Disability Insurance Archives - Page 4 of 41

New Hope If Your Disability Insurance Claim is Denied

If you file a claim for long-term disability insurance benefits, and that claim is denied, arrange at once to meet with a California life and disability insurance claims attorney. That attorney will take the appropriate steps to fight for the disability insurance benefits you deserve and need.

If you have purchased long-term disability insurance through your employer, your policy is likely governed by ERISA, the Employee Retirement Income Security Act of 1974. ERISA sets minimum standards for the group insurance plans provided through private employers.

If your ERISA disability insurance claim is rejected, you will not be alone. Claims for disability benefits under ERISA are frequently rejected. If your own claim for disability benefits is denied, arrange at once to speak with a California life and disability insurance claims lawyer.

What Determines Your Eligibility for Disability Insurance Benefits?

Proving to an insurance company that you are disabled is a challenge. A doctor’s statement is usually not sufficient. Even disability claims that are approved by the Social Security Administration may be rejected by an insurance company if you are covered under a group disability policy through an employer.

It is the insurance company’s definition of a disability – and not the Social Security Administration’s definition – that will determine if you qualify for long-term disability insurance benefits.

However, in a recent California case, the Social Security Administration’s award of disability benefits played a key role in a judge’s decision in favor of the plaintiff. It is a precedent-setting decision that may help many more disability insurance applicants obtain their benefits.

What is an Administrative Record?

What is notable about Logan v. Prudential Insurance Company of America is the way the judge considered Mrs. Logan’s Social Security Disability Insurance (SSDI) award letter.

Her attorneys at McKennon Law Group PC filed a motion to include the SSDI award letter with the administrative record of the case because it was evidence that Mrs. Logan was in fact disabled and because the award letter was not available until after the case’s administrative record had already been prepared.

Generally speaking, new evidence may not be introduced in these cases. When a federal judge hears an ERISA case, the administrative record is typically the only evidence considered. It includes every document provided by the plaintiff or the plan administrator that is pertinent to the case.

Why Was Logan v. Prudential Insurance Company of America Important?

The motion to include the SSDI award letter with the administrative record of Mrs. Logan’s case was denied. However, the judge wrote that the “Social Security Administration’s decision . . . corroborates [Mrs.] Logan’s own and her doctors’ accounts of her disabling pain.”

While the SSDI award letter did not become part of the administrative record, the simple fact that the SSDI award letter was issued was considered supporting evidence for Mrs. Logan’s claim.

As a result of Logan, a court can now use the issuance of an SSDI award letter to support a disability insurance claim even if the award letter is not included in the administrative record of the case.

What if Your Own Disability Insurance Claim is Denied?

If your own ERISA-based disability insurance claim is denied, consult a California life and disability insurance claims attorney and appeal that denial. Your lawyer will help you prepare an appeal and ensure that you are compliant with ERISA guidelines.

U.S. District Courts have jurisdiction over ERISA-related cases. If you file an administrative appeal with the insurance company to no avail, your California life and disability insurance claims lawyer may then bring a lawsuit against the insurance company in federal court.

After Logan v. Prudential Insurance Company of America, if you have been awarded disability benefits by the Social Security Administration, your lawsuit against an insurance company that has denied your disability claim is now more likely to prevail.

If you need ERISA disability or life insurance benefits and your claim has been rejected, act now, and promptly schedule a consultation with a California life and disability insurance attorney such as the highly successful and experienced team for ERISA Claims at McKennon Law Group PC.

Good News if Your Claim for Long-Term Disability Insurance Has Been Rejected

If your application for long-term disability insurance is denied, discuss your rights at once with a California life and disability insurance claims lawyer. That lawyer will take legal action to help you obtain the disability benefits you need and deserve.

In some cases, the denial of a claim for disability insurance may constitute an abuse of discretion by the insurance company, according to a recent ruling handed down by the U.S. District Court for the Central District of California entitled McGuire v. Life Insurance Company of North America, a case that McKennon Law Group PC handled for its client, Brenda McGuire.

The case was heard in federal rather than state court because the plaintiff’s insurance plan was purchased through her employer, and employer-provided group insurance plans are governed by ERISA, the federal Employee Retirement Income Security Act of 1974.

What Are the Two Standards of Review?

If you sue an insurance company that rejects your ERISA governed disability claim, and your California life and disability insurance claims attorney persuades the court that the company’s decision was wrong, even then, your lawsuit may not succeed, depending on the review standard.

Two review standards are used by the courts that hear these cases. A court may use the “abuse of discretion” standard of review or the “de novo” standard of review:

To win a lawsuit under the abuse of discretion review standard, a court must determine that an insurance company’s rejection of your claim abused that company’s discretion. This standard, in which courts must give some deference to disability insurers, is a more difficult standard for a disability insurance claimant to prove under ERISA.

Under the de novo standard of review, a judge only decides whether an insurance company’s rejection of your claim was wrong or right. The de novo standard provides neither side with an advantage going to trial.

What Was Decided in McGuire v. Life Insurance Company of North America?

The District Court determined that Life Insurance Company of North America (LINA) abused its discretion by denying long-term disability benefits to a former community relations manager at Republic Services, a firm that provides waste disposal services across the United States.

The case was decided under the abuse of discretion standard, which is uncommon in ERISA cases pending in California because of a California statute that makes most ERISA cases subject to the de novo standard of review. The court clarified under what circumstances an insurer who denies a disability insurance claim has abused its discretion.

When a court reviews a decision to reject benefits in an ERISA case, it often does so under the de novo standard, which gives no advantage to the insurance company.

Most policies, however, give an insurance company the discretion to determine eligibility for benefits and to construe the policy’s conditions and terms. In these types of cases, the abuse of discretion standard applies if the claimant is from a state that does not have an anti-discretion statute, such as California’s anti-discretion statute.

What Were the Issues in McGuire v. LINA and Why is this Decision Important?

LINA contended that ERISA did not require them to have particular specialists review McGuire’s medical records. The judge Carmac Carney disagreed and found LINA’s failure to use specialists was a procedural irregularity indicating an abuse of discretion.

LINA contended that ERISA does not require that an insurance company have a claimant examined in-person by one of its health professionals and that by not doing so, it did not matter and had no effect on whether it abused its discretion. However, in deciding whether LINA abused its discretion, Judge Carney ruled that this decision to do so does matter.

LINA additionally contended that McGuire’s medical records did not precisely explain how her medical condition prevented her from working. The judge noted that LINA never contacted the doctors to seek clarification and ignored other evidence that verified McGuire’s reports of pain.

LINA also insisted that because McGuire declined surgery and pain medication, she was not disabled. The judge stated that McGuire could not be faulted because pain medications and surgery both carry considerable risk.

The judge found no evidence that McGuire was a malingerer, but he determined that LINA had abused its discretion. The court ruled in McGuire’s favor and awarded her the long-term disability benefits.

Read from the full case file here.

What Should You Know About Disability Insurance Claims?

If you file a disability insurance claim and your claim has been denied – you need the advice that a California life and disability insurance claims lawyer can provide.

Your first legal consultation is provided without cost or obligation. It is your chance to receive the advice you may need and to find out more about how the law may apply to your own situation.

If you need ERISA disability or life insurance benefits and your claim has been rejected, act now, and promptly schedule a consultation with an ERISA claims lawyer such as highly successful and experienced team at McKennon Law Group PC.

According to the Centers for Disease Control and Prevention (“CDC”), around 7.5 percent of American adults have long COVID. This condition refers to a variety of symptoms that can last more than three months after someone gets COVID-19.

In some cases, long COVID symptoms can be debilitating enough that they keep an individual from enjoying life normally. They may also keep someone from working or earning enough income to support their lifestyle. In these cases, individuals suffering from long COVID symptoms might wonder if they have the option to file a disability claim with their insurer.

If you are experiencing such symptoms, learn more about whether long COVID is recognized as a potential disability and what options you have for applying for benefits in California, as well as learning how a life and disability insurance claims lawyer can help.

What Is Long COVID?

The CDC notes that people with long COVID can experience a wide range of symptoms, and not everyone with this condition has the same severity of symptoms.

To be considered long COVID symptoms, the conditions must have started when someone contracted the COVID-19 virus or after that. If symptoms were present before someone contracted COVID, they would likely be considered part of another condition or disease process.

