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Lawsuit Causes of Action

  • Private Disability Insurance Benefit Denial Legal Options
  • Things to Expect if Your Disability Insurance Claim was Denied and a Lawsuit Must be Filed
  • Deposition of Insurance Co. Employee in a Disability Insurance Benefits Denial Lawsuit (Ep. 19)
  • Deposition of medical consultant hired by MetLife for a disability insurance claim (Ep. 18)

If a disability insurance company has denied benefits to an insured, there may be multiple causes of action that can be alleged in a lawsuit against the insurance company. Each state has different laws and it is possible that some of the causes of action listed below may not be viable in the state where a claimant’s lawsuit must be filed. Attorneys Dell Schaefer has filed lawsuits against disability insurance companies in both state and federal courts throughout the country.

Breach Of Contract

The most common reason for denial of an insured’s claim for benefits is that the insurer has rendered an opinion that the insured is not “disabled” as defined by the subject disability policy. If the insured has been wrongfully denied benefits, the legal cause of action that may be filed against the insured is a first party breach of contract action. Similar to most first-party insurance cases involving a denial of benefits by an insurer, disability insurers are subject to actions for breach of contract. In order to prevail in an action for breach of a disability insurance contract the insured must prove the traditional common law elements for breach of contract:

  1. existence of a contract;
  2. a breach of the contract;
  3. damages resulting from the breach.

Additionally, in most cases, the burden of proof is on the insured to show:

  1. that he or she was regularly engaged in an occupation at the time of their disability;
  2. that he or she is disabled (either totally or partially);
  3. he or she is under the reasonable care of a physician qualified to treat them for their disabling condition.

Any lawsuit filed for breach of contract must have a copy of the disputed disability policy attached as an exhibit to the complaint. Most disability breach of contract actions involve questions of facts for the jury, therefore it is appropriate to demand a trial by jury in the complaint.

Breach Of Implied Covenant Of Good Faith And Fair Dealing

Every contract imposes upon each party a duty of good faith and fair dealing in its performance and enforcement. Under the law of most states, the implied covenant of good faith and fair dealing is a part of every contract. Asserting a claim of breach of implied covenant of good faith and fair dealing is often raised in first party disability insurance actions. Some insurance companies will move to strike an allegation of breach of the implied covenant of good faith and fair dealing on the basis that it is nothing more than a bad-faith claim in disguise. However, there is a clear distinction between an action for bad faith and alleging that the insurance carrier breached the implied covenant of good faith and fair dealing.

There are several important points that must be understood to properly allege breach of the implied covenant of good faith and fair dealing. It is important to note, that no independent cause of action exists for breach of the implied covenant of good faith and fair dealing. “Where a party to a contract has in good faith performed the express terms of the contract an action for breach of the implied covenant of good faith and fair dealing will not lie.” [A] claim for breach of the implied covenant of good faith and fair dealing cannot be maintained without identifying express contractual provisions that have been breached. In addition, the allegations pleading breach of the implied covenant of good faith and fair dealing should not be redundant where the conduct which forms the alleged violation is duplicative of the companion cause of action.

The implied covenant of good faith and fair dealing is limited in two ways: first, the claim must be accompanied by an allegation that an express term of the contract has been breached; and the implied obligation of good faith cannot be used to vary the terms of an express contract. Hence, to establish this cause of action, a plaintiff “must demonstrate a failure or refusal to discharge contractual responsibilities, prompted… by a conscious and deliberate act, which unfairly frustrates the agreed common purpose and disappoints the reasonable expectations of the other party, thereby depriving that party of the benefits of the agreement.“ Generally, the courts have been split on allowing the insured to plead breach of the implied covenant of good faith and fair dealing.

Fraud: Intentional Or Negligent Misrepresentation

An insured can plead an action for intentional misrepresentation against the disability insurer. In order to succeed in a claim for fraud or intentional misrepresentation against the disability insurer and/or the insurance agent, the insured must prove: “(1) a misrepresentation of a material fact; (2) which the person making the representation knew to be false; (3) that the misrepresentation was made with the purpose of inducing another person to rely upon it; (4) that the person relied on the misrepresentation to his detriment; and (5) that this reliance caused damages.” An allegation of fraud must be made with particularity. Where fraudulent misrepresentations were made by an agent of the insurer, both the agent and the insurer are liable. Furthermore, the insurer is estopped to deny coverage in accordance with the misrepresentations.

An insured or insurance company may also plead negligent misrepresentation. In order to succeed, the plaintiff must prove that: “(1) the defendant made a misrepresentation of material fact that he believed to be true but which was in fact false; (2) the defendant was negligent in making the statement because he should have known the representation was false; (3) the defendant intended to induce the plaintiff to rely… on the misrepresentation; and (4) injury resulted to the plaintiff acting in justifiable reliance upon the misrepresentation.“

Intentional Infliction Of Emotional Distress

“A cause of action for ‘intentional infliction of severe mental or emotional distress,’ more appropriately called ‘outrageous conduct causing severe emotional distress,’ essentially involves the deliberate or reckless infliction of mental suffering on another, even if unconnected to any other actionable wrong.” An insurer need not intend to cause emotional distress to be subject to an action for intentional infliction of emotional distress; it need only be shown that the insurer “intended [its] specific behavior and knew or should have known that the distress would follow.“

Fraudulent misrepresentations by the insurer or its agents can give rise to a cause of action for intentional infliction of emotional distress, as can the denial, delay and interference with medical treatment and the claims process. The key is that the conduct, when “[m]easured by the standards of human decency and societal expectations,“ would cause one to be outraged.

Breach Of Fiduciary Duty:
Misrepresentations By Insurance Broker Or Agent

Under the law of most states, an insurance broker is in a fiduciary relationship with an insured. An insured may bring an action against his/her agent whose negligence causes the insured to become embroiled in litigation to secure coverage and incur attorney’s fees and costs.

Declaratory Judgment: Clarifying Policy Terms

In the disability insurance arena declaratory judgment actions are most often plead to clarify ambiguous terms in the disability insurance policy. “Questions of fact and disagreements concerning coverage under insurance policies are proper subjects for a declaratory judgment if necessary to construction of parties’ legal rights.“  “Generally, declaratory relief is not available to settle factual issues upon which coverage questions turn under an insurance contract which is clear and unambiguous, because such instances present no need for contract construction or interpretation.“ Actions for declaratory judgment are appropriate when the Plaintiff is entitled to a declaration of rights. “To state a cause of action for declaratory relief, a complaint must allege that there is a bona fide dispute between the parties and that the moving party has a justifiable question as to the existence or non-existence of some right, status, immunity, power or privilege, or as to some fact upon which the existence of such right, status, immunity, power or privilege does or may depend, that plaintiff is in doubt as to the right, status, immunity, power or privilege, and that there is a bona fide, actual, present need for the declaration.“

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