There are many tactics that insurance companies use to downplay, or even ignore, the severity of an insured’s illness or injury in an attempt to deny a claim for long-term disability insurance benefits. For example, insurance companies will often attempt to limit their determination of whether a person is disabled to the date a claim is filed, regardless of whether a condition is progressive or takes a turn for the worse after the claim is filed. However, under Employee Retirement Income Security Act of 1974 (“ERISA”), once documentation of a worsening condition or worsening symptoms is provided to the insurance company prior to a final denial, it must be considered. Additionally, insurance companies will often ignore the actual requirements of a person’s job, and rely upon a description of a similar occupation contained in the Dictionary of Occupational Titles (“DOT”), a publication produced by the United States Department of Labor which identifies, among other things, the physical requirements of various occupations. Insurance companies will then rely on the often less demanding physical requirements of a comparable occupation contained in the DOT in order to claim that disabled individuals are capable of performing the requirements of their occupation. As demonstrated in a recent decision from the Northern District of California, judges will not allow insurance companies to use their subtle tricks to avoid paying a valid claim for disability benefits.

In Montoya v. Reliance Standard Life Insurance Company, No. 14-cv-02740-WHO (N.D. Cal. Sep. 27, 2016), Mr. Montoya was a mental health therapist who filed a claim for disability benefits from Reliance Standard Life Insurance Company (“Reliance”) due to his carpal tunnel syndrome, pain in both of his hands, neck pain, back pain, acute stress reaction, and depression. After initially concluding that Mr. Montoya was disabled for a limited period of time due to evidence of temporary psychiatric impairment, Reliance denied his claim insisting his medical records failed to support an impairment that would preclude returning to work. Mr. Montoya’s pain and symptoms became progressively worse after he filed his claim for disability benefits with Reliance. After Mr. Montoya appealed Reliance’s denial of his claim, he was examined by a physician hired by Reliance to determine his level of impairment. Reliance requested that the examining physician determine the presence or absence of an impairing condition only as of the date that Mr. Montoya’s temporary psychiatric impairment ended. Based upon Reliance’s request, the examining physician did not consider Mr. Montoya’s subsequent medical records indicating he was unable to return to his job duties due to worsening of his carpal tunnel syndrome, revealing additional diagnoses of wrist derangement and cervical radiculopathy, and showing a significant increase in his pain since the date Reliance determined his temporary psychiatric impairment ended. The examining physician hired by Reliance prepared a report indicating that based upon his examination of Mr. Montoya, he was capable of working in a sedentary capacity as of the date his temporary psychiatric impairment ended.

Reliance also ignored the amount of typing and fingering required by Mr. Montoya’s occupation by citing to the DOT title for “caseworker/Social Services,” last updated in 1991, which only required “occasional” fingering and typing. However, Mr. Montoya’s testimony and the job description provided by his employer indicated his job required computer work at least 40% of the time, significantly more than “occasionally.” Mr. Montoya argued that Reliance should not be able to rely on a DOT title that was last updated in 1991 for a determination of what his occupation entails in terms of fingering and computer work. Instead, Mr. Montoya asserted that Reliance should consider his actual job tasks which required substantial typing/fingering that he is not able to perform.

The District Court found that Reliance erred in relying upon its examining physician’s report. Specifically, the court noted that the examining physician failed to explain why he could testify as to what Mr. Montoya’s limitations were when his temporary psychiatric impairment ended. The court noted that it was improper for Reliance to fail to explain why it was appropriate to limit its review of Mr. Montoya’s physical ailments after the date his psychiatric impairment ended when the record was replete with evidence that his pain worsened significantly after that time. In other words, as long as records indicating Mr. Montoya’s worsening condition were provided to Reliance prior to a final decision regarding his entitlement to disability benefits, they were part of the administrative record and must be considered in the determination of his disability. The District Court further determined that Reliance should have considered Mr. Montoya’s actual job tasks as a mental health therapist which required substantial typing/fingering that he is not able to perform. The court noted that it was unreasonable for Reliance to rely solely on the DOT definitions last updated in 1991 to determine the requirements of Mr. Montoya’s job as of 2012, particularly given the evidence in the record.

The court ruled in favor of Mr. Montoya and determined that Reliance acted unreasonably. It is important to remember that this case was decided under the de novo standard of review, like almost all cases involving claims for disability benefits under ERISA in California. This means that the judge reviews all of the documents in the insurer’s possession at the time it rendered a final decision, and then determines whether the insured is entitled to disability benefits without deferring to the insurer’s decision. Therefore, while a worsening condition or worsening symptoms will be considered in determining a claimant’s entitlement to disability benefits, is important to understand that the administrative record essentially closes when your insurer renders a final decision on your claim.

Ultimately, as the Montoya case illustrates, if your insurer denied your claim while ignoring portions of your medical records or ignoring your actual job requirements, there is a good chance we can help. Please contact McKennon Law Group and let us see if we can assist you.