Bruce Tracia (“Tracia”) was an employee of Comcast Cable Communication Management, LLC (“Comcast”) and held the job of a business account executive. He had previously worked as a line technician and several other positions while working for Comcast. Through his employment with Comcast, Tracia was covered by a Group Disability Income Policy. Liberty Life Assurance Company of Boston (“Liberty Life”) both administered the policy and paid benefits out. In order to receive long term disability benefits, Tracia had the burden of providing “Proof of continued . . . Disability.”
The term “disability” or “disabled” means that “during the Elimination Period and the next 12 months[,]” an employee “as a result of Injury or Sickness, is unable to perform the Material and Substantial Duties of his Own Occupation[.]” After that time, the definition changes to include that he “is unable to perform, with reasonable continuity, the Material and Substantial Duties of Any Occupation.” “Own Occupation” further means the job that the employee “was performing when his Disability . . . began.”
Tracia began experiencing pain in his left ankle in May of 2011. Tracia’s podiatrist, Dr. Drew Taft, opined that he had tarsal tunnel syndrome, which led to Tracia ceasing work and filing a short term disability claim. On May 17, he began to receive these benefits. In June, Tracia had a tarsal tunnel release surgery, which led to increased pain and a loss of sensation in the toes and heel. In July, Tracia underwent an MRI which indicated that he had mild-to-moderate spondylosis and post-surgical spinal changes in the lumbar area, in addition to a mild annular disc bulge and L4-5. In November of 2011, Tracia’s short term disability benefits expired.
Upon review of his file and determining that he was disabled, Liberty granted Tracia long term disability benefits on November 29, 2011. Tracia then received evaluations by a Dr. Rathmell, where he was said to be experiencing “chronic lumbar radiculopathy – chronic low back pain and left leg pain” that was likely “long term.” Further, his primary care physician, Dr. Chin, explained that Tracia was unable to walk, sit, or stand for greater than 20 minutes as a result of his pain, and that he was unable to complete any job requirements that involved walking, driving, sitting, or standing for any sustained amount of time.
By May of 2012, Liberty sent Tracia a letter explaining that it would be gathering information from him in order to maintain his level of benefits. On June 5, Liberty had Hub Enterprises, Inc. perform surveillance on Tracia but was unable to capture any evidence regarding same. Liberty then asked Dr. Chin to complete a Restrictions Form citing Tracia’s limitations. Dr. Chin again explained that Tracia was “unable to sit/stand for prolonged periods [secondary to] pain” and that he would be unable to conduct any job duties in a full-time setting.
In the summer of 2012, the Social Security Administration granted approval for Tracia to receive disability benefits starting June 4, 2012. Tracia challenged this date because the alleged onset date of his disability was that of May 11, 2011, and the Social Security Administration ultimately ruled that the benefits should have begun in November of 2011. As a result, Liberty sent Tracia a letter reducing his monthly benefits and demanded that he repay $22,282.93 because of an overpayment of funds that the Social Security Administration would have supplemented.
At this time, Liberty also chose to reevaluate Tracia’s file and rejected his claim for long term disability benefits. It argued that he was able to perform the job duties of an order clerk, sales representative, and customer service representative, which meant that he did not meet the definition of disability under “any occupation.” Tracia appealed, citing his inability to work because of “severe rheumatoid arthritis, coagulation disorder, tarsal tunnel syndrome and another painful condition known as Complex Regional Pain Syndrome (‘CRPS’) that severely limit his mobility.” He also provided a Short Form Physical Capacities Evaluation and Medical Assessment form from Dr. Chin. She disagreed with Liberty’s evaluation that he was able to perform the alleged job duties.
Liberty then had two doctors review the file, as well as a Vocation Case Manager review. All three of them opined that Tracia’s conditions did not prevent him from performing full-time work. On August 12, 2013, Tracia was then informed that Liberty was affirming its denial of his benefits. He then filed the instant suit. The main issues in the case stem from whether Liberty appropriately imposed a requirement for objective evidence that was in line with the policy language and whether Liberty’s decision that Tracia could perform full-time work was based on sufficient evidence.
Tracia believed that Liberty required objective evidence to prove his disability even though the language of the policy does not call for this. The court’s analysis cited the First Circuit, stating that there is “[…] a distinction between requiring objective evidence of the diagnosis, which is impermissible for a condition . . . that does not lend itself to objective verification, and requiring objective evidence that the plaintiff is unable to work, which is allowed.” Here, the court emphasized the fact that Liberty could certainly require objective evidence, but that it never explained to Tracia what type of evidence he needed to submit in order to prove his disability. Further, Liberty relied on the arguments of physicians who did not examine Tracia and failed to obtain any objective evidence related to his pain and ability to work. The court concluded that this was not substantial evidence upon which Liberty should have made a decision regarding Tracia’s claim.
As a result of Liberty’s failure to inform Tracia of the type of necessary information it needed to prove his disability, the court ruled that it had prevented Tracia from receiving a full and fair review of his claim. Therefore, the court chose to remand the suit back to Liberty in order to conduct further review of the administrative proceedings.
[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:
