Definition of "Total Disability" Deemed Unambiguous; Precludes Coverage for Gainfully Employed IME Physician
In White v. Continental Cas. Co. (NY Nov. 27, 2007), the New York Court of Appeals considered whether the definition of “total disability” in a disability income policy was ambiguous, and, if not, whether the insured had satisfied the definition to permit recovery under the policy. The court held it was not, and that the insured failed to establish his entitlement to benefits.
The suit was filed by an orthopedic surgeon who was denied disability benefits after claiming he was unable pursue his occupation as an orthopedic surgeon due to a hip condition. Under the terms of the policy, the insured was totally disabled if he was “unable to perform the substantial and material duties of [his] Occupation due to an Injury or Sickness,” and not “[performing] the duties of any gainful occupation for which [he is] reasonably fitted by education, training, or experience.”
The insured argued that he qualified for the coverage under the first provision of the definition, and that the second provision was ambiguous and rendered the coverage illusory. The court agreed that the insured was totally disabled under the first provision of the definition; however, the court found the second provision of the definition was clear and unambiguous. The insured could not satisfy the provision because he continued to render second medical opinions on spinal surgery, perform independent medical examinations, and serve as an expert medical witness.
