Physician who cannot perform one material and substantial duty of his occupation is totally disabled

Dowdle v. National Life Ins. Co., 407 F.3d 967 (8th Cir. 2005) Minnesota

Dr. Dowdle was an orthopedic surgeon who spent half his time performing surgeries and the other half in office consultations. Outside of his surgical practice, Dr. Dowdle performed approximately 7 Independent Medical Examinations per week. However, surgery and surgery-related care comprised 85% of Dr. Dowdle’s orthopedic practice.

As the result of an accident in a private aircraft he was piloting, Dr. Dowdle suffered a closed head injury and a heel bone fracture. His injuries prevented him from standing at an operating table for an extended period of time, and thus, he was no longer able to perform orthopedic surgery. Pursuant to the terms of his disability income policy and Business Overhead Expense policy with National Life Insurance, Dr. Dowdle filed a disability claim. His claim was reviewed and he began receiving his maximum monthly total disability benefit.

Both disability policies defined total disability as the inability to perform the substantial and material duties of the Insured’s occupation. Residual disability is defined as the inability to perform one or more of the important daily duties of the Insured’s occupation or the inability to engage in the Insured’s occupation for as much time as was usual prior to the start of disability.

Within the next year, Dr. Dowdle began to perform office visits and some IMEs. Because Dr. Dowdle resumed duties he performed before his disability, National Life determined that he was now only partially disabled. Dr. Dowdle disagreed with this determination on the basis that his inability to perform orthopedic surgery, the most important part of his occupation, rendered him totally disabled.

Under Minnesota law (as well as Florida law and the law of many other jurisdictions), if the insurance policy language is ambiguous, it must be interpreted in favor of coverage. The Court’s review of the disputed policy language led it to conclude that an ambiguity exists, as the policies’ definition of “total disability” are susceptible to differing interpretations because they do not speak in terms of “any”, “all”, or “the most important part” of Dr. Dowdle’s duties. Accordingly, the 8th Circuit Court of Appeals found that the previous court’s holding, that the policies are to be construed in favor of Dr. Dowdle, was correct.

More specifically, the Court found that at the time he incurred his disability, Dr. Dowdle was engaged predominantly in the occupation of an orthopedic surgeon. The IME practice was separate and distinct from his surgery practice. Therefore, the fact that Dr. Dowdle performed IMEs both before and after the accident has no bearing on whether he can perform the “material and substantial” duties of being an orthopedic surgeon. Because Dr. Dowdle can no longer perform orthopedic surgery, which both parties concede is the most important substantial and material duty of Dr. Dowdle’s occupation as an orthopedic surgeon, he is entitled to disability benefits under Minnesota law.

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