ALABAMA, FLORIDA AND GEORGIA Disability Benefit Qualification Lawyers
Although most claimants will not qualify for total disability benefits based on their inability to perform one of the material duties of their occupation, the question often arises as to how many of the material and substantial duties a claimant must be unable to perform to be considered totally disabled. The courts of Alabama, Florida and Georgia have sought guidance in the words “the material and substantial duties” contained in the policy’s definition of total disability. In one recent case, for example, the policy defined total disability as “your inability due to injury or sickness to engage in the substantial and material duties of your regular occupation.” Before the district court, the claimant, a dentist turned real estate developer, proved he was unable to perform a “substantial majority” of the material and substantial duties of his real estate occupation. For instance, the claimant was able to perform such material duties as “selecting house plans, materials, and contractors.” The insurer argued the claimant was precluded from recovering disability benefits because the plain language of the policy disallowed benefits unless the claimant was unable to perform “all” of the material and substantial duties of his occupation. The district court rejected the insurer’s argument, concluding the claimant was unable to perform “substantial portions” of his occupational duties as a real estate developer.
On appeal, the court found “the” ambiguous, and construed the language in favor of the claimant. The court further noted that the insurer could have included “all” in the policy language, but chose not to. The court, therefore, interpreted “the” to mean the claimant was unable to perform “most” or the “majority” of his substantial and material duties. The disability benefit lawyers of MyLTDbenefits.com have repeatedly argued ambiguous policy language against the insurer and to the benefit of our clients.
“Selling Peanuts or Pencils” Does not Disqualify Claimant
In another recent case, the claimant was entitled to benefits only if he or she was “totally disabled and continues to be totally disabled by reason of bodily injury or disease so as to be prevented thereby from engaging in any occupation or employment for remuneration or profit.” The court held that “an absolute and literal interpretation” of that language, according to which “the affected individual must be utterly helpless to be considered disabled,” could not withstand even deferential review. The court read the plan’s language in light of the Congressional intent underlying the Employee Retirement Income Security Act of 1974 (ERISA), “that those who participate in the plans actually receive the benefits they are entitled to and do not lose these as a result of unduly restrictive provisions or lack of sufficient funds.” In light of this purpose, the court rejected a “strict, literal construction of such a provision which would deny benefits to the disabled if he should engage in some minimal occupation, such as selling peanuts or pencils, which would yield only a pittance.”
The phrase “any gainful employment” in the context of the insurance plan may not reasonably be read as denying benefits to a person who is physically capable of any employment whatsoever, so long as s/he earns a nominal profit. Nor may it be read as allowing an administrator to disregard a claimant’s individual vocational circumstances. To do so would “render the plan’s promise of a disability pension hollow for all but the most grievously incapacitated claimants,” would deprive plan participants of their reasonable expectations, and is arbitrary and capricious under the law of Alabama, Florida and Georgia. Our firm of disability benefit lawyers, MyLTDbenefits.com, has defeated insurance companies who claim that our client is physically capable of sedentary work. Such a finding is meaningless without some consideration of whether our client is vocationally qualified to obtain such employment, and to earn a reasonably substantial income from it, rising to the dignity of an income or livelihood, though not necessarily as much as she earned before the disability. This standard reflects the “most important purpose” of ERISA, which is “to assure American workers that they may look forward with anticipation to a retirement with financial security and dignity, and without fear that this period of life will be lacking in the necessities to sustain them as human beings within our society.”
The Cause-Based Approach to Determining Whether the Disability is Mental or Physical
The Eleventh Circuit uses a cause-based approach, which analyzes whether the illness has a physical (or “organic”) cause. The disability benefit lawyers of MyLTDbenefits.com always determine whether the policy specifies whether mental illness is determined by examining cause or manifestation. If not so specified, organically-based illnesses do not fall within the limitation, even if they manifest psychological symptoms, such as OCD.
Is our experience at MyLTDbenefits.com that courts taking a cause-based approach have typically decided in favor of insureds, either because they found the definition of mental illness in a disability policy to be ambiguous or because they found many such diseases to be physically-based. These courts find a symptom based definition for mental illness to be unsatisfying principally because such a definition logically would exclude many ailments that laypeople would commonly consider to be physical illnesses, such as abnormal behavior caused by a head injury or brain trauma, brain cancer, Alzheimer’s disease, or delirium resulting from a fever or staph infection.
The treatment-based approach focuses on how the condition was treated by the insured’s doctors. Under this approach, illnesses treated by psychiatrists employing such methodologies as psychotherapy and psychotropic medication have been considered to be mental illnesses. For example, post-partum depression was found to be a mental illness because treatment was rendered by a psychiatrist.
In reviewing the administrative record in a treatment-based approach, the disability attorneys of MyLTDbenefits.com find it helpful to identify the ICD-9 codes used in the medical records. ICD-9 codes 290-319 are generally reserved for mental disorders. A list of those codes is available online from numerous sources. They are divided into categories including psychoses (290-299), neurotic disorders (300-316) and mental retardation (317-319). (The ICD-9 codes will be replaced by ICD-10 codes by 2013)
Please contact us for experienced assistance with your ALABAMA, FLORIDA AND GEORGIA Disability Benefit Qualification claim. We pride ourselves on providing cost-effective solutions.