Do I Qualify For Total Disability Insurance Benefits In Texas?

Since 1922, disability claimants in the state of Texas have been arguing with disability insurance companies as to whether they are entitled to “total disability” benefits. In most private disability insurance policies, “total disability” is defined as the inability to perform the substantial and material duties of your own occupation. The answer to whether a claimant is entitled to receive total disability benefits is a fact specific question that requires an understanding of the definition of “total disability” in Texas and a detailed analysis of the exact work duties the claimant was performing during the time period immediately before he or she became disabled.

Let’s take a look at a lawsuit brought by an OBGYN against Provident Life and Accident Company (also known as UNUM) in which the Texas appellate court explained and interpreted the definition of “total disability” after this doctor’s claim for total disability was denied by UNUM.

OBGYN Doctor Sues Provident Life Seeking Total Disability Benefits

An OBGYN, Dr. K, was involved in a plane crash that resulted in a fracture to his spine and kept him out of work for two months. Dr. K returned to work in a full time capacity but there were various medical procedures that he could no longer perform. Unum denied his claim for total disability benefits by claiming that he could perform some of his pre-disability duties and he did not satisfy the 90 day elimination period by returning to work in 60 days.

The exact duties of what Dr. K. was able to do pre-accident versus post-accident were not discussed in the Texas Appellate court’s decision. Dr. K’s initial lawsuit was dismissed as the Judge agreed with Unum that Dr. K was not eligible for total disability. Dr. K appealed and his Texas disability insurance lawyer argued that a jury must be able to decide if he is totally disabled based upon the facts of his case and not a Judge. The appellate court agreed with Dr. K. and issued a detailed written opinion explaining how Texas courts and insurance companies must interpret the definition of “total disability” in Texas.

The Texas Court Systems Interpretation of “Total Disability”

In a disability insurance dispute, Courts are called upon to interpret the terms of an insurance contract. In Dr. K’s case, his disability policy contained the following definition: “Total Disability means that due to Injuries or Sickness, you are unable to perform the duties of your occupation.” With respect to the dispute between Dr. K and Unum, the most important words are “the duties of your occupation.” Unum argued that Dr. K cannot be totally disabled under the policy unless he is unable to perform all the duties of his occupation. On the other hand, Dr. K contends that he is disabled if he is unable to perform any duty of his occupation.

The Texas Appellate court cited numerous disability cases going back to 1922 and explained that the construction of Dr. K’s definition of total disability in his disability policy is governed by a series of Texas Supreme Court cases dealing with total disability policies. We have quoted below the court’s historical explanation of these cases and the court’s reasoning for reversing the lower court’s dismissal of Dr. K’s lawsuit:

Commonwealth Bonding & Casualty Ins. Co. v. Bryant, 113 Tex. 21, 240 S.W. 893 (1922), involved an insurance policy which provided for the payment of weekly total disability benefits if the insured sustained injuries which would “wholly disable and prevent the insured from performing any and every kind of duty pertaining to his occupation.” The court refused to give a literal interpretation to the policy’s definition of total disability. Instead, the court ruled that the insured was totally disabled if he was substantially unable, in the exercise of ordinary care, to perform every material duty pertaining to his occupation.

In Great Southern Life Ins. Co. v. Johnson, 25 S.W.2d 1093, 1097 (Tex. Comm’n App.1931, holding approved), the insurance policy provided for total disability benefits if the insured was “wholly prevented from performing any work for compensation or profit or from following any gainful occupation.” The court further stated:

A policy requiring payment for total disability ordinarily is not one of indemnity against loss of income but against loss of capacity to work. Cooley’s Briefs on Insurance (2d Ed.) 5536.

“Total disability” is necessarily a relative matter, and must depend chiefly on the peculiar circumstances of each case and on the nature of the occupation or employment and the capabilities of the person injured. It does not mean absolute physical disability of the insured to transact any kind of business pertaining to his occupation, but exists if he is unable to do any substantial portion of the work connected therewith. – (Emphasis added)

“Thus, Johnson modified Bryant by deleting the requirement that every material duty be impacted. The court in Prudential Insurance Company of America v. Tate, 162 Tex. 369, 347 S.W.2d 556 (1961), reaffirmed the holdings in Johnson. As per the holdings in Johnson and Tate, Dr. K was totally disabled if he was unable to do any substantial portion of the work connected with his occupation.

The holdings in Johnson and Tate are based on policy grounds which reject the express definitions contained in each of the insurance policies that were at issue. It would appear that the holdings in these cases possibly conflict with the Texas Supreme Court’s current approach to construing insurance policies. In Trinity Universal Insurance Company v. Cowan, supra at 823, the court held that, when terms are defined in an insurance policy, those definitions control. We would note in this regard that, after the enactment of the ERISA in the 1970s, the vast majority of reported cases involving disability insurance have been litigated in the federal court system. Be that as it may, the holdings in Johnson and Tate speak directly to the meaning of total disability in an insurance context, and they have not been overruled.

Provident (Unum) argues that Johnson and Tate are distinguishable because the policies at issue in this case provide for the payment of partial disability benefits. We disagree with this assessment. The policies defined partial disability as the inability to perform “one or more, but not all” duties. Provident contends that, if one harmonizes the partial disability definition of “one or more, but not all” duties with the definition of total disability, the policies imply that all duties must be impacted in order to constitute total disability. Even if one assumes that the policies contain an implied requirement that all duties be impacted for the total disability provision to apply, Johnson and Tate are still controlling because those cases rejected express requirements that all duties be affected.

