Standing Up to Insurer’s “In-House” Doctors: Zemel v. Provident Life & Accident Insurance Company
FOR 25 YEARS Dr. Simon Zemel worked as an obstetrician specializing in high-risk pregnancies. His duties required a steady hand, a firm back, sharp mental acuity and the physical and mental stamina to work long shifts.
By 1997 Dr. Zemel was suffering from a bulging lumbar disc and a tremor in his right hand that attending physicians believed indicated early stages of Parkinson’s Disease. At times Dr. Zemel also was afflicted with a condition termed “instant paralysis.” Dr. Zemel furthermore was being treated for prostate cancer and severe depression.
It was clear to Dr. Zemel and his physicians that he was medically and professionally unable to perform the duties of his occupation.
Dr. Zemel’s disability was clear, that is, to everyone but his disability carrier, Provident Life & Accident Insurance Company. Provident ignored the treating physicians’ reports and the litany of medical evidence proving Dr. Zemel’s disability and denied the claim. Their denial constituted the belief that Dr. Zemel was still somehow fit to perform high-risk surgical procedures in the delivery room.
Zemel came to attorney Frank Darras, a nationally recognized legal expert on disability insurance, who couldn’t help but wonder how many afflictions a person would have to endure to be granted a disability claim.
As typically happens in such cases, Provident had relied on the opinion of its own “in-house” doctors in denying the claim. These doctors made only a paper review of the case and never physically examined Dr. Zemel.
Darras compiled the necessary evidence, reviewed Dr. Zemel’s policy, confirmed reports from all involved physicians and confronted the insurance company. Fearful of how its behavior in the matter would play out in court, Providence worked with Darras to reach a favorable settlement for Dr. Zemel.
Although the terms of the settlement are confidential, both Darras and Dr. Zemel showed the disability insurance industry that relying on so-called in-house doctors to decide a claim, without considering other medical evidence, may constitute insurance bad faith.