Some symptoms associated with long COVID include:

Brain fog, which refers to challenges with concentration, focus, or memory
Headaches
Trouble breathing or experiencing random shortness of breath
Fatigue or tiredness that does not have other obvious causes
Dizziness, especially when standing
Unexplained cough
Aches or soreness in joints and muscles that cannot be explained
Pain in the chest that is not associated with another condition
Heart palpitations, which are fast or irregular beatings of the heart
A loss of taste or smell that may come and go
Anxiety or depression

Is Long COVID Recognized as a Disability?

Yes, long COVID is recognized as a potential disability under the Americans with Disabilities Act (“ADA”). The ADA includes provisions to protect people with disabilities.

Guidance from federal agencies notes that long COVID can be considered a protected disability under the ADA when it “substantially limits one or more major life activities.”

Some activities considered under this umbrella include:

Caring for oneself, such as bathing, dressing, and preparing and eating meals
Using natural senses, including seeing and hearing
Breathing in a manner that supports normal activity
Reading and writing
Speaking, communicating and interacting with others
Working

But, just because it is a recognized disability under the ADA does not necessarily mean you will qualify as totally or partially disabled under a long-term or short-term disability policy, as we discuss below.

Can You Apply for Short or Long Term Disability Benefits Through Your Insurance Company Because of Long COVID in California?

If you have disability insurance provided through an employer or purchased separately from an insurance company, the answer is yes.

Depending on the definition of disability under your short-term disability policy or long-term disability policy, you may be able to apply for benefits through your individual or group disability insurance company based on long COVID. However, not every case of long COVID is considered a disability by insurance companies. An assessment is required for each case to determine whether the symptoms associated with the condition impact your ability to perform your job or some other job for which you are qualified by education, training and experience.

Insurance policies define “disabled” differently. Generally speaking, an insurance policy may provide short-term or long-term disability benefits if a claimant is unable to perform the material duties of their regular job because of an injury or sickness. Insurance companies typically look at how that type of job is performed across the country instead of with the specific employer. Long-term disability policies may also provide benefits on this basis for a limited time, such as two years. After two years, long-term disability policies usually changes the definition of disability such that the claimant is disabled if he or she is unable to perform any job when considering the claimant’s education, training and experience.

For example, if someone has brain fog and fatigue related to long COVID that is annoying and unpleasant but does not impact the performance of their job duties, they would be not be approved for disability benefits. However, if someone has cognitive long COVID symptoms that are impacting memory to the degree they are unable to perform their job, they may qualify for benefits.

In another example, someone who experiences minor shortness of breath every few weeks due to long COVID may not see a substantial impact on their ability to work. In comparison, someone who experiences trouble breathing on a daily basis due to lung damage associated with COVID may be unable to work and go about their regular daily activities. This may enable them to receive disability benefits.

How Can the McKennon Law Group Help?

To qualify for disability benefits from a disability insurance company due to long COVID symptoms, you must demonstrate that your symptoms impact your ability to work. To do this, you must undergo an evaluation and may need to present medical records and other documents in support of your claim.

Applying for disability benefits through an insurance company can be a long and frustrating process, especially if your claim is denied. The nature of long COVID symptoms can make it easier for insurance companies to deny disability claims—just as they can increase the chance of insurance bad faith disability denials.

Having an experienced disability and life insurance claims attorney on your side can help you make your case for a short-term or long-term disability claim. At McKennon Law Group PC, we offer guidance and support that helps you get through the disability application or appeals process if your claim gets denied. Our team has over seven decades of experience in dealing with disability insurance claims, and we are not afraid to face off against large insurance companies to fight for your rights.

To find out more about how we can help with your long COVID disability claim, call McKennon Law Group PC today and request a free consultation.

Most Americans obtain their insurance benefits through their employment. These employee benefits include health insurance, dental insurance, disability insurance, and life insurance. Most of these benefits are governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA imposes a variety of fiduciary obligations on the administrators for these employee benefit plans. One of those obligations is to not make misrepresentations to plan participants, i.e., the employees and insureds. When either a plan administrator (usually the employer) or a claims administrator (usually an insurance company) provides misinformation to a plan participant, the administrator may have breached its fiduciary duty to the plan participant. McKennon Law Group recently brought a breach of fiduciary duty claim in the Western District of Kentucky and defeated the employer’s Motion to Dismiss (the “Motion”) for failure to state a claim. See Blackburn v. Reliance-Standard Life Ins. Co., 2022 WL 17082673 (W.D. Ky. 2022).

