexities and subtleties that occur when interpreting a disability insurance policy. Do you know how your state interprets your policy’s provisions? Insureds who are considering filing a claim on their policy should not attempt to navigate the insurer’s claims process, policy definitions, and the law on their own. An experienced attorney specializing in disability insurance law can ensure that insureds have an equal footing with their insurer should there be any legal disputes regarding a policy.

Our attorneys provide legal representation to protect the disability benefits of medical and dental professionals nationwide and throughout metropolitan Phoenix, Scottsdale, Tucson, Flagstaff, Sedona, Lake Havasu City, Prescott, and Yuma. We provide disability income claim advice, assistance with filing disability claims, including completion of disability claim forms and representation in disability insurance litigation.

1 Bilezikjian v. Unum Life Ins. Co. of Am., 692 F. Supp. 2d 1203, 1208 (C.D. Cal. 2010); Provident Life & Accident Ins. Co. v. Hallum, 576 S.E.2d 849, 850 (Ga. 2003)
2 Bilezikjian, 692 F. Supp. 2d at 1206; Provident, 576 S.E.2d at 850.
3 692 F. Supp. 2d at 1205; 576 S.E.2d at 850.
4 Bilezikjian, 692 F. Supp. 2d at 1223.
5 Provident, 576 S.E.2d at 851.
6 Id.
7 Id.
8 Id.