If I Lose My Pinky Finger In An Accident But Can Walk, Talk And Read, Do I Qualify For Disability Benefits?

If I Lose My Pinky Finger In An Accident But Can Walk, Talk And Read, Do I Qualify For Disability Benefits?

One of the difficulties in determining whether you qualify for disability benefits after suffering an accident is whether you can perform the duties of your Own Occupation. Let’s pretend you are trimming your hedges, with a gas powered hedge trimmer, on a bright, summer day. A bee stings you while, trimming. The shock of the sting causes you to drop the trimmer. It lands on your dominant hand, and cuts your pinky finger badly. Fortunately, your finger is not severed, but your pinky is so damaged that you have lost most functionality. You can no longer close your pinky to the palm of your hand.

The result really depends on your profession. A professional golfer and a trial lawyer uses his pinky in different ways in connection with his respective occupation.

Unable to work effectively as a golf professional, you file a made a claim for benefits under a disability insurance policy that pays a monthly indemnity when “you are unable to perform the Material and Substantial duties of your Own Occupation.” One insurance company defines Material and Substantial duties as, “the set of tasks or skills required in a specific occupation. These are duties that cannot be reasonably omitted or modified without impairing an employee’s ability to perform his of his occupation.” Does that really provide guidance? I don’t think so.

Other than the loss of use of your pinky, you can do many of your regular job duties, including, walking, talking, reading and analyzing information. Will the insurance company pay you? It depends. “Own Occupation” may be defined as the duties of your occupation at the time of the accident or illness. Again this is not very helpful.

Given that your occupation is golf professional, making the case why the insurance company should pay you is not too difficult, or is it? What are the Material and Substantial duties of a gold professional? Walking, talking, writing, swinging a golf club, placing the ball on the tee, schmoozing with members at the club, etc. A tough insurance company might argue and say you can do almost all of your material and substantial duties, you just can’t grip the golf club as well but you can still swing it.

This type of disability insurance policy language could be interpreted reasonably “to cover both ‘qualitative’ and ‘quantitative reductions’ in one’s performance as a result of an injury or sickness.” McFarland v. Gen. Am. Life Ins. Co., 149 F.3d 583, 588 (7th Cir. 1998). A qualitative reduction would be one where as a result of an injury a core skill, i.e., gripping a golf club would render you “totally disabled.” Id. A “quantitative loss” might be one where used to give 7 golf lessons a day, but now due to fatigue in your hands because you had to modify your grip, you are limited to 3 lessons per day. Your output is 50% reduced from your normal work day.

Most of the time, people who are unable to work due to an accident or illness, can still do some of their job duties, such as talking and reading. Take a trial lawyer, duties include thinking, comprehending, analyzing and communicated information and of course, dealing with stressful situations. In Gallagher v. Reliance Standard Life Ins. Co.,), where the definition of disability provide that the insured is totally disabled when, as the result of an injury or sickness, he “cannot perform each and every material duty of his/her regular occupation” during the elimination period.” Gallagher v. Reliance Standard Life Ins. Co., 305 F.3d 264, 270 (4th Cir. 2002), as amended (Oct. 24, 2002). The Court interpreted the definition literally, Given that Mr. Gallagher continued to be able to read despite suffering from chronic pain the Court held that the insurance company did not need to pay him, because he could still do at least one of the duties of his occupation, a public relations executive. Most Courts, however, will hold that construing the language literally is not enforceable, because the only person who could conceivably qualify is a person in a coma. See, e.g., Helms v. Monsanto Company Inc., 728 F.2d 1416 (11th Cir. 1984) (a literal construction would render the entire plan meaningless and undermine the purpose of the disability coverage).

So the answer depends on your actual occupation, and to what extent that you have suffered a quantitative loss or qualitative loss, or both. The answer is not as simple as you may think at first.

Author: Jonathan M. Feigenbaum