Opinion ID: 63756
Heading Depth: 4
Heading Rank: 1

Heading: Is the policy ambiguous?

Text: Tarver argues that the contract is ambiguous because the policy does not specify a temporal component and does not list all of the activities from which one must be restricted; however, we hold that the terms of the policy are clear. Under the “Benefits for Sickness” heading, the policy defines “totally disabled or disabled” as being “unable to work at your job for pay or benefits” and “under the care of a doctor.” A policyholder who is unemployed will receive benefits if the claimant is kept “at home” by the illness and “under the care of a doctor.” The policy further defines “at home” as “in your house or yard.” However, a policyholder may leave home if so directed by a physician. “Under the care of a doctor” is defined as “being cared for on a regular basis by a doctor other than yourself unless the doctor states that continued treatment in the future would be of no benefit to you.” Coverage depends on a physician’s assessment of a claimant’s unique condition and attendant restrictions. The insurance policy provides $1,000 of total disability benefits per month up to a twelve-month period for those who qualify under the “at home” provision. Thus, the period of the disability itself is irrelevant as are the particular activities from which a claimant is restricted. The “at home” contract language does not evidence an attempt by Colonial to disregard Tarver’s rights or deny his claim without a legitimate basis. Because the contract language is not ambiguous, Tarver’s argument based on the “at home” provision fails to support a finding of bad-faith breach of contract. (2) Did Colonial act in bad faith in reaching its conclusion that 5 No. 08-60060 Tarver was not totally disabled under the terms of the policy? The record shows that Colonial reviewed Tarver’s own claim statement, the treating physician’s assessment of his condition, his physical therapist’s analysis of his functional capabilities, and also sought the advice of its own medical consultant. Although Tarver’s surgeon stated that, in his opinion, Tarver was totally disabled, the surgeon never stated that Tarver was confined “at home.” The surgeon’s opinion that Tarver was disabled, without an attendant finding that he met the “at home” provision, is not sufficient to qualify under the disability requirements of the policy. None of the professionals who examined Tarver or his medical records found him to be totally disabled as defined by the policy. Colonial based its decision on evidence from several medical experts and did not act in bad faith in denying Tarver’s claim. (3) Did Colonial fail to investigate Tarver’s claim and pay the benefits due? The record reveals that from August 24, 2003, when Tarver filed his claim with Colonial, to February 7, 2005, when Tarver filed suit, Colonial repeatedly attempted to ascertain whether Tarver was restricted to his home by his doctor, the length of the restriction, and the conditions that led to this decision by his doctor. Through its review of available evidence, Colonial determined that Tarver’s shoulder surgery may have caused some period of disability, if only for the period of recovery. Thus, Colonial paid Tarver seven weeks of disability while continuing to seek medical records to substantiate a longer disability period. Colonial sought waivers from Tarver to review his medical files and sent follow-up questions to his surgeon. Colonial’s investigation of Tarver’s claim cannot be characterized as conduct that violates standards of decency, fairness, 6 No. 08-60060 or reasonableness. See Cenac, 609 So.2d at1275.1