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Life Health > Health Insurance

California Doctor Questions Guardian's 'Total Disability' Definition

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A California physician is challenging the way Guardian Life Insurance Company of America defines “total disability” in an individual disability insurance policy.

The plaintiff, Dr. Henry Kamali, and Guardian are clashing over whether a California disability insurer can prohibit working as part of the requirements for an insured who seeks to be classified as totally disabled, according to a complaint filed in the U.S. District Court in San Jose, California, and available on Law.com Radar.

Kamali is asking the court to let him represent a class consisting of all Guardian disability insureds in California who have trouble collecting benefits due to a “no work” policy provision.

What It Means

If Kamali is successful, clients who file individual disability insurance claims in California might have an easier time collecting benefits.

Case Details

Kamali was working as a board-certified anesthesiologist in 2016 when he learned that he had prostate cancer, which subsequently spread to his lymph nodes.

Surgery and chemotherapy left him with effects such as fatigue, insomnia, joint pain and anemia.

Kamali is now the medical director of a hospital and the CEO of a large anesthesiology practice, but he says he can no longer work as a clinical anesthesiologist.

In most of the United States, Guardian and other issuers of individual disability insurance often use a relatively broad definition of a term such as “total disability” during the first few years after an insured qualifies for benefits, and then shift to a tighter definition later.

Guardian contends that Kamali can qualify as being totally disabled after five years only if “because of injury or sickness, you are not able to perform the major duties of your occupation, and you are not at work in any occupation,” according to an excerpt from the denial letter included in the complaint.

Kamali contends that, in California, state law always requires an issuer to use a relatively broad definition of “total disability” and never lets the issuer make not working at all part of the total disability definition.

He further asserts that, under California law, he qualifies as being “totally disabled” because he “cannot perform the substantial and material duties of his own occupation in the usual and customary manner with reasonable continuity.”

Perspectives

Representatives for Guardian said the company does not comment on pending litigation.

Matthew Bourhis, the lead attorney on the plaintiff’s team, said in an interview that his firm is one of just a handful of firms in California that handle many disability insurance claim cases.

Many disability insurance issuers use their national definitions for total disability in California, and a large percentage of those issuers back away from that approach once they understand that California has had its own statutory definition of the term since the 1940s, Bourhis said.

Bourhis said that he represents several California clients who have run into problems with total disability claims because of Guardian’s approach and that he’s trying to determine how many other claimants have faced similar situations.

(Image: Sergign/Adobe Stock)


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