A Successful California Disability Insurance Claim Does Not Require “Absolute Helplessness”

One of the most hotly disputed areas among California disability lawyers focuses on the definition of “total disability” in private long-term disability insurance policies. An insurance company will routinely deny coverage, relying on policy language that, in its view, requires that the employee not only suffer from a disability but also that the disability prevents any type of work at all. These wrongful denials usually result in a dispute between residual disability and total disability. The difference in dispute is often several hundred thousand or millions of dollars. Disabled employees have successfully challenged these denials of coverage by convincing courts that the definition of totally disabled is not as strict as the insurance companies would like.

California Law Regarding Total Disability is Well Settled and Pro-Claimant

A California appellate court addressed this issue in Joyce v. United Insurance Company of America. The plaintiff in that case worked as a toolmaker at the Stanford University Electronics Laboratory. In 1957, he bought a disability insurance policy from United Insurance that would pay him $100 a month if he were totally disabled. In late 1957, he injured his shoulder while moving equipment. A month later, he hurt himself again. This time, he injured his right arm while moving a heavy-duty vise. He tried to return to work six months later but could not work more than a few minutes at a time. As a result, his employer fired him because he could not perform his job duties.

United Insurance denied benefits, claimed the employee’s total disability ended the moment he returned to work. But in California, “total disability” does not mean an “absolute state of helplessness.” Instead, it requires only that the insured cannot perform the “substantial and material acts” necessary to work in the “usual or customary way.” The employee argued that he couldn’t make tools in the usual or customary way because his injured arm would not allow him to move machinery or use his arm for more than a few minutes at a time.

California Disability Insurance Claimant Wins

The California appellate court held that the employee was totally disabled under California law. Even though the employee returned to work twice, the court pointed to the fact that the employee could not perform “substantial and material acts” to work in the “usual or customary way.” And, under California law, a “totally disabled” claimant does not lose this status simply because he can perform sporadic tasks. As the claimant’s attempts to resume work were short-lived, the court properly found the employee should receive disability benefits. If you have been denied disability benefits, contact our California disability attorney for a free consultation.

Joyce v. United Ins. Co., 202 Cal. App. 2d 654 (1962).

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There are 4 comments

  • Mark,

    What long term disability carrier would your claim be through?

    Stephen JessupMar 17, 2015  #4

  • This is my problem. In 1979 I was struck by an automobile (veh. vs ped.) and lost my right arm. I did receive compensation, but elected to luckily return to the same occupation. I continued in the Land Surveying field until 2010, I took my retirement and took on another occupation. My sister in law hired me as a supervisor/purchasing agent/truck driver, I do wear allot of hats. At this time, I live in allot of pain now a days and my accident is now taking its toll on the rest of my body. My symptoms are major arthritis in my hand, elbow and shoulder, I also have back pain from my compensating for so many years. My original Attorney is now retired and is unavailable, at the time of settlement, he told me in the future, I should be able to make a new claim, if I where to have any other physical problem. Can you help, or do I have to keep struggling?

    Mark Steven RombalMar 16, 2015  #3

  • Andrew,

    If your policy is governed by ERISA it would be wise to comply with the request to obtain the records. If the hospitalisation occurred 18 months ago (which would presumably mean the after effects would have been present in 2012) then those records would logically appear to be pertinent to your claim as is stands today. As I am unsure as to the facts surrounding your claim I do not know if Standard is also reviewing the claim for a pre-existing condition limitation. Additionally, if you have signed authorisations at the inception of your claim allowing Standard to gather medical information, they would have the right to do so, unless the authorisation is revoked. If you would like to discuss your claim further you may contact us directly to consult with one of our disability attorney.

    Stephen JessupJun 7, 2013  #2

  • I was hospitalised for life threatening bacterial meningitis about 18 months ago. Cognitive impairment worsened over 13 months leading to a medical leave which is in it’s 90th day. I am a professional with an ethical obligation to acknowledge and address my cognitive issues or risk malpractice and losing my license.

    Treatment and testing for “post meningitis syndrome” with objective neuro-psychological testing showing noticeable impairment. Although I have had worsening symptoms over 18 months, formal evaluation and treatment did not begin until March 2013.

    Standard Insurance initially accepted my STD and paid 10 days of benefits, then stopped payment claiming that they have not received my doctor’s records from 2012, but she does not have them since I started treating with her in March of 2013. My doctor placed me on leave for 90 days.

    Standard now wants obtain records from all of my doctors in 2012 to present. Can I refuse absent a showing of good cause as to the issue those records could address? This seems like a fishing expedition. Please help.

    AndrewJun 6, 2013  #1

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Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

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In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

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Steve Dell has done an exceptional job with my disability application process. The firm is extremely well managed. They have acquired an incredible amount of experience over many years. I recommend them for disability insurance claims without reservation. 

Don (Florida)

I called this firm a few months ago completely disparaged due to a company cutting off disability benefits at a time that nearly caused me to lose everything.

Attorney Alex Palmera and Danielle worked hard to reach an amicable settlement and my case was settled a few months later. This is a good firm and the specific expertise in disability claims saved me countless hours of hassle at a time when an already fragile state existed.

Thank you Mr. Palamara and Danielle.

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I have nothing but good things to say about how my buyout was handled with my disability claim. The level of professionalism was amazing. All of my questions and concerns were answered either by Danielle L. or Alex P. in such a timely manner and with such care I would recommend them in a heartbeat to anyone needing to approach their provider with buyout options.

They did a fantastic job communicating between the provider and me, always keeping my best interest at heart and always answering my many many questions. They really did take most of the stress out of this whole situation. I would give them a 10 out of 10 for every step of this crazy journey. Thank you so much for helping me through this.

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I needed assistance with an appeal for a LTD claim that was initially denied. Stephen understood what needed to happen to win the appeal and he did win the appeal for me.

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Greg Dell and his assistant Anneli have been extremely responsive and helpful, not only our initial consultations, but in follow-ups 1 and 2 years later with the insurance company to ensure that they comply with their agreements (which they did), as well as a separate and only slightly-related inquiry about our health insurance. I always hear back from them very quickly, which is rare and greatly appreciated.

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