Opinion ID: 3202226
Heading Depth: 2
Heading Rank: 1

Heading: The Standard Claim

Text: In order to qualify for either total or partial disability benefits under the Group Policy, Duda was required to prove not just that he was “Disabled” during the benefit period itself, but also that he was continuously Disabled during a preliminary “Benefit Waiting Period.” (JA 1808-09; see also JA 1832 (stating “Benefit Waiting Period” to mean “the period you must be continuously Disabled before [long-term disability] 1 Duda also claimed that he was disabled due to vitreal damage resulting from a 2007 boating accident. However, Duda’s Opening Brief raised no arguments with respect to that alleged disability, and his Reply Brief does not dispute Standard’s contention that he has abandoned that basis for his disability claims. Thus, we consider Duda’s claims only with respect to his wrist injury. 3 Benefits become payable”).) The defined period was 180 days. Duda could qualify as “Disabled” by showing that, “as a result of Physical Disease[ or] Injury,” he was “unable to perform with reasonable continuity the Material Duties” of his “Own Occupation” (total disability) or he was unable to earn his “Own Occupation Income Level” (partial disability). (JA 1809.) To prove Disability, he was required to file a “Proof of Loss,” which the Group Policy defined to mean “satisfactory written proof that you are Disabled and entitled to [long-term disability] Benefits.” (JA 1827 (emphasis added).) The Group Policy did not, however, define what constitutes “satisfactory written proof.” In the disability claim forms that Duda sent to Standard, he provided proof that Leatherwood, acting as his attending physician, had diagnosed him with “Scapholunate Dissociation” – or so-called “SLAC[] wrist” – on his dominant right hand and had represented that Duda should stop working in or around “08/2006.”2 (JA 1658.) Duda also stated that, since the start of his disability, he had been “unable to perform total j[oin]t replacement [and] other open procedures,” but that he continued to see “office patients” and perform arthroscopic surgery. (Id.) Upon Standard’s request for records of Leatherwood’s treatment of Duda, Leatherwood drafted a March 24, 2009 letter explaining that he had treated Duda “on a periodic basis” over the “last eight years” but “ha[d] not kept detailed formal records” because all such treatment was conducted merely as a professional courtesy to his business partner. (JA 1247.) 2 But see JA 2795 (Leatherwood’s Attending Physician Statement for Duda’s Lincoln disability claims, also dated March 5, 2009, wherein he represented that he first noticed Duda’s physical restrictions in “2007”). 4 After Standard conducted further examination of the claim, its claim administrator informed Duda that it was denying his claim for benefits under the Group Policy. Then, during Duda’s appeal of that determination, the Standard employee who was reviewing the claim requested copies of “all of [Duda’s] medical records from at least January 1, 2006 through the present” that would be relevant to document the claimed disability. (JA 1592.) In a reply letter, Duda responded that, as an orthopedic surgeon, he “ha[d] been self treating for many years” and “ha[d] not kept any records documenting treatment.” (JA 1210). By letter dated November 6, 2009, Standard notified Duda that it was denying his appeal.