Is A Physician Who Is No Longer Able To Perform Surgery Totally Disabled Under An Own Occupation Disability Insurance Policy?

Numerous cases exist where a physician who has specialized as a surgeon becomes unable to perform surgical procedures due to injury or illness but remains able to still perform other duties as a physician. Whether or not this is considered a total or residual disability benefits claim is contingent upon the specific disability insurance coverage you have with your insurance company. Insurance companies frequently either deny these types of disability claims by physicians outright, or attempt to pay these claims only as “residual disability,” which usually involves a much reduced disability income benefit when compared to the “total disability” benefit at issue. There is legal authority to support the position that a physician who is no longer able to perform surgery is totally disabled under own occupation disability insurance coverage, particularly where “specialty” own occupation disability insurance coverage is at issue. However, having a disability insurance claim approved by an insurance company as such is another story entirely.

Take for example the case of Kraft v. Massachusetts Casualty Insurance Company, 320 F. Supp. 2d 1234 (N.D. Fla. 2004). Dr. Kraft was a cardiologist who practiced in the specialty area of invasive and interventional cardiology. He was insured under a disability policy that included both residual and total disability provisions. The term total disability under his policy meant a “complete inability of the Insured to engage in his regular occupation or profession” and the term residual disability meant the “ability of the Insured to perform some but not all of the important duties of his regular occupation or profession.”

Unfortunately, due to degenerative disc disease causing back pain radiating into his legs, it became necessary for Dr. Kraft to undergo a lumbar discectomy. Dr. Kraft attempted to resume working as an invasive and interventional cardiologist, but was unable to, as it required him to wear a “weighty protective apron, to stand for periods of time, to rotate his body, and to bend over for extended periods.” Dr. Kraft’s partners agreed that he would remained employed by the practice, but that he would not perform any further invasive procedures and instead would continue to work only as a general cardiologist.

Upon Dr. Kraft submitting a total disability claim to his insurance company (Massachusetts Mutual), Mass Mutual denied his claim, asserting that Dr. Kraft would have to submit a residual disability claim instead, because he was still working as a cardiologist. Dr. Kraft’s treating doctors clearly found him to be disabled as an invasive and interventional cardiologist. Central to the case was determining that Dr. Kraft’s regular occupation was in fact that of an invasive and interventional cardiologist and not merely a cardiologist. As the Court explained, “determining Dr. Kraft’s regular occupation or profession is the central issue in this case. Dr. Kraft insists that his ‘regular occupation or profession’ should be considered his specialty, ‘invasive and interventional cardiology’ rather than merely his general field of cardiology. The reason this distinction matters is that the evidence in this case is uncontroverted that Dr. Kraft can perform ‘some but not all of the important duties of’ a cardiologist, but that he can perform none of the important duties of an ‘invasive and interventional cardiologist.’” The Court went onto to determine that Mass Mutual’s denial of total disability benefits to Dr. Kraft was incorrect and ordered Mass Mutual to pay total disability benefits.

There is also the case of Groff v. The Paul Revere Life Insurance Company, 887 F. Supp. 1515 (S.D. Fla. 1993). Dr. Groff was a successful ear nose and throat surgeon. Prior to his disability, Dr. Groff’s occupation consisted of a significant clinical practice, minor surgery, and major neck and head cancer surgery. As a result of injuries sustained, Dr. Groff became unable to perform major neck and head cancer surgeries without assistance. As a result, Dr. Groff hired a surgeon to aid him in the performance of these types of surgeries. The Court found that these major neck and head cancer surgeries could not be characterized as merely a nominal part of Dr. Groff’s practice, as he “performed many such surgeries, and accepted such referrals from many local physicians.” A Florida jury later found (which was upheld by the Court) that Dr. Groff was in fact totally disabled under the terms of his Paul Revere contract, because he could no longer perform these major neck and head cancer surgeries unassisted. All the while, Dr. Groff was able to maintain a thriving minor surgery and clinical practice, which was held not to affect his entitlement to total disability benefits under his contract.

Another relevant case is that of Dowdle v. National Life Insurance Company, 407 F.3d 967 (8th Cir. 2005), Dr. Dowdle was an orthopedic surgeon who filed a disability claim upon him becoming unable to perform orthopedic surgery. Prior to Dr. Dowdle’s accident causing his inability to perform orthopedic surgery, he was also involved in performing some non-surgical duties for the practice, including independent medical examinations and managing patients’ medicines and rehabilitations. The insurance company paid residual disability benefits rather than total disability benefits under the policy in light of Dr. Dowdle’s ability to perform non-surgical tasks. However, the court held that this was incorrect, and that the insurer had misclassified his disability claim as residual when in actuality it was a total disability claim in light of Dr. Dowdle being unable to perform the most important substantial and material duty of his occupation as an orthopedic surgeon, which was orthopedic surgery. As such, the court found that because Dr. Dowdle was prevented from performing the most important part of his occupation, he was entitled to total disability benefits.

Still further is the case of Oglesby v. Pennsylvania Mutual Life Insurance Company, 877 F. Supp. 872, 881 (D. Del. 1994). In that case, the physician practicing as an interventional and vascular radiologist suffered from degenerative cervical spine problems which ultimately required surgery. Following surgery, Dr. Oglesby’s condition deteriorated and he could no longer perform interventional procedures, but could still perform the duties of a radiologist. Critical to the case was whether Dr. Oglesby’s regular occupation according to the disability insurance policy terms was that of a general radiologist or an interventional and vascular radiologist. The Court in that case ultimately determined that Dr. Oglesby’s “usual work” was that of an interventional and vascular radiologist and not a general radiologist, and that he could no longer perform the substantial and material duties of that “usual work” since he could no longer wear the heavy lead apron required to perform the interventional procedures at issue.

There are numerous other cases similar to those summarized above, some of which resulted in a judgment by a court favorable to the insured physician, and some which resulted in a judgment by a court favorable to the insurance company. The chances of a lawsuit being decided in favor of a plaintiff physician is very much influenced by how the physician’s disability claim is handled by the physician prior to the lawsuit being filed, and the skill and expertise of any attorney involved both pre-litigation and in the litigation.

If you are a physician experiencing an illness or injury that has interfered with your ability to perform surgery or a major duty in your specialty area of medicine, contact one of our experienced and skilled attorneys today to receive a free consultation in regard to your disability insurance claim.