The present case involves an appeal by Aetna Life Insurance Company (“Aetna”) from a successful motion for summary judgment granted in Christopher Patterson’s (“Patterson”) favor. Regarding the same case, the court had also denied a motion for summary judgment filed by Aetna. Patterson was covered under a long-term disability policy by Aetna through his employer Fire Consulting Group, Inc. Patterson had been receiving benefits under the policy as the result of back surgery in 2007. This surgery resulted in his inability to work. Aetna ended the payment of these benefits in 2014 because it determined that Patterson was no longer disabled.
Under the long-term disability policy, the term “disability” is defined as the following:
“You will be deemed to be disabled on any day if:
- You are not able to perform the material duties of your own occupation solely because of: disease or injury; and
- Your work earnings are 80% or less of your adjusted predisability earnings.”
Aetna asserted that Patterson was not considered to be disabled because he could perform the material duties of his “own occupation” “in the national economy.” Further, Aetna alleged that Patterson’s occupation was “sedentary” and that he could perform “sedentary” work. This decision was made without determining whether Patterson could carry out his “job as performed for his specific Employer” even though that work appeared to be more demanding as opposed to his “occupation as it exists in the national economy.”
Upon Aetna’s denial of his benefits, Patterson filed the present claim. The court determined that Aetna’s decision was arbitrary and capricious and contradictory to the language of the policy which covered Patterson. More specifically, Aetna did not consider whether Patterson’s could perform his own job duties, instead utilizing a “national economy” interpretation. Additionally, the court found that “travel and standing to give presentations are material duties of [Patterson’s] own occupation.”
According to case law, “An administrator’s decision is arbitrary and capricious ‘if it is without reason, unsupported by substantial evidence or erroneous as a matter of law.’” Further, when using an arbitrary and capricious standard, the court defers to the reasonable interpretation of ambiguous plan language by an administrator. However, an administrator may not interpret ambiguous language in conflict with the plain language of the plan. While Aetna, as administrator, had the authority to interpret the language of Patterson’s policy, unambiguous language did not need interpreting.
Here, the court cited its own precedent in the Lasser case. Under Lasser, the court interpreted a “disabled” person to mean “if as a result of injury, illness or disease he is capable only ‘of performing the material duties of his/her regular occupation on a part-time basis or some of the material duties on a full-time basis.’” The case also states that the term “regular occupation” is unambiguous and points to “the usual work that the insured is actually performing immediately before the onset of disability” if no other definition is noted in the policy. Because of this, the court held that “regular occupation” is not a job “in the general economy.”
Here, Aetna argued that there is a difference between the terms “own occupation” and “regular occupation.” However, the court held that they, in fact, were the same. The Lasser case cited that “the purpose of disability insurance and the modified his/her before regular occupation made clear the analysis had to be conducted based on the insured’s own occupation.” Other courts have additionally noted that there is no legal distinction between the two phrases, stating that “the only possibly significant distinction between that case and the present one is that there the policy term was ‘regular occupation’ and here it is ‘own occupation.’ That relatively minor difference in language does not warrant a different result.”
The court further held that, if anything, using the words “own occupation” is more likely to mean one’s own job duties than the words “regular occupation.” In support of this assertion, the court cited another case stating that “whatever the meaning of ‘regular’ is, it is not synonymous with ‘own.’ … Construing the policy language according to its ‘plain meaning in an ordinary and popular sense’ then, ‘own occupation’ refers to [the insured’s] actual job duties.” Also, the court provided a citation indicating that an attorney’s “regular occupation” was “not restricted to his own specific job.” The court felt that there should be no different treatment of those two terms “regular” and “own” in the instant case.
To further support its stance, the court stated that Aetna even argued successfully that “own occupation” and “regular occupation” are the same. The citation is very specific: “The relevant policy language … actually referred to ‘regular’ rather than ‘own’ occupation. However, these terms, as Aetna asserts, are interchangeable.” More importantly, that case was being argued while Patterson was receiving benefits under the policy at hand.
The court’s reasoning in this case is that because “own occupation” and “regular occupation” are both to be used in the same manner, the Lasser case controls “own occupation” here as well. Therefore, the meaning of “own occupation” is “the usual work that the insured is actually performing immediately before the onset of disability.” Aetna impermissibly utilized a “national economy” interpretation of “own occupation” which was not defined in the policy. As such, “own occupation” must be construed to mean Patterson’s actual job duties.
The final holding by the court is that the District Court’s judgment should be confirmed. This means that Patterson’s granted motion for summary judgment stands, just as the denial for Aetna’s motion for summary judgment stands. In other words, Patterson remained successful in his appeal over Aetna’s denial of his benefits.
Here is a PDF copy of the decision: