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Milton Disability Cases in the News
WHAT DOES ‘TOTALLY DISABLED’ MEAN IN DISABILITY CLAIMS?
Long-term disability plans commonly require a claimant to be ‘totally disabled’ before the person is eligible to receive long-term disability (LTD) benefits under their plan. In the first two years after becoming disabled, a person must show that their disability prevents them from performing their current job. After two years and potentially, until retirement age (65), the person’s disability must preclude them from performing any job for which they are reasonably qualified, based on their education, experience or training
But what does ‘totally disabled’ mean? The Supreme Court of Canada made a ruling on this question in the leading case, Paul Revere Life Insurance Co. v. Sucharov (1983). In this trial, the insurer appealed an earlier finding by the Manitoba Court of Appeal, which decided that a man who was claiming LTD benefits was entitled to recover for total disability, not simply for partial disability, under his insurance plan. The Supreme Court was tasked with determining whether the lower courts applied the correct legal test to differentiate between total and partial disability.
In this case, the claimant’s insurance policy defined 'total disability' to mean:
"that, as a result of such injury or sickness, the Insured is completely unable to engage in his regular occupation; however, after Monthly Indemnity has been payable hereunder during any continuous period of disability to the Insured’s fifty fifth birthday or for a period of sixty months, whichever is the longer, then during the remainder, if any, of the period for which Monthly Indemnity is payable, “total disability” shall mean complete inability of the Insured as a result of such injury or sickness to engage in any gainful occupation for which he is reasonably fitted by education, training or experience, giving… consideration to his economic status at the beginning of disability."
Partial disability, under the insurance policy meant:
"…the inability of the Insured to perform the regular daily duties of his occupation at least one-half of the time usually required in that occupation or the inability to perform one or more of the important regular duties of his occupation."
The trial judge stated that the law is quite clear with respect to total disability provisions in insurance policies – specifically, a plaintiff must show that they are totally unable to perform the duties covered by their given insurance policy which, it must be noted, may differ from the provisions set out in other insurance policies. In the case of Paul Revere Life Insurance Co., in order to be entitled to receive LTD benefits, the plaintiff was obligated to prove that he was suffering from a continuous disability which required regular care from a physician and “caused him to be totally disabled and completely unable to engage in his regular occupation”, as the owner-manager of an insurance brokerage business. However, the trial judge noted that ‘total disability’ in the later period of disability did not require that the claimant is so disabled that they cannot work in any gainful occupation; rather, the policy states that the claimant is entitled to benefits if he proves that he is “not able to pursue any other similar gainful employment”.
The Court of Appeal upheld the trial judge’s finding and asserted that the key issue was whether, based on all the evidence provided, the insured is entirely unable to engage in his occupation as owner-manager of the insurance brokerage business. Justice Hall, speaking for the Court of Appeal, found that the trial judge made no legal or factual errors in assessing the scope of the claimant’s coverage.
The insurer’s main argument was that the insured is not totally disabled because his disability did not entirely prevent him from engaging in his occupation -- he was able to perform some aspects of his job, including selling insurance, bookkeeping and making phone calls.
Justice Hall disagreed with the insurer’s argument, noting that a reasonable interpretation of the insurance contract is that the insured is eligible for coverage if they are completely unable to engage in their regular occupation, and in this instance, although the insured was able to carry out some of the aspects in the running of his business, the essential point is that “he was completely unable to perform the whole of his regular occupation”. Justice Hall pointed to undisputed medical evidence that showed that, when attempting to function as owner-manager, the insured suffered attacks of nervousness and stress that bordered on hysteria. The judge concluded that the insured is totally disabled from performing his occupation when he cannot perform substantially all of the duties of that job.
The Appeal Court referenced Couch on Insurance (1983), where it was stated that the question of toal disability is satisfied when the situation is such that a reasonable man would conclude that they should not engage in a particular activity even when they are not necessarily physically unable to perform the activity. This means that an insured individual may be considered totally disabled, as defined under an insurance policy, when their disability is such that prudence and care requires that they cease working in their occupation in order to facilitate their own recovery or to prolong their life.
Justice Hall rejected the insurer’s reliance on the decision in Harding v. Prudential Insurance Co. of America (1940) where, in that case, total and permanent disability required that the insured is wholly, continuously and permanently unable to perform any type of employment for any compensation, for the rest of his life. The judge found that the insurance provisions in Harding were different and thus, not relevant to the current case, which is more favourable to the insured.
The Supreme Court upheld the Court of Appeal’s arguments and ruling, and the insurer’s appeal was dismissed.
Today, the commonly accepted conditions of long-term disability contracts require that, in the first two years of becoming disabled, the insured is eligible for LTD coverage if they are unable to perform ‘substantially all’ of the duties of their current occupation. This is generally interpreted to mean that the insured is totally disabled if they cannot perform all the essential tasks of their job. After two years, the requirements demand an inability on the part of the insured, to perform the essential tasks of any occupation, for which they may be reasonably suited.
If you were denied long-term disability by your insurer on the basis that they found you are not totally disabled or for any other reason, call Kotak Personal Injury Law. At Kotak Law, we specialize in representing Milton clients in disability claim disputes against insurance companies, and our lawyers offer the expertise and legal knowledge necessary for resolving your claim favourably.
Disclaimer: This article is intended to supply general information to the public. We make every effort to ensure the accuracy of this information. However, as laws change quickly, the reader should always ensure the accuracy and applicability of such information with respect to their particular case. The information contained in this article cannot replace a thorough and complete review of the reader's situation by competent legal counsel who has had an opportunity to review all of the facts.
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