In the present case, Dave Nagy (“Nagy”) was a Quality Assurance Analyst employed by Oracle America, Inc. (“Oracle”). Around September 8, 2011, he began experiencing symptoms of Chronic Fatigue Syndrome (CFS) as well as other mental health and possibly autonomic dysfunctions. Nagy applied for short-term disability (STD) benefits but was denied by Hartford Life and Accident Insurance Company, et al. (“Hartford”), the policymaker. However, the California Unemployment Insurance Appeals Board reversed that decision and Nagy received STD benefits through September of 2012.
Subsequently, Nagy applied for long-term disability (LTD) benefits which Hartford again denied. Nagy appealed and Hartford denied the same. Nagy filed suit on January 3, 2014, and the Court eventually granted Nagy an award of benefits extending from December 12, 2011, to December 11, 2013. The Court then directed Hartford to determine whether Nagy was entitled to LTD benefits beyond that date. Hartford again denied Nagy’s benefits. As a result, the instant suit was filed.
Oracle’s insurance plan defines “Total Disability” as “during the Elimination Period and for the next 24 month(s), as a result of injury or sickness, You are unable to perform with reasonable continuity the Essential Duties necessary to pursue Your occupation in the usual or customary way.” Further, “Your occupation” means “any employment, business, trade or profession and the substantial and material acts of the occupation You were regularly performing for Your employer when the disability began.” After the twenty-four month period, the definition of disability changes from “Your occupation” to “Any Occupation.” Any Occupation is “an occupation You could reasonably be expected to perform satisfactorily in light of Your age, education, training, experience, station in life, and physical and mental capacity.
On June 17, 2016, Nagy supplied Hartford with the information that he was being treated by a number of physicians: Dr. William Early, since January 2012; Dr. Anne Todd, since September 2014; and Dr. Mark B. Van Deusen in February 2016. Nagy further indicated that he had appointments to see Dr. Jose Montoya in June of 2016 and could see Dr. Christopher R. Snell, Ph.D. in 2016. Hartford chose to have medical peer reviews by Neuropsychologist Cynthia Bailey, Ph.D., Occupational Medicine doctor Joseph Rea, M.D., an Infectious Disease doctor Imad Durra, M.D.
Upon review of Nagy’s records, Dr. Bailey did not find any evidence of psychological or cognitive conditions that were functionally impairing. She opined that Nagy’s cognitive weakness was the result of anxiety and depression. As a result, she stated that he was able to work eight hours a day, forty hours a week from December 12, 2013, to the present.
Dr. Joseph Rea’s review of the records indicated that there was no support for any restriction or limitation, except that of a note for safety regarding dizziness. He attempted to reach Dr. Montoya on seven different occasions but was unable to get a response. After reviewing Dr. Christopher Snell’s report, he opined that Nagy should have a minor restriction or limitation regarding full-time sedentary work. However, he could “push, pull, lift, or carry up to 10 pounds on an occasional basis; to stand for up to 20 minutes at a time for up to a total of three hours over an eight-hour period of time; to walk for 15 minutes at a time for up to two hours over an eight-hour period of time; and to avoid larger truncal or leg actions, such as crouching, crawling, or squatting.” Additionally, “[t]here would be no obvious limitation in regard to sitting, reaching, or the use of hands, while any climbing or kneeling should be limited to a rare or less than occasional frequency.”
After reviewing Nagy’s records, Dr. Imad Durra stated that Nagy’s diagnoses were previously identified as obstructive sleep apnea, restless leg syndrome, anxiety, GERD, and depression. He also found no potential limitations or restrictions related to infectious disease. Dr. Durra opined that he was unable to make a determination regarding chronic fatigue syndrome or myalgic encephalitis without ruling out other causes first.
Hartford then conducted a Vocational Review based on the restrictions and limitations in Nagy’s medical records. The report showed that there were sixteen occupations in the “closest” level, which were crossed with Nagy’s functional capabilities, education, skills, and earning potential. Several of those positions were located in the area where Nagy resided.
Nagy also provided a statement of what his typical day looked like. For example, he provided the following as an explanation of the types of things he would do: “[…] household chores. Maybe I’ll go to the store and buy groceries. Maybe I’ll vacuum either the upstairs or downstairs. Maybe I’ll mow one of the lawns. Perhaps I’ll take our tortoise out for a walk. Last week, I needed to drive my Wife [i]nto Atlanta for a doctor’s appointment, so that turned out to be the only thing I accomplished on that day.”
As a result of the above, Hartford alleges that Nagy is unable to prove that he had a continuous disability throughout the “Any Occupation” period from December 12, 2013, to the present. More specifically, Hartford contends that there is a lack of disability certification from Nagy’s physicians, that the reviewing physicians agree that Nagy can perform sedentary work and that Nagy has a record of failing to comply with his physicians’ treatment recommendations. Nagy argued that his medical records showed that he could not return to sedentary work. However, there is a ten-month gap in the treatment record that is unaccounted for. As such, he failed to show a continuous disability throughout the “Any Occupation” period. Further, Nagy’s own statement showed that he would be capable of performing sedentary work. Additionally, Nagy failed to follow recommendations by his treating physicians. Dr. Todd suggested that Nagy commits to a gentle exercise routine, which he did not do. Dr. Todd also noted that Nagy failed to regularly take his prescribed medication.
One of Nagy’s final arguments was that none of the sixteen employers that Hartford identified would hire him. However, Hartford’s only requirement was to show that there are opportunities, not to show that Nagy would necessarily be hired. Because Nagy failed to prove his burden that he was continuously disabled during the “Any Occupation” period, the court held that Hartford was proper in denying his 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 PDF copy of the decision: