WHAT IS THE DEFINITION OF “DISABILITY” AND “TOTAL DISABILITY” IN CALIFORNIA?
April 22, 2016
If your insurance company has denied your disability insurance claim and your claim is governed by California law, you must establish that you are disabled under California law. Whether your policy requires that you establish that you are “disabled” or “totally disabled,” the same definition should apply. California law supersedes the definition in your policy — and, commonly, definitions in disability insurance polices violate California law because they are unduly restrictive and deceptive.
Establishing that you are disabled, may depend on whether you need prove that you are disabled from your “own occupation” or disabled from “any occupation.” The most common definition of “disability” or “total disability” under California — as stated in a well known California Department of Insurance document titled the “California Settlement Agreement” — is as follows:
a disability that renders one unable to perform with reasonable continuity the substantial and material acts necessary to pursue his or her usual occupation in the usual and customary way.
a disability that renders one unable to perform with reasonable continuity the substantial and material acts necessary to pursue his or her usual occupation in the usual and customary way and to engage with reasonable continuity in another occupation in which he or she could reasonably be expected to perform satisfactorily in light of his or her age, education, training, experience, station in life, physical and mental capacity.
This definition stated by the California Department of Insurance is derived from an important California appellate decision, Moore v. American United Ins.Co., (1984) 150 Cal.App.3d 610, 618. The Moore decision itself is based on California law originating in the 1930’s.
Another California definition of “disability” or “total disability” provides that a person is disabled if, in the exercise of reasonable prudence, she should desist from work. As one California court stated in 1938, “In determining whether there has been total disability, the test of disability is not what the insured actually did in the effort to perform his duties, but what, in the exercise of due prudence he was reasonably able to do.” (Wright v. Prudential Ins. Co. (1938) 27 Cal.App.2d 195, 216)
In evaluating your case, you should be sure to review and apply all definitions of “disability” and “total disability.” You can bet your insurance company has not.