People in Chicago and elsewhere in Illinois with ERISA covered long term disability insurance plans provided by an employer often ask me why evaluating a disability case is so complicated. Often individuals think about disability only in the context of their medical condition. But in fact, every disability claim is like a three-legged stool. It takes consideration of all three “legs,” as I call them. Those three legs to the stool are (1) the medical leg, including restrictions and limitations due to your medical condition, (2) the vocational leg, including the material and substantial duties of your own occupation or the transitional “any occupation,” and (3)the terms of the plan document or insurance policy. Without considering all three of these “legs,” a disability claim cannot be properly reviewed, approved, or denied.
At the most basic level, the vocational “leg” can be critical if your medical condition precludes you from extensive use of your legs, and your occupation requires you to be on your feet a significant portion of the day. The terms of the policy can often be critical as well. Some occupations require in excess of a 40-hour work week, and there may be limitations from working more than 40 hours. But many policies expressly state working more than 40 hours per week is not deemed a material and substantial duty. Most of our cases are far more complicated than these examples, but they demonstrate the many moving parts of a disability case and why all three “legs” of the stool must be considered. In a recent case, UNUM improperly denied a claim for long term disability benefits under an ERISA plan because it failed to consider the occupational duties, and how the medical restrictions and limitations affected the claimant’s ability to perform those duties in Doe v. Unum Life Insurance Co. of America, No. 13-6900, 2014 U.S. Dist. LEXIS 162042 (E.D. Pa. Nov. 18, 2014).
In Doe, the Plaintiff (proceeding as “Jane Doe”) worked as a validation process engineer for a pharmaceutical company. She stopped working in 2010 due to her anxiety and depression. Doe’s physician’s restricted her from returning to work at her position due to her stress and anxiety. The insurer reviewed records and concluded that there was inadequate support to establish Ms. Doe could not perform “consistent, sustainable work,” but it did not connect the limitations from Ms. Doe’s condition to the duties and responsibilities of her occupation as a validation process engineer. While Unum did obtain the job description from Ms. Doe’s employer, and retained a vocational consultant to opine on the material and substantial duties of the occupation, it never referenced any of those duties in denying the claim. After Ms. Doe sued to recover her benefits under ERISA § 502(a)(1)(B), the court held Unum’s failure to do so was arbitrary and capricious.
This sort of review that does not take into account all three “legs” of a long term disability claim is quite common, and grounds to invalidate a long term disability denial. If you have been denied a claim for long term disability benefits, contact an experienced ERISA attorney.