Lots of people in Arlington, Grand Prairie, Fort Worth, Dallas, Mesquite, Garland, Richardson, Burleson, Benbrook, Crowley, and other places in the Dallas-Fort Worth metroplex area have purchased insurance policies that provide payment to them in the event they become disabled and are unable to work. A natural question would be: What happens if the insurance company denies a claim for disability benefits because of total disability and the case goes to trial?
This is what happened in the case styled, Occidental Life Insurance Company of California v. Robert L. Duncan. This case was decided by the San Antonio Court of Appeals in 1966.
The record in this case shows that Duncan was engaged in the selling of labels as an independent contractor for Louis Roesch Company on a commission basis. Louis Roesch Company manufactures labels and Duncan sells them, generally to canners. He has been in the label selling business for some twenty years. He was in an airplane accident on October 25, 1957, and was rather severly injured, Occidental Life Insurance Company of California, (Occidental) paid him for total disability from the time of the accident until September, 1963, when it stopped payment. Duncan sued.
Duncan was injured in his back, right knee and right foot. He was in the hospital for five months and thereafter confined to his home for some time. At the time of trial, he still had pain to his back but learned to live with it, his right knee was somewhat recovered. His right foot problem still existed. The joints in the metatarsal section were fused, the pressure caused the joints in his foot to separate, and he wore a brace with a steel plate under his foot to relieve some of the pressure. Motion in that area of his foot caused great pain. His right ankle was shorter and completely stiff. The ankle was solid bone. He could not walk up slopes; he once fell trying to negotiate a slope in Houston, a year and a half before trial, calling on a customer. The fall caused a brain concussion. He had numerous other falls, averaging one a month. He could not negotiate rough terrain, wet ground, snow or ice. Uneven gravel surfaces were hard for him to walk on. It was difficult for him to get into some of the plants that have slopes. Before the accident he would run and catch trains, from time to time; at trial he could not run at all. Prior to his accident he had a total of one hundred and ten accounts that he had sold at one time or another; at trial he had only nineteen of those accounts remaining. He could not follow through with his accounts because of his limited ability to travel long distances.
Before his injury he often drove his automobile 50,000 miles per year, and traveled a total of about 100,000 miles. At trial he was unable to drive more than 6,000 to 10,000 miles per year. A great deal of traveling was necessary in his business. At trial he introduced into evidence his income.
He showed is was unable to establish major accounts since the accident.
In this case the jury found in favor of Duncan, however, this appeals court remanded the case for a new trial based on issues surounding jury misconduct. The part of the case dealing with the way insurance disability cases are analysed is still good law.
The Occidental insurance policy defined total disability as:
‘Disability shall be deemed to be total whenever the Insured becomes disabled as the result of injury or disease so as to be wholly unable to engage in any occupation and to perform any work for compensation or profit.’
The court in analysing this case said:
“The controlling issue in this case is whether an ordinarily prudent person in the exercise of ordinary care would have refrained from working under the same or similar circumstances.”
The trial court in connection with the issue summitted to the jury regarding whether or not Duncan was totally disabled, gave the following instruction:
“In connection with the above question you are instructed that disability shall be deemed to be total whenever an individual becomes disabled as the result of injury or disease so as to be wholly unable to engage in any occupation and to perform any work for compensation or profit. It does not mean, however, an absolute physical inability to perform any of the duties pertaining to his occupation; but total disability, as inquired about in the above question, exists if such disability prevents the individual from substantially performing every essential operation necessary to the performance of his occupation.”
An experienced Insurance Law Attorney is needed whenever a denial of benefits is received from an insurance company. The above case is a good beginning point for evaluating these cases.
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