A California Federal District Court has granted a motion for summary judgment under F.R.C.P. Rule 52 in favor of a disability claimant, holding that an insurer must consider a long-term disability (“LTD”) claim in accordance with the correct classification of the claimant’s “occupation” as determined by the claimant’s “actual duties.”

In McCulloch v. Hartford Life and Accident, 2020 WL 7711257 (N.D. Cal. 2020), the plaintiff suffered from “involuntary tremors and body jerking, fatigue, and cognitive impairment” that, inter alia, affected her ability to drive.  Id., *1.  The insurer denied the disability claim and ensuing appeal, whereupon the “plaintiff filed a complaint against [the insurer], alleging a cause of action under 29 U.S.C. § 1132(a)(1)(B) to recover LTD benefits under the terms of [the insurer’s] Plan.”  Id.

The Court found that, after having been bitten by a tick, the plaintiff developed various symptoms, including an impairment of “cognitive capacity”, whereupon one of her physicians wrote to the insurer, “I believe that [claimant’s] health issues are serious and limiting.  She cannot work because of cognitive impairment as corroborated by her decidingly [sic] abnormal SPECT scan.”  Id., *4.  The insurer, however, determined that plaintiff’s occupation involved “light work” in the workplace, and denied the claim on the ostensible basis that “plaintiff’s medical records ‘did not provide any objective exam findings or other assessments to support the severity of … symptoms’ and did not state specific work restrictions.”  Id., *5.  Although the plaintiff appealed on the basis of the reports of several health care practitioners, the insurer denied the appeal on November 20, 2019.  Id., *7.  Notably, on August 30, 2020, the Social Security Administration (“SSA”) awarded the plaintiff monthly benefits because “under SSA’s rules, [the claimant] became disabled on March 12, 2018.”  Id., *8.

The Court observed, “the issue before this Court is whether plaintiff qualifies as disabled under the Plan’s ‘Your Occupation’ definition” and whether the plaintiff was disabled thereunder.  Id., *7.  The Court first addressed the plaintiff’s “occupation.”  The term, “Your Occupation,” was defined in the LTD Plan as “the [e]ssential [d]uties of the job [claimant] is performing for [her] [e]mployer.”  Id.  Observing that a determination of disability must be based on the plaintiff’s “actual duties”, the Court held that the insurer applied the incorrect definition of “occupation;” rather than “light work” as proffered by the insurer, the plaintiff’s “occupation involved concentration, frequent driving, traveling by airplane, and keyboarding.”  Id. *7-8.

The Court then concluded that the plaintiff was, in fact, disabled under the foregoing definition of “occupation.”  The Court rejected the insurer’s assertion that the plaintiff’s “real problem seems to be that she found her job and lifestyle extremely stressful.”  Id., *8.  Rather, because “[o]bjective tests support plaintiff’s disability”, the Court concluded that “plaintiff’s condition prevents her from driving and significantly impairs her physical and cognitive ability” such that “the Court finds that plaintiff is disabled under Hartford’s LTD Plan.”  Id., *8-9. In reaching this conclusion, the Court was not persuaded by the insurer’s consulting physicians, concluding that the consultants neither correctly addressed the actual work required of the plaintiff nor the effects of her disability thereon.  Id., *9-10.

McCulloch underscores that a disability claim must be evaluated under the proper classification of a claimant’s “occupation” as determined by the claimant’s actual duties. In making this determination, evidence is relevant as to the effects of the disability on the tasks inherent to the claimant’s actual work.  Accordingly, delineating the claimant’s actual duties may preclude an insurer from introducing evidence not relevant to the claimant’s “occupation.”

We have significant experience in handling ERISA and non-ERISA disability insurance cases in which an insurer denied a claim based on a lack of objective evidence or a claimant has a disability condition that is subjective in nature and difficult to prove and measure.  If your insurer or plan administrator has denied your disability claim, please contact McKennon Law Group PC for a free consultation so that we may assess your matter.