Policy Definition Of Total Disability

Arlington lawyers handling insurance disability claims need to know all the places to look to find law helpful to their client. This includes not only the Texas Insurance Code, but also the Texas Administrative Code.
But first, a case helpful to disability case understanding is a 1970, El Paso Court of Appeals case styled, Travelers Insurance Company v. Solomon.
Solomon received a jury verdict in his favor against Travelers for anticipatory breach of an insurance contract. The contract was an accidental disability policy issued by Travelers. Under the policy Travelers agreed to pay the sum of $200.00 per month during the period of any total disability sustained by Soloman which commenced within 30 days after he received accidental injuries. The policy defines ‘total disability’ as meaning an inability of the insured to perform any and every duty pertaining to his occupation during the first 24 months of any period of disability; thereafter, the term is defined to mean complete inability of the insured to engage in any and every occupation or employment for wage or profit.
Solomon sustained accidental injuries on November 4, 1963 and was paid the full policy benefits for a period of 24 months after, because he was unable to perform every duty pertaining to his occupation during that period of time. Travelers, at the expiration of the two-year period, took the position that Soloman was not unable to engage in any occupation or employment, and therefore paid no further benefits after the said two-year period.
The policy provides: “Total disability’ as used herein means complete inability of the Insured to engage in any and every occupation or employment for wage or profit, but during the first 24 months of any period of disability the Insured shall be deemed totally disabled while he is unable to perform any and every duty pertaining to his occupation and is not engaged in any occupation or employment for wage or profit.’ The policy of insurance describes the insured as a ‘Driver Truck & Bulldozer’.
Solomon won this case.
This case is highlighted here showing where the courts deal with these cases but there is also now a specific statute that is helpful with disability policies. This statute is found in the Texas Administrative Code, Title 28, Section 3.3012. It says:
(a) A general definition of “total disability” may not be more restrictive than one requiring the individual to be totally disabled from engaging in any employment or occupation for which he or she is or becomes qualified by reason of education, training, or experience, and such individual is not in fact engaged in any employment or occupation for wage or profit.
(b) “Total disability” may be defined in relation to the inability of the person to perform duties, but such inability may not be based solely upon an individual’s inability to:
(1) perform “any occupation whatsoever” or “any occupational duty”; or (2) engage in any training or rehabilitation program; however, an insurer may specify the requirement of the inability of the person to perform all of the substantial and material duties pertaining to his or her regular occupation, or words of similar import.
(c) The definition may reasonably require regular care and attendance by a physician, other than the insured or a member of the insured’s immediate family.
(d) The definition may require that the total disability be “continuous” or “uninterrupted” for a specified period of time or to a specified age. If the insured’s total disability shall continue to such specified age or for such specified period and shall then and thereafter continue, the definition may predicate continuance of benefits on the insured’s inability to perform any work or occupation for which he is reasonably trained or qualified by education or experience.
The provisions of this statute were initially adopted in 1977.