Our client, Ashley Blackburn, is a nurse. She and her husband, Ray Blackburn, both worked for Baptist Healthcare System (“BHS”) in Kentucky. Through their employment, they obtained a variety of employee benefits, including disability insurance and life insurance. Our client and her husband obtained life insurance through Reliance Standard Life Insurance Company (“Reliance Standard”) that covered themselves. They also obtained supplemental life insurance that covered the other spouse. Before doing so, they asked BHS’s representative whether they were allowed to obtain supplemental coverage. They were told that they could. BHS’s representative told them that they were allowed to obtain up to $100,000 in supplemental coverage.

The couple paid for their supplemental coverage for ten years. During that time, our client’s husband developed cancer. Through BHS, he had disability insurance. While out on disability, his life insurance was automatically maintained under a waiver of premium provision of his disability policy. Our client had to spend increasingly longer periods of time away from work to tend to her husband and ultimately had to leave her job. When she left BHS, she converted the supplemental life coverage for her husband into an individual policy. This allowed her to maintain the insurance even though she had left her job to tend to her ailing husband.

Unfortunately, our client’s husband passed away due to cancer. When she submitted a life insurance claim to Reliance Standard, it denied her claim because the supplemental life insurance was improper and disallowed by the Plan language, contrary to what our client had been told by BHS’s representative. Ms. Blackburn hired McKennon Law Group PC, and we sued both the employer and Reliance Standard under ERISA Section 502(a)(3) alleging defendants breached their fiduciary duties by misleading her into believing that she was insured. She also sought statutory penalties under Section 1132(c) for defendants failing to timely disclose plan documents upon request. BHS moved to dismiss our claims against it. It insisted that even assuming that everything in our complaint was true, Ms. Blackburn was not entitled to relief. BHS raised a variety of arguments. It insisted that our client’s breach of fiduciary claim was improper because it was duplicative of an improper denial of benefits claim (a separate type of ERISA claim) and that, ultimately, any oral misrepresentations by BHS’s representative were irrelevant. The Court disagreed and denied the Motion.

The Court explained that a plan participant, such as our client, may bring a claim for breach of fiduciary duty when an administrator provides misinformation to the plan participant. The Court relied heavily on a Sixth Circuit case, Gregg v. Transportation Workers of America International, 343 F.3d 833, 847 (6th Cir. 2003). The Court explained:

[An administrator] also has a duty to honestly respond to all the beneficiary’s inquiries. See Gregg v. Transp. of Am. Int’l, 343 F.3d 833, 847 (6th Cir. 2003). “[O]nce an ERISA beneficiary has requested information from an ERISA fiduciary who is aware of the beneficiary’s status and situation, the fiduciary has an obligation to convey complete and accurate information material to the beneficiary’s circumstance . . . .” Krohn, 173 F.3d at 547. In Gregg, a union administered a group life insurance policy for its members. 343 F.3d at 847. At a meeting where members asked questions about the union’s new life insurance plan before deciding whether to join it, the union’s leaders neglected to share material facts about the policy and gave members information that was contrary to the policy’s express terms (which one of the leaders did not read). Id. at 847–48. The court held that the union breached its fiduciary duties to provide its members with all material information and to truthfully answer their questions. Id. at 848.

Here, Baptist, as the plan administrator, had a duty to answer all of Mrs. Blackburn’s insurance questions truthfully. See Gregg, 343 F.3d at 847; [DN 20-3 at 24]. When she asked whether she could obtain supplemental life insurance on her husband’s life, Baptist was dutybound to tell her she could not, for it knew full well that Mr. and Mrs. Blackburn were both Baptist employees.

Blackburn, 2022 WL 17082673, at *4. Contrary to BHS’s assertions, the oral misrepresentations were potentially a breach of its fiduciary duties to our client. It does not matter that the misrepresentations were not made in writing. It also does not matter what the applicable plan documents state. What mattered is that BHS actively misrepresented information to our client. See id. at **4-5.

As for BHS’s argument that the claim was duplicative and improper, the Court explained that some claims are of such a nature that a claimant cannot pursue a claim for improper denial of benefits in court because, pursuant to the applicable policy/plan terms, the insurer properly applied the plan terms. Instead, the injury stems from improper conduct directed to a plan participant. While Reliance Standard was correct that, under the plain language of the Plan documents, supplemental life insurance was not available to our client and her husband, that did not change the fact that BHS actively provided misinformation to and harmed our client. The Court correctly noted that there must be a remedy for such conduct. See id. at *3.

