Disability Claimant Not Barred from Benefits by Mental Disability or Sedentary Functional Work Capacity

If you are disabled to work, the experience is stressful for both you and family members who are financially dependent on you as a breadwinner.  If you have purchased disability insurance to mitigate this risk, it can be an extremely frustrating experience when you file a claim and do not receive the funds promised by your disability insurer.  While disability insurance companies often rely on obtuse and confusing policy language to discontinue, deny or underpay claims, securing the advice and representation of an experienced Miami disability claims attorney can protect your interests.

A recent Fifth Circuit Court of Appeals case out of the Federal District Court in Texas, which is an extremely conservative court, ruled in favor of a claimant in a situation faced by many claimants.  The disability insurance carrier denied the claim based on two separate rationales.  The first basis for denial was rooted in the fact that the insured experienced both mental and physical impairment.  Under the language of the policy, the maximum duration for payment of benefits was limited where mental impairment “caused or contributed” to the disability.  The policy limited the duration of payments for a mental impairment to two years.

In addressing this basis for denial, the appellate court observed that the policyholder was totally disabled because of the physical disability irrespective of any accompanying mental disability.  Based on the claimant’s total disability based on physical impairment, the court explained that the “caused or contributed” language did not constitute a valid basis to discontinue benefits.

The court's analysis is important because it protects many claimants who are both physically and mentally disabled.  The “caused or contributed” language related to mental impairment is common in disability policies, so the language protects claimants suffering from both forms of disability.  Predictably, many claimants who are physically unable to work suffer depression and related mental impairments.  While this federal court decision is not controlling precedent in Florida disability claims, the decision provides persuasive reasoning for claimants struggling with the emotional and mental impact of severe physical injury or illness.

The second justification for denial of the claim was based on the contention that the insured did not meet the definition of “disability” because the claimant could perform sedentary work.  The court rejected this argument by the insurer which was based on the contention that the claimant could work in some occupation.  The court observed that the insurer failed to produce evidence from a vocational expert to support this assertion.  The court also pointed out that the policy did not establish mere employability in some other occupation as the standard for determining disability.  The policy provided coverage if the claimant was unable to engage in an alternate occupation that would generate a comparable income to the claimant’s prior livelihood.

Based on its rejection of the two justifications offered by the insurer for discontinuing benefits, the appellate court reversed the trial court and found for the claimant.  If you have questions about Florida disability insurance claims, you are welcome to contact my Miami insurance claims dispute law firm.  My law firm represents policyholders in claims disputes in Miami and throughout Florida.  The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations.  No Recovery, No Lawyer Fees.  Call 305-461-1095 or Toll Free 1-866-71-CLAIM.

Be the first to comment!
Post a Comment