Case Name: Mark Sapp v. Liberty Life Assurance Company of Boston a/k/a Liberty Mutual Insurance Company
Court: United States District Court for the Eastern District of Virginia.
Type of Claim: Long Term Disability.
Insurance Company: Liberty Life Assurance Company of Boston a/k/a Liberty Mutual Insurance Company (hereinafter “Liberty”).
Claimant’s Employer: Republic National Distributing Company.
Claimant’s Occupation / Job Position: Wine Salesman.
Disabilities: Plaintiff suffered from severe back pain. On February 25, 2014, Plaintiff injured his back on the job while lifting boxes of wine that weighed approximately 45 pounds. The injury was so extensive that it required surgery. After the surgery, Plaintiff was discharged with restrictions limiting the amount of weight he could lift and how long he can sit or stand.
Definition of Disability:
The Plan defines a “disabled employee” as one whom:
“as a result of injury or sickness, is unable to perform the Material and Substantial Duties of his Own Occupation.”
For purposes of determining Disability under the Plan, Liberty considers the Covered Person’s occupation as it is normally performed in the national economy.
Further, the Plan defines “Material and Substantial Duties” as:
“responsibilities that are normally required to perform the Covered Person’s Own Occupation, or any other occupation, and cannot be reasonab[ly] eliminated or modified.”
The Plan provides that “Own Occupation” is:
“the Covered Person’s occupation that he was performing when his Disability or Partial began.”
Benefits Paid? Claimant received short-term disability benefits. Long Term Disability benefits were not paid to claimant. Liberty denied coverage on August 8, 2014, stating that the post-surgery restrictions placed on claimant by his doctors would not interfere with a “light work” position, and, as a result, he did not qualify as disabled.
Procedural history: The claimant was denied coverage on August 8, 2014. On August 28, 2014, the claimant appealed the denial and incorporated additional key information regarding the nature of his duties as a wine salesman. On October 21, 2014, Liberty denied the appeal.
Key Physician Opinions: Liberty employed a vocational expert to analyze the validity of Plaintiff’s claim. The vocational expert reviewed the entire claims file and reviewed the Dictionary of Occupational Titles (a standard vocational resource) in making her determination. Liberty had described Plaintiff’s position as a “Sales Representative-Retail,” to which the vocational expert concluded that there was no appropriate DOT description applicable to that job description. Specifically, the vocational expert assessed two other classifications- (1) Sales Representatives, Services, All Other and (2) Sales Representatives, Wholesale and Manufacturing, Except Technical and Scientific Products.” The vocational expert concluded that the “occupation of Sales Representatives is not performed in one definitive manner in the national economy. Rather taking into consideration the nature of the work descriptions, the occupation is most performed at the sedentary and light levels of physical demand based on the Department of Labor descriptions found in the DOT, with sufficient opportunity at both levels.” Liberty utilized the vocational expert’s report in denying Plaintiff coverage. Liberty described Plaintiff’s occupation as one that is categorized as a “light work” position under the Department of Labor occupations. Further, Liberty concluded that the post-op restrictions placed on Plaintiff would not interfere with a “light work” position, and therefore he did not qualify as being disabled under the policy.
Issues: Plaintiff makes two related arguments in support of his Motion for Summary Judgment. (1) First, he argues that Liberty’s denial of benefits was not reasonable because it ignored important evidence in defining his Own Occupation. Further, Plaintiff argues that the information he provided to Liberty when he submitted his appeal was also outright ignored. When appealing his decision, Plaintiff included and incorporated additional information into his claim. In regards to his job description, Plaintiff included that he was driving more than 24, 000 miles per year; filling shelves; lifting cases of wine that weigh an average of 45 pounds; bending, kneeling, and reaching for wine bottles on store shelves. He also provided medical notes, as requested by Liberty. (2) Second, Plaintiff argued that Liberty failed to consider the more appropriate occupational title of 53.3021.00- “Driver/Sales Worker,” which is a “medium work” position. In its initial determination that Plaintiff was not disabled, Liberty asserted that Plaintiff’s “Own Occupation” was “41-4012.00-Outside Sales Representative,” which is categorized as a “light work” position per the Department of Labor’s occupational guidelines. In conjunction with this finding, Liberty concluded that the post-surgery restrictions placed on Plaintiff by his doctors would not interfere with a “light work” position, and as such, he did not qualify as disabled.
Holdings: (1)The Court concluded that Liberty abused its discretion in denying Plaintiff Long Term Disability benefits. In support of its conclusion, the Court first stated that in making its determination that Plaintiff’s “Own Occupation” was that of an “Outside Sales Representative,” Liberty ignored or failed to consider important evidence about Plaintiff’s actual physical job duties. More specifically, the Court stated “Liberty did not engage in the ‘deliberate, principled reasoning process’ that was required of it.” When Plaintiff filed his appeal on August 22, 2014, he laid out in precise detail the substantial physical demands of his job, of which the vocational expert and Liberty failed to consider. The Court stated, “it was unreasonable for Liberty to not consider the job’s actual physical duties in performing its occupational analysis. (2)Secondly, the Court determined that in light of all the evidence, Liberty’s vocational expert should have considered the alternate DOT occupation of “Driver/Sales Worker” as opposed to “Outside Sales Representative.” Plaintiff provided Liberty with ample evidence concerning the exact nature of his job and coinciding physical duties, which involved driving in excess of 24,000 miles a year and regularly lifting approximately 45 pounds. The Court stated, “it seems only reasonable that the expert would search the DOT and other databases more broadly to look for other similar occupations based on the job descriptions provided.” Liberty’ s complete failure to consider the Driver/Sales Worker occupation was a fatal flaw in deciding the outcome of Plaintiff’s claim. (3)The Court further concluded that Liberty’s dual roles of being responsible for both administering the plan and making the benefits determination created a clear conflict of interest. When Liberty assessed Plaintiff’s claim and rendered its decision, it chose to rely almost exclusively on the report generated by a vocational expert who was deeply intertwined with Liberty. The Court concluded that had the vocational expert been independent and therefore unbiased in its relation with Liberty, there would be no evidence of a conflict of interest. However, because Liberty was responsible for both administering the plan and assessing the validity of Plaintiff’s claim, and thus making the final determination as to benefits, there was a clear conflict of interest.
Summary: The Court granted Plaintiff’s motion for Summary Judgment. Specifically, the Court stated “Liberty abused its discretion in denying Plaintiff’s claim for long-term disability benefits.” Because Liberty outright failed to consider the evidence of Plaintiff’s job description in its determination of Plaintiff’s occupation, which ultimately led to their denial of Plaintiff’s claim, Liberty abused its discretion under the policy and incorrectly denied Plaintiff’s claim. In assessing the appropriate remedy for the case, the Court saw no need to remand the case back to the administrator. The Court stated “there is no need for remand in this case because there was no evidence missing from the initial determination. The Court concluded that a remand here would prove to be a “useless formality.” As a result, the Court concluded that Plaintiff was entitled to retroactive long-term disability benefits that began on the date his short-term benefits expired.