London v. Berkshire Life Insurance

Citation: 71 F. App'x 881Docket: Docket No. 02-9251

Court: Court of Appeals for the Second Circuit; August 4, 2003; Federal Appellate Court

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Anthony R. London appeals the dismissal of his breach of contract claim by the United States District Court for the Northern District of New York regarding a disability policy from Berkshire Life Insurance Company. After Berkshire denied his claim for total disability benefits following his coronary artery disease diagnosis in 1997, London filed suit, which was removed to federal court. The policy, purchased in 1981, originally defined total disability as the inability to engage in one’s occupation, but this was revised in 1984 to define total disability as the inability to perform the material and substantial duties of one’s occupation.

After reducing his workload and applying for benefits, Berkshire determined that London could still work as a cardiologist, leading to the denial of his claim. London did not pursue residual benefits under the policy. In his motion for summary judgment, London argued he had substantially reduced his office hours and could no longer perform key hospital duties, while Berkshire contended he still worked in all categories of his role. London also claimed there was a factual issue regarding his ability to perform his job's essential duties and highlighted a misinterpretation by the district court regarding his work schedule. The court reviews the summary judgment de novo, affirming that such judgment is proper only when no material facts are disputed and the moving party is entitled to judgment as a matter of law.

Material facts in legal contexts are defined as those that could influence the case's outcome under applicable law. An issue is deemed genuine if a reasonable jury could favor the nonmoving party. In New York, the interpretation of "material and substantial duties" in occupational disability policies is well-established. A claimant is considered "totally disabled" when they can no longer perform the essential duties of their job. The assessment focuses on the insured's regular professional activities at the disability's onset. If a claimant can perform duties of a similar nature requiring comparable skills, they are not deemed totally disabled.

In the case referenced, despite a reduction in hours and certain responsibilities, the claimant, London, continued to perform duties similar to his pre-disability role as a cardiologist, treating patients and utilizing the same skills. Although London argued he had become a mere consultant, evidence showed his work remained fundamentally unchanged. Previous cases where claimants were deemed totally disabled involved substantial changes in job duties post-disability. In contrast, London’s work did not reflect such a fundamental difference, thereby failing to meet the criteria for total disability. Additionally, he did not satisfy the second requirement of the "material and substantial duties" test.

The reduction of patient diagnosis and treatment hours to 18 per week, spread over three days, is significant but still substantial in terms of care provided. The district court's reference to London’s work schedule, whether it was three and one-half days or one and one-half days, does not alter the conclusion that he is not totally disabled. Consequently, the District Court's judgment is AFFIRMED. New York substantive law applies to this diversity case. To claim benefits under the policy's definition of 'residual disability,' the insured must prove at least a 25% reduction in earnings. Berkshire argues it cannot assess London's eligibility for residual benefits due to his failure to submit earnings information. The 1984 policy language change aimed to align with established New York law. London admits to seeing up to 15 patients on the days he is in the office.