As the Court explained, whereas some courts state that a claimant cannot “repackage” a claim under both an improper-denial-of-benefits theory and a breach of fiduciary duty theory, those holdings relate to the damages sought, not to the nature of the claim. Under ERISA, a plan participant cannot obtain double relief, a payment under both legal theories. However, when the two claims arise from different conduct, then either claim is a viable avenue to relief, so long as the claimant only obtains relief once. Given that our client did not have a viable claim for relief under an improper-denial-of-benefits theory, the breach of fiduciary duty claim could not be a “repackaging” of such a claim. See id.

The Court accurately explained this area of the law. It is well established throughout the country that neither plan administrators nor claims administrators may provide misinformation to plan participants. To do so may be a breach of fiduciary duty.

When such conduct causes a plan participant harm, the plan participant may seek a variety of forms of equitable relief. The U.S. Supreme Court has addressed these types of fiduciary issues extensively and explained in Cigna Corp. v. Amara, 563 U.S. 421, 439 (2011), that a variety of equitable remedies such as reformation, surcharge, and equitable estoppel are available to ERISA plan participants when they establish breach of fiduciary duty claims. In short, they are entitled to the value of the benefits that they were promised.

Breach of fiduciary duty claims under ERISA are very complicated. There are multiple ways in which an administrator may breach its fiduciary duty to a plan participant. These issues are often intensely litigated. However, courts throughout the country are clear that an administrator may not make material misrepresentations to plan participants who rely on them. When a plan fiduciary such as Reliance Standard or BHS speaks, they must speak truthfully.

Seventy-five million U.S. families depend on a life insurance policy to protect their financial security and future. As we discuss below, if you file a life insurance claim and that claim is denied, you should seriously consider scheduling a consultation to speak with a an experienced California life and disability insurance claims lawyer.

If you are the beneficiary of a life insurance policy and your claim is rejected, what are your options? What steps should you take? What damages can you receive if you are wrongly denied a life insurance claim and you prevail in a legal action against the life insurance company?

Most importantly, when should you contact a California life and disability insurance claims attorney? If you continue reading this brief discussion of life insurance claims and beneficiaries’ rights, you will find the answers you may need.

What Should Beneficiaries Know About Life Insurance?

Life insurance policies are purchased to protect beneficiaries from financial hardship in the unfortunate event of someone’s passing. You expect an insurance company to pay the death benefit under a life insurance policy after premium payments have been made, often for years or decades. You do not need the prospect of financial hardship added to your grief.

Families are not the only ones who depend on life insurance policies. A life insurance policy may be purchased by a business to protect the business or its owners financially if an owner or executive passes away.

All life insurance companies will try to avoid paying a death benefit to a policy’s beneficiary if they can find any reason to do so, and those companies will use a variety of different tactics. If you submit a life insurance claim, and your claim is denied, you do not have to fight the insurance company by yourself. A highly experienced and reputable California life and disability insurance claims attorney can assist you to get the money to which you are entitled.

If Your Claim is Denied, How Will a Life Insurance Claims Attorney Help You?

In some cases of denied life insurance claims, a life and disability insurance claims lawyer will be able to negotiate with the insurance company to obtain the death benefit for you. However, in other cases a life and disability insurance claims lawyer will advise you to file an appeal with the insurer in an attempt to reverse their claim denial. If both negotiations and direct appeals to the insurance company fail, your lawyer may prepare a complaint to initiate a lawsuit to collect your death benefit.

Life and disability insurance claims lawyers routinely fight insurance companies for their clients and they are familiar with the strategies these companies use to avoid paying death benefits. With an attorney’s help, you are far more likely to have the matter resolved in your favor.

How Do Life Insurance Companies Avoid Paying Death Benefits?

Listed here are the most common ploys a life insurance company will use to avoid paying a death benefit:

The company may claim that the decedent misrepresented key facts regarding himself or herself and therefore void or rescind the policy.
The company may claim that the decedent died in a way that the life insurance policy does not cover, such as by an exclusion for death caused by suicide or while intoxicated.
The company may claim that the policy has lapsed, is voided, or that some payments were not timely made.

This list is not exhaustive. Insurance companies concoct numerous ways to avoid paying life insurance claims. If you get only delays and unreasonable denials, you may have a claim for insurance bad faith.

California and most states have laws that protect life insurance consumers when their insurers engage in bad faith behavior. You should seek the help of a life insurance claims lawyer if a life insurance company is avoiding its obligation to you.

How is Insurance Bad Faith Defined?

When a life insurance company does not take seriously its obligation to you as a beneficiary, you may have grounds for filing an insurance bad faith claim against the company. An insurance bad faith claim must be based on an insurance company’s specific acts or failures to act. To establish bad faith, you must prove that the insurer acted unreasonably or without proper cause in denying a life insurance claim. See our FAQs for more information on insurance bad faith.

Insurance companies are like any other business, they want to make a profit. There is nothing wrong with a company making a profit when it provides the goods and services that it advertises. However, an insurance company should not be permitted to place profits over the legitimate claims of its policyholders and their beneficiaries.

How can you determine if you are the victim of insurance bad faith? Only by consulting a California life and disability insurance claims lawyer who regularly handles insurance bad faith cases will you know if the company’s actions constitute bad faith under the law and whether you have a good bad faith case.

What Can a Beneficiary Recover by Taking Legal Action?

If your life insurance claim is denied and you take legal action and prevail against the insurance company, what can you receive? California plaintiffs who pursue insurance bad faith claims may recover their attorneys’ fees separately and in addition to the original death benefit.

In many cases, a plaintiff may also recover consequential damages (for damages caused by the company’s bad faith), court costs, interest on the unpaid death benefit and – if the bad faith was egregious or intentional – a plaintiff may also be awarded punitive damages.

A beneficiary who is victimized by an insurance company’s bad faith needs to be “made whole.” If the life insurance company was responsible for additional losses beyond the policy’s death benefit amount because the claim was handled inappropriately, the insurer may be held responsible for these damages as well.

Was the Life Insurance Policy Purchased Through an Employer’s Group Plan?

If the life insurance policy in question was purchased through an employer, it is most likely governed by the Employee Retirement Income Security Act (ERISA), which is federal law. If ERISA governs the policy, your legal options are reduced and the damages you may recover are limited. Whether a life insurance policy is governed by ERISA can be a very complicated question and a qualified and experienced life insurance attorney may be your only resource for making that determination.

ERISA damages in cases involving life insurance policies include only the amount of the death benefit and in some cases, attorneys’ fees, costs and interest. While you cannot file a bad faith claim in cases that are governed by ERISA, you still have significant legal options.

A California life and disability insurance claims attorney who has experience in cases that are governed by ERISA will explain those options to you, protect your legal rights and guide you through the complicated ERISA appeals process if your initial life insurance claim is denied.

What Else Should Beneficiaries Know?

If the life insurance policy was purchased privately without employer involvement and you bring a lawsuit to recover the death benefit, state and federal courts have jurisdiction. However, if the life insurance policy is governed by ERISA, only federal courts have jurisdiction and they will have the final say in determining your rights.

There may be many issues that arise in determining who or what entity is entitled to a life insurance death benefit. Even though you may be the beneficiary of a life insurance policy, it is possible that you will not be entitled to all or any of the death benefit. Sometimes there are complicated questions about who is entitled to a death benefit and only an experienced life insurance claims attorney will be able to answer questions about who may be entitled to receive a death benefit.

What Will It Cost to Take Legal Action?

Depending on the life insurance lawyer you hire, there may be no fee or cost unless you get a recovery. A life and disability insurance claims attorney may handle your case on a contingency fee basis and if for any reason your attorney’s efforts are not successful, you will owe that attorney nothing. These insurance claims attorneys often offer beneficiaries a free case evaluation. That free evaluation is your opportunity to learn how the law applies to your specific circumstances and make an informed decision about moving forward with a legal action.

If you have had a life insurance claim denied, the aggressive and highly experienced life and disability claim attorneys at McKennon Law Group PC can provide you with a free consultation to determine your options under a life insurance policy.

In Winters v. Liberty Life Assurance Co. of Boston, 2022 WL 6170588 (D. Mass. 2022), the First Circuit recently denied Liberty’s motion for a judgment on the administrative record on the basis that Liberty had not sufficiently analyzed whether the claimant, Winters, could perform his own occupation. Winters had been receiving long-term disability (“LTD”) benefits, which Liberty terminated based on its review of the medical evidence and occupational analysis of Winters’ occupation as a mortgage consultant for Wells Fargo. The court found, inter alia, that Liberty failed to properly investigate Winters’ job duties and apply them to the medical evidence. The court stated that Liberty’s decision to terminate Winters’ LTD benefits was “unreasonable based on the record before it because Liberty did not complete an assessment of whether Winters was able to carry out all of the material and substantial duties of his own occupation as defined by the relevant disability plan. Rather, Liberty made a determination that Winters could perform sedentary or light physical work.” (Emphasis added).

Liberty’s position when it terminated Winters’ benefits was that according to the medical evidence, he should be able to perform the duties of his own occupation. Liberty’s review included independent medical review reports, vocational review reports, and a labor market survey. However, the court, citing McDonough v. Aetna Life Insurance Co., 783 F.3d 374 (1st Cir. 2015), stated that the relevant question “is not whether Winters is able to perform sedentary or light physical work. The proper inquiry is whether he is able to perform the Substantial and Material Duties of his Own Occupation – his particular position as a Mortgage Consultant or Financial Services Sales Agent.” Because Liberty’s vocational review reports and labor market survey focused on the physical demands generally associated with “sedentary” or “light physical” work, rather than on the substantial and material duties of Winters’ own occupation, Liberty had performed only part of the inquiry required of it under ERISA.

The court distinguished between physical and non-physical duties of Winters’ occupation and concluded that Liberty’s analysis as to whether Winters could perform sedentary or light physical work was only part of the relevant inquiry of whether Winters could perform the material and substantial duties required of a Mortgage Consultant or Financial Services Sales Agent. Liberty identified non-physical duties of Winters’ occupation in his employer’s job description, but it did not analyze the non-physical duties in the context of the medical evidence, did not include them in its labor market survey, and did not discuss them in the denial letters it sent to Winters. The court concluded that while Liberty may have properly reached its decision to terminate Winters’ LTD benefits, it was not apparent from the administrative record, as Liberty never made the requisite comparison of the medical evidence against the non-physical duties of Winters’ occupation. The court stated that “[i]t was insufficient for Liberty to rely on blanket statements from the doctors that restrictions and limitations are not supported by the record without addressing the duties Winters was called upon to perform.” The court also noted that Liberty was obligated to analyze the medical assessments as compared with the job requirements, rather than in the abstract context of whether Winters could perform “sedentary” or “light physical” work.

In response to Winters’ contention that Liberty should have provided his job description to its reviewing doctors, the court explained that the proper focus of the inquiry was not Winters’ job description or whether he could perform the duties of his particular position at Wells Fargo, but whether he could perform the duties of his own occupation, as defined in the local economy. While Winters’ job description may accurately describe the duties of his own occupation, Liberty was also permitted to draw on other sources, like the Department of Labor Dictionary of Occupational Titles, to determine the duties of Winters’ own occupation.

The court ultimately concluded that Liberty did not adequately explain how Winters would be able to perform the duties of his own occupation (particularly the non-physical duties), but rather only analyzed whether Winters could perform sedentary or light work. Whereas Winters’ job may have been properly described as “sedentary” or “light,” Liberty’s determination that Winters could perform the duties of his job because he had the physical capacity to perform such work failed to take into account other requirements of Winters’ occupation not adequately contemplated by the definition of “sedentary” or “light” work.

The court’s decision makes it clear that insurers like Liberty must apply the medical and vocational evidence to the occupational profile and determine whether a claimant like Winters is disabled. Liberty’s flaw was that in its analysis, it “improperly conflated Winters’ Own Occupation with general sedentary or light work” (citing McDonough, supra, at 380). The court went on to explain that while it was possible that Liberty’s decision was sufficiently supported by the medical evidence, it was not evidenced from the administrative record and Liberty did not communicate it properly in its decision letters to Winters.

The subtle distinction discussed by the court in Winters presents a nuance that is often overlooked. Therefore, it is critical for a claimant like Winters to retain legal counsel who will know and understand the distinction and how it can impact a given disability claim.

The attorneys at McKennon Law Group PC are highly experienced in handling ERISA claims, including claims for LTD benefits like in Winters.

SSDI Award Letter Helps Client Win ERISA Case