The case involves a dispute over long-term disability (LTD) benefits between Geiger, the claimant, and Zurich American Life Insurance Company of New York (“Zurich”), the administrator of an ERISA-regulated benefits plan.
Geiger worked at CBS News in New York as a writer/editor. In March 2018, at the age of 58, Geiger could not go to work because of shortness of breath and other cardiovascular issues.
Additional treatment revealed that Geiger had a severe heart condition. In June 2018, he received a heart catheterization. And on July 5, 2018, he underwent open heart surgery to replace his aortic valve. Geiger was initially approved for short-term disability benefits and then for LTD benefits by Zurich. However, Zurich required regular updates on Geiger’s medical condition to continue providing LTD benefits.
As Geiger’s condition improved, Zurich reassessed his eligibility for continued LTD benefits. This reassessment was based on updated medical records provided by Dr. Izzo, which showed Geiger’s health improvements, including a normal echocardiogram, no ongoing heart symptoms, increased physical activity, and significant weight loss.
Based on the improved medical condition, Zurich determined that Geiger no longer met the plan’s definition of being disabled, which required an