The determination of whether or not Dr. K was unable to do any substantial portion of the work connected with his occupation when his total disability benefits were terminated is inherently a fact question. See Prudential Insurance Company of America v. Tate, supra at 554. Dr. K testified to various procedures which he could not perform as a result of his disability. This testimony raises an issue of fact precluding dismissal as to the ground that Dr. K was not disabled when Provident denied his claims for total disability benefits.

Attorneys Dell & Schaefer have Helped Thousands to Collect Total Disability Benefits

Similar to the battle that Dr. K had with Unum, our law firm has handled this same exact situation on behalf of thousands of physicians and other professionals. The ultimate decision comes down to a jury and our disability attorneys have been through a jury trial with Unum and litigated countless cases dealing with the total vs. residual disability issues. The key is to collect your disability benefits without ending up in court. Every claim is fact specific and there are often things that a claimant can do in order to either strengthen their claim or position themselves to collect total disability benefits in the future. Dr. K did not understand his disability policy and he unfortunately waited many years to battle Unum. Time is of the essence with disability claims and it is always best to consult with a disability attorney in order to make sure that you are maximizing the terms of your disability insurance policy. Contact us for a free consultation to discuss your disability claim options.


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Low payments

Reviewed by Dorothy on November 30th 2023   Verified Policyholder | November 2023 date of disability
I was injured at work. I did house keeping in a hospital. I tore just about everything imaginable in my knee. I was let go from my job, because I was no longer able to do ... read more >
Unum

They closed my claim and I have been without income since they closed it

Reviewed by Mary C. on November 8th 2023   Verified Policyholder
Went off work on 9/26/22 due to back issues. Applied for Short Term Disability. On Jan 2023 switched over to Long Term Disability and Unum had me to apply for Social Secur... read more >
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I feel like Unum is giving me the runaround!

Reviewed by Rachelle H. on May 11th 2022   Verified Policyholder
I have contacted UNUM multiple times since I’ve needed them. I feel like they are giving me the runaround! Please help!
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Sent on May 11th 2022 by Attorney Stephen Jessup

Rachelle, the law provides certain timelines and deadlines with which to provide information or decisions. Please feel free to contact our office to discuss your situat... read more >

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Unum terminated my benefits with no warning

Reviewed by K. Potter on September 9th 2020   Verified Policyholder
I was told I was covered with Unum through my employer (continuum). I got an email today for my termination, no prior talks of infractions with attendance, no warnings, no... read more >
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Sent on September 9th 2020 by Attorney Stephen Jessup

K. Potter, termination as in your employment was terminated or a disability claim was terminated? If your employment was terminated and you had not filed a claim for di... read more >

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I've been trying to care care of my Unum benefits for over a year. They’ve been so rude

Reviewed by Tracey W. on August 30th 2020   Verified Policyholder
I have been trying to take care of my Unum benefits for over a year. I’ve called and back in November I did appeal letter, they say they never received. I did everything... read more >
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Sent on August 30th 2020 by Attorney Gregory Dell

Tracey, I am sorry to hear of your issues with Unum. We would love to learn more about your claim to see if we can get Unum to pay or if we can sue them with you. Pleas... read more >

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I've paid for STD for 20+ years. Now, I'm actually sick and can't get paid

Reviewed by Natalie on June 29th 2020   Verified Policyholder
My employer uses unum for short-term disability. I was hospitalized back on june 13 and discharged on june 25. I was admitted for double pneumonia and hypoxia, which I end... read more >
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Sent on June 29th 2020 by Attorney Rachel Alters

Natalie, hopefully your claim will be approved. If they deny the STD claim then you will need to appeal the determination.

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Unum thought I was fine to work. I wasn't

Reviewed by Elizabeth L. on May 21st 2020   Verified Policyholder
48 yoa dentist POTs Dx aug 22. Attempted to return to work initially but got sick. Was going to go back 2 days/wk in September but could not. Then did go back part time as... read more >
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Elizabeth, please contact our office to discuss the denial of your claim and your rights to pursue legal action against Unum.

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Reviewed by Kevin on February 6th 2020   Verified Policyholder
Hi, I am currently receiving LTD from UNUM. I used to work as a Radiologist Tech at Vanderbilt Medical Center in Nashville, TN. for about 10 years. Than I started having g... read more >
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Kevin, I am sorry to hear all that you are going through and the stress this is causing you. The policy governing your claim likely does allow Unum to conduct an in-per... read more >

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Preparing a strong disability appeal package is an art that requires you to understand how the courts interpret your disability policy language, ERISA regulations / laws, and how to strategically present evidence in support of your definition of "disability". We encourage you to contact any of our attorneys for a free immediate review of your disability denial.

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We are disability insurance attorneys that know how to get your short or long term disability benefits paid. As a nationwide law firm we have helped thousands of disability insurance claimants throughout the United States to collect hundreds of millions of dollars of disability insurance benefits from every major disability insurance company.

In more than 98% of our cases, our attorneys have been able to either get our clients paid monthly disability benefits or obtain a one-time lump-sum settlement. Our disability insurance lawyers have seen it all when it comes to disability insurance claims and we know exactly what it takes for your disability claim to be approved.

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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.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

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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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via phone, email, fax, or video conferencing sessions. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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