Archives for August 3, 2018

While most people tend to have a common-sense view of what it means to be disabled, under long-term disability (“LTD”) policies, an insured must satisfy the terms of a disability policy and its specific definitions of “disability” to receive LTD benefits.  Within the first two years of a disability claim, “disability” in a policy is normally defined as the inability to perform the essential duties of one’s own job. Thereafter, “disability” is usually defined as being prevented from performing one or more essential duties of any occupation for which an insured is qualified by education, training and experience.  This “own occupation” versus “any occupation” analysis is the source of a substantial amount of judicial opinion.

Insurance companies typically argue that even if an insured is unable to perform the essential duties of a job, an insured can perform some type of sedentary desk job, where sitting is a large component of the workday.  The battle usually turns to whether a disabled employee can perform full-time work where sitting is a large component of the workday.

In a recent case in the Western District of Washington, the court in Reetz v. Hartford Life and Accident Ins. Co., 294 F.Supp.3d 1068 (W.D. Wa. 2018) addressed this analysis as it related to a sedentary occupation.  In Reetz, the court considered whether the claimant Kirsten Reetz (“Ms. Reetz”) was disabled under the plan’s “own occupation” standard and “any occupation” standard, where she was only able to sit for 30 minutes at a time for a total of six hours a day.

Ms. Reetz began working at Byram Health Care, Inc. (“Byram”) as a senior customer service representative in October 1999.  As described by Byram, the position was a sedentary level occupation, requiring six hours of sitting at a time, for a total of seven hours of sitting per day.  Alternating sitting and standing as needed was not allowed. There would be a 30-minute break during the eight-hour work day, and a typical work-week consisted of 40 total work hours, with 35 of those hours spent sitting.  

While at Byram, Ms. Reetz participated in an LTD benefit plan (“Plan”) administered by Hartford Life and Accident Insurance Company (“Hartford”).  The Plan “offers benefits for the 90-day elimination period and two years following that period if the claimant cannot perform the essential duties of his or her own occupation.  But after those two years, the Plan will only pay benefits if the claimant is unable to perform the essential duties of any occupation for which he or she is qualified.” Id. at 1072.

Ms. Reetz worked at Byram until March 2014, when she took leave due to persistent pain resulting from fibromyalgia, a musculoskeletal pain disorder, and spondyloarthropathy, a form of inflammatory arthritis.  Ms. Reetz submitted a claim for benefits on March 10, 2014, and Hartford paid her benefits from March 7, 2014 to June 5, 2014. Hartford initially approved LTD benefits on June 23, 2014 and paid LTD benefits to Ms. Reetz through April 2016.  Due to her spondyloarthropathy, lumbar back pain and fibromyalgia, Ms. Reetz’s treating physician noted that Ms. Reetz could only sit for 30 minutes at a time, for a total of four to six hours a day.

Utilizing a vocational case manager, Hartford identified ten occupations it believed Ms. Reetz could perform.  The identified occupations were sedentary occupations that involved sitting and clerical work. With this information, Hartford determined Ms. Reetz was no longer disabled as defined in its Plan and terminated Ms. Reetz’s benefits by an April 28, 2016 letter.  Hartford concluded that since Ms. Reetz’s job required her to sit most of the time and Ms. Reetz was limited to sitting for 30 minutes at a time for a total of six hours a day, she was able to perform the essential duties of her own occupation. Hartford further concluded that there were several sedentary occupations for which she was qualified that were within her physical capabilities.  Thus, Hartford deemed Ms. Reetz capable of performing the essential duties of her own occupation or any occupation.

Ms. Reetz appealed the LTD denial decision, but Hartford upheld its determination.  Ms. Reetz subsequently filed suit under ERISA, which sets minimum standards for many LTD plans and serves to provide protection for individuals in these plans.  ERISA allows employees like Ms. Reetz to recover benefits under a covered plan, like the Plan with Hartford.

The federal court looked at the requirements of Ms. Reetz’s job and the medical record to determine whether Ms. Reetz had established by a preponderance of the evidence that a sickness prevented her from performing the essential duties of her own job.  The court found that evidence that Ms. Reetz could only sit for 30 minutes at a time for a total of no more than six hours per day was persuasive that Ms. Reetz could not perform her own occupation. The court also found there to be no evidence of improvement in Ms. Reetz’s condition and found her award of Social Security Disability benefits constituted evidence of her disability.  The court also gave weight to Ms. Reetz’s treating physicians over Hartford’s independent reviewing physicians, as Hartford’s doctors did not examine Ms. Reetz in person.

The court then considered whether Ms. Reetz established by a preponderance of the evidence that a sickness prevented her from performing the essential duties of any occupation for which she was qualified.  In assessing this, the court reviewed the Ninth Circuit opinion, Armani v. Northwestern Mutual Life Insurance Co., 840 F.3d 1159 (9th Cir. 2016).  In Armani, the Ninth Circuit held that where the claimant’s attending physicians agreed he could sit at most four hours per an eight-hour workday, he was unequivocally disabled from performing his own sedentary occupation as a full-time controller and disabled from any other sedentary occupation, because sedentary jobs require mostly sitting and generally at least six hours per day.  Id. at 1163-64.

In light of the Armani opinion, the court accorded significant weight to the evaluation of her treating physicians, who concluded that Ms. Reetz could sit for only 30 minutes at a time for a total of less than six hours a day.  Because Ms. Reetz could only sit for half-an-hour at a time for, at most, six hours a day, the court found she could not perform any sedentary occupation. The court added that even if Ms. Reetz were able to sit for more than six hours per day, she would need the significant accommodation of taking breaks every half hour.  This supported the finding that she was disabled from “any occupation.”

Conclusion

Many disability insurance claimants suffer a debilitating disease or condition that makes sitting painful or requires them to stand or walk around frequently to manage pain.  The Reetz court provides guidance for insureds who are unable to sit for long periods of time, especially when insureds are limited to sitting for only 30 minutes at a time.  Although many courts and the federal government’s Dictionary of Occupational Titles define sedentary jobs as requiring sitting for six hours per day, the Reetz opinion looked not at the total time sitting, but the restrictions of periods of time a person is able to sit.  Importantly, the court noted that even if an insured can sit for more than six hours per day, taking breaks every half hour would be a significant accommodation to support a finding of disability.  Thus, this opinion helps to expand the extent to which an insured may claim disability benefits due to difficulty sitting for long periods of time.