Opinion ID: 3202226
Heading Depth: 2
Heading Rank: 2

Heading: The Lincoln Claims

Text: Lincoln is the successor insurer on the Personal Policies – comprised of Policy No. 000528000A3 and Policy No. 000664107. Both Personal Policies cover total disability and residual disability. In the claim forms he sent to Lincoln, Duda described himself as “PARTIALLY disabled” as of August 10, 2007 (JA 2791 (original emphasis)); although he stated that he was “no longer able to perform total joint replacement or open corrective surgery,” he acknowledged that he continued to work “40+” hours per week since the date of his disability (JA 2793), continued to “[s]ee patients in [his] office,” and was “still 3 As the District Court observed, Duda was originally covered by the nowinoperative Policy No. 000528000. Duda v. Standard Ins. Co. et al., No. 12-1082, 2015 WL 1961170, at  n.4 (E.D. Pa. April 30, 2015). From Duda’s arguments in the District Court, we infer that that previous policy may have provided a stronger basis from which to argue that Duda’s regular occupation should have been defined solely in terms of his ability to perform orthopedic surgery. However, Duda has not raised the continuing efficacy of Policy No. 000528000 as an issue in this appeal. 5 doing non-open arthroscopic surgery” (JA 2791). As with the Standard claim, Leatherwood filled out a statement as Duda’s Attending Physician, diagnosing Duda with “Scapho-Lunate Dissociation” and “SLAC [] Wrist (Scapho-Lunate Advanced Collapse).” (JA 2794.) Although Duda had claimed to be only partially disabled, Lincoln apparently considered his eligibility for both total and residual disability benefits. It denied Duda’s claims as they pertained to total disability, told him that it was “unable to approve Residual Disability benefits at this time,” and requested additional medical, financial, and billing information so that it could make a final determination with respect to residual disability benefits. (JA 2831.) During Duda’s appeal of the denial of his total disability claims, and after Lincoln made several more requests for additional information to analyze Duda’s eligibility for residual disability benefits, Duda’s counsel told Lincoln that Duda would not submit any of the requested information because he intended to focus “exclusively” on the total disability claims. (JA 2876.) Counsel allowed, however, that if Duda “elect[ed] to seek residual benefits at a later point in time,” he would “then provide the additional information … .” (Id.) Lincoln affirmed the denial of Duda’s total disability claims on November 4, 2011, and this litigation followed.