Cara R. Denney (“Denney”) was an employee of Wagner Equipment Company (“Wagner”) where she was a Computer and Technology Instructor. Her job duties “required extensive computer use” and “the ability to instruct employees on the use of various computer systems.” She was also required to travel up to fifty percent of the time, be able to lift up to twenty-five pounds and be able to stand and/or walk for more than a third of the workday. Through her employment with Wagner, she was covered by both short-term and long-term disability benefits plans that were administered by Unum Life Insurance Company of America (“Unum”).
On June 25, 2015, Denney had her last day of work, which was immediately followed by bilateral reconstructive surgery on her left foot on the next day. She later had the same surgery on her right foot on July 20. Denney filed for short-term disability benefits which were subsequently granted. Denney’s surgeon, Dr. Joseph Mechanik, estimated that she would need about six months to recover, suggesting a return to work date of December 31. However, with her surgeon’s approval, she began to work part-time in October.
Previously, Denney had experienced two herniated disks which led to an L4-S1 lumbar fusion in October of 2001. She occasionally reported “flareups” and “failed back surgery syndrome” but she also explained that she had “overall improvement of her severe pain from the surgery.” Once Denney began physical therapy for her bilateral reconstructive surgery, she began to experience neck and back pain that appeared to be severe. She was then referred to a Dr. Michael Gesquiere for Pain Management, and Christopher LaFontano, a neuromuscular specialist.
After Denney had an exam with Dr. Mechanik on December 14, 2015, he limited her to part-time work with restrictions of standing for no more than fifteen minutes per hour, or forty-five minutes a day. He also limited her from stooping, bending, or lifting anything over ten pounds. Dr. LaFontano further restricted her from working completely, explaining that the restriction could be permanent. He also suggested that she may be in need of another surgery in the future. At this point, Denney filed for long-term disability benefits because of her back and feet issues.
On April 22, 2016, Unum denied Denney’s claim, only finding her disabled from June 23 through December 14 of 2015. The language of the notice cited, “We have determined you are able to perform the duties of your occupation on a full-time basis prior to the end of the 180-day elimination period and benefits are not payable.” Denney then appealed and provided additional medical records from her treating physicians. Unum again denied the appeal and Denney filed a voluntary second appeal. This was also denied.
Then, Denney filed the instant suit, alleging that she “suffered from a sickness/illness,” “was unable to perform the essential duties of her own occupation (or any other reasonable occupation) due to said sickness,” and “was, and is, unable to perform the essential functions of her own occupation, and/or any other occupation for which she is qualified.” Denney brought forth a number of arguments against Unum, which the Court then analyzed.
First, Denney argued that the Plan’s language is unclear, requiring a claimant to be “continuously disabled through the elimination period” while not allowing any days that a claimant is not disabled to count toward the 180-day elimination period. As such, she believes that this means she can “use non-consecutive days of disability to satisfy the elimination period when working.” In response to her argument, the Court stated that “An insurer’s decision for denying a claim must be clear so as to allow the insured an opportunity to properly respond to the denial.”
It goes on to cite that “The remedy when an ERISA administrator fails to make adequate findings or to explain adequately the grounds of her decision is to remand the case to the administrator for further findings or explanation.” The Court explained that Unum should have been able to provide Denney with a clear interpretation of the Plan regarding whether she must have a continuous disability for 180 days. Further, Unum should have then explained whether or not this then applied to Denney’s case. Because it did neither of those things, the Court believed that the case should be remanded to the administrator for further review.
In addition, Denney argued that Unum did not “fairly consider” her job requirements and instead heavily relied on language found in the U.S. Department of Labor Dictionary of Occupational Titles. Under the Dictionary’s definition of Training Representative, Denney’s role is defined as that “which requires occasional exertion up to twenty pounds, frequent exertion up to ten pounds, frequent sitting, keyboarding, occasional standing, walking, reaching, handling, and fingering.” After review, a vocational rehabilitation specialist noted that Denney’s job description was more in line with that of a Training Instructor.
Regardless of these categorizations, Denney stated that Unum did not give sufficient consideration to the fact that her job requires travel. Unum explained that the record showed that a vocational rehabilitation consultant did indicate that travel “would typically be completed on a local basis achieved primarily via automobile/driving,” but “this particular level of travel [is] a job specific requirement of the insured’s position with this policyholder and not necessarily representative of the manner in which the overall Training Instructor occupation is performed.”
The Court then chose to defer to the language of the Plan which explained that the claimant’s occupation is compared to that of the national economy, as opposed to how the claimant carries out her work. Therefore, it chose not to remand this particular issue back to Unum for review. Even so, overall, the Court ruled in favor of Denney, ordering that the case be remanded to Unum for further review relating to whether she must be continuously disabled for 180 days and if that standard then applies to her claim for benefits.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a copy of the decision in PDF: