Opinion ID: 767720
Heading Depth: 2
Heading Rank: 1

Heading: The Reasonableness of the Defendant's Request

Text: 11 Courts in other jurisdictions have universally held that a disability claimant's failure to accede to an insurance company's reasonable request for an IME constitutes the failure to perform a condition precedent and may absolve the insurer of further obligations under the contract. See, e.g., VanHaaren v. State Farm Mut. Auto. Ins. Co., 989 F.2d 1,5 n.7 (1st Cir. 1993) (applying Maine law); Fernandez v. Connecticut Mut. Life Ins. Co., 917 F. Supp. 120, 124 (D. Puerto Rico 1996) (applying Puerto Rico law); Hansen v. State Farm Mut. Auto. Ins. Co., 936 P.2d 584, 589 (Colo. Ct. App. 1996), rev'd on other grounds, 957 P.2d 1380 (1998); Hudson v. Omaha Indem. Co., 360 S.E.2d 406, 408 (Ga. Ct. App. 1987). Although New York courts have not yet addressed the failure to perform a condition precedent in the context of disability claims and IME's, they have found that an insured's failure to submit to an examination under oath with respect to fire insurance claims is grounds for an insurer's refusal to pay under the policy. See, e.g., Azeem v. Colonial Assurance Co., 468 N.Y.S.2d 248 (4th Dep't 1983), aff'd 62 N.Y.2d 951 (1984); Pizzirusso v. Allstate Ins. Co., 532 N.Y.S.2d 309 (2d Dep't 1988); Rosenthal v. Prudential Prop. & Cas. Co., 928 F.2d 493 (2d Cir. 1991) (applying New York law). It appears that New York law would treat a disability policyholder's unjustified failure to attend a reasonably demanded medical evaluation as the breach of a condition precedent. 12 Judge Hurd based his finding that Paul Revere's request was unreasonable upon his determination that Mowers was entitled to full benefits, under the terms of the policy, so long as there was any important duty of his practice that he could not perform. 3 As it was clear that there were aspects of his work that he could not perform, the court believed Paul Revere's demand for an FCE was overkill. We find it unnecessary to determine the propriety of the District Court's reading of the contract's total disability clause, because, even under such a reading, the defendant may have had valid reasons to request an FCE. 13 There are many reasons an insurance company might reasonably request a physical examination of a client to whom it is paying disability benefits, even in the face of prior examinations determining him to be disabled. Depending on the circumstances, it might be reasonable for the insurer to check periodically to establish whether the insured remains totally disabled, to request additional tests to determine whether claims of pain survive objective verification, or simply to monitor the course of the illness to estimate future liability and evaluate possible treatment options. 14 Evidence suggests that some of these reasons may have motivated Paul Revere's request. Before the IME with Dr. Rinehart, Mowers had not been examined by an independent physician in two and a half years, despite the fact that several of the earlier IME's had suggested that his disability was temporary and might eventually lessen. On one reading of Dr. Rinehart's complex report, his request for an FCE was motivated by a need to obtain objective verification for Mowers's subjective claims of pain. The fact that several of the doctors who examined Mowers, including Dr. Rinehart, considered him only partially disabled also may have justified the defendant's desire to obtain further medical information. 15 Determinations of the insurer's motivations and the reasonableness of the insurer's request are are jury questions (unless under the circumstances jurors could not reasonably differ). See, e.g., Hansen, 936 P.2d at 589; Hudson, 360 S.E.2d at 408. Given the many reasons that might have justified the demand for the FCE and the complicated factual considerations that go into evaluating whether such a request is reasonable, we can see no justification for the trial court's determination as a matter of law that the defendant's demand for an FCE was not reasonable. 4 16