New York Supreme Court, Appellate Division - 730 N.Y.S.2d 272, 285 A.D.2d 73, 730 N.Y.S.2d 272
In Acquista v. New York Life Insurance Company (2001), the New York State Appellate Court reviewed a case about a doctor, Angelo Acquista, who sued for disability benefits from his insurance company. He had bought three policies from New York Life Insurance and was diagnosed with a blood disorder that could potentially convert into leukemia and limited his ability to do certain essential medical procedures. The insurance company denied his claim, arguing that he was not "totally disabled" as defined by the policies.
Acquista sued for breach of contract, bad faith, fraud, and emotional distress. The lower court dismissed his claims, except for one based on partial disability benefits. Acquista appealed.
The appellate court partially agreed with Acquista. It found that he could have a valid claim for breach of contract, noting his income loss and inability to practice his specialty. The court also recognized potential claims for bad faith and fraud due to the insurance company's alleged deliberate delays and misrepresentations.
This case is important because it shows the legal hurdles involved in claiming disability benefits from insurance companies. It also highlights how courts handle issues like breach of contract, bad faith, fraud, and emotional distress in insurance disputes.
The plaintiff, a physician with a blood disorder, purchased three disability insurance policies from New York Life Insurance Company. The defendant insurer rejected his application for disability benefits, claiming that he can still perform some of the substantial and material duties of his job. The plaintiff filed a lawsuit for breach of contract, bad faith and unfair practices, fraud and fraudulent misrepresentation, and negligent infliction of emotional distress. Defendants filed a motion to dismiss all but one of plaintiff's causes of action, which was based on the policy provision for residual and partial disability benefits. The Supreme Court granted the motion, but the order was modified to reinstate some of the dismissed causes of action. Defendants argued that plaintiff's breach of contract claims should be dismissed because he can still perform some of the substantial and material duties of an internist, which is one of his specialties. Two of the policies define total disability as the inability to perform the substantial and material duties of the insured's regular job or jobs, while the third policy defines it as the inability to perform any of the substantial and material duties of the insured's regular job or jobs. Defendants relied on a 1996 deposition of plaintiff in an unrelated action, where he stated that he was assistant chief of the ICU at Lenox Hill Hospital, teaching residents two to three times per week and rotating through the ICU two months out of the year. Defendants also referred to a "Confirmation of Interview" form where plaintiff stated that he is not totally disabled, but rather "virtually totally disabled" from his pulmonary medicine practice. Lastly, defendants cited a letter from plaintiff's counsel stating that plaintiff can still perform some substantial and material duties of other work activities, including other types of medical practice and certain business, managerial, and administrative activities.
The dissenting opinion in this case agrees that the plaintiff was able to practice some aspects of medicine, but there are still factual questions regarding whether he was "totally disabled" as defined by the insurance policies. The lower court erred in dismissing the breach of contract claims, but did not err in dismissing the other claims. The plaintiff's claim that New York Life's conduct constituted a public wrong was dismissed because there was no evidence of a confidential relationship or any basis for disregarding stare decisis. The plaintiff's claim that defendant engaged in bad faith and unfair practices by delaying a decision on his claims was dismissed because such allegations are insufficient to establish a gross disregard of the insured's interests. The court held that a bad-faith plaintiff must establish that the defendant insurer engaged in a pattern of behavior evincing a conscious or knowing indifference to the probability that an insured would be held personally accountable for a large judgment if a settlement offer within the policy limits were not accepted. The plaintiff's tort claims against the insurance company were also dismissed because they were essentially a private contract dispute and there were issues of fact regarding coverage under the policies.
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