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Is an Emergency Room Physician Working as a General Practice Physician Totally or Partially Disabled under a Disability Insurance Policy?

Whether an emergency room physician working as a general practice physician is totally disabled or partially/residually disabled under a disability insurance policy depends on the type of disability insurance policy that is at issue, and the law governing the policy and claim filed. However, under many "own occupation" disability insurance policies, an individual whose occupation at the time of "disability" was truly emergency room doctor should be considered "totally disabled" if he or she is unable to perform the material and substantial duties of an emergency room doctor. This should be regardless of whether the individual is working in a new occupation, even if the new occupation is as a general practice physician, such as an internal medicine doctor, primary care physician, hospitalist or the like. Of course, many times disability insurance companies will deny total disability claims filed by an emergency room physician if they are not handled properly from the beginning by the physician, and litigation will become necessary to achieve a proper result.

Consider the case of Carlyon v. Mutual of Omaha Insurance Company. 220 Mich. App. 444 (Mich. Ct. App. 1996). Dr. Carlyon was a medical doctor who had been working in various hospitals as an emergency room physician until he became disabled due to a back injury. Dr. Carlyon's own occupation disability insurance policy provided for total disability benefits when the insured became unable to perform the material and substantial duties of his or her regular occupation. The disability insurance policy additionally included a rider for partial disability benefits and explicitly stated that "[e]arnings in an occupation other than the Insured's regular occupation will have no effect on benefits."

Mutual of Omaha Insurance Company initially approved and paid Dr. Carlyon total disability benefits. However, after Mutual of Omaha later learned that Dr. Carlyon had been working part-time as a prison doctor, it denied any further total disability benefits and only agreed to pay partial disability benefits under the policy. Dr. Carlyon thus filed a lawsuit to pursue the total disability benefits he believed he was rightfully owed under his disability insurance contract with Mutual of Omaha.

In court, Dr. Carlyon contended that under his particular disability insurance contract, he was entitled to total disability benefits because, although he was able to work as a general practice prison doctor, he was disabled from his "regular occupation" as an emergency room physician. Mutual of Omaha on the other hand maintained that Dr. Carlyon was not entitled to total disability benefits because his work as a prison doctor was within the scope of his "regular occupation" as a general practice physician. Mutual of Omaha presented an expert witness attesting that both emergency room physicians and prison physicians must treat a combination of acute and chronic medical conditions, and thus that Dr. Carlyon was not totally disabled under the policy. However, both the trial court and appellate court reviewing the case determined that Dr. Carlyon's regular occupation was emergency room physician, as virtually any physician might be called upon to render some type of emergency aid in crisis situations but this did not mean that being an emergency room physician was not a distinct occupation. The courts determined that an emergency room physician is a separate occupation from a general practice physician, as emergency medicine is a recognized specialty that requires the ability to perform specialized tasks not required of a general practice physician.

The courts concluded that because Dr. Carlyon's could not reasonably perform various medical procedures essential to emergency medicine due to his medical condition, he was totally disabled for purposes of the disability insurance policy at issue because he could not perform the material and substantial duties of an emergency room physician. The court did give specific consideration to the rider attached to the insurance policy in making its conclusion.

A determination under most own occupation disability insurance policies that an insured is only partially disabled versus totally disabled in a situation like Dr. Carlyon's saves the insurance company thousands if not millions of dollars on an individual disability claim. Likewise, it could cost you thousands or even millions of dollars at a time when your career in your trained specialty has been cut short due to a disabling medical condition. The attorneys at DI Law Group have successfully handled numerous cases where insurance companies have disputed the true regular occupation of a physician or found a physician to only be entitled to partial or residual disability benefits when the physician was rightfully owed total disability benefits under his or her insurance contract. We have provided aggressive representation in these cases which has allowed for pre-litigation claim resolution obviating the need for a lawsuit, however, we have likewise aggressively litigated these cases in court where necessary. Contact one of our experienced attorneys today for a complimentary consultation about your disability insurance policy or claim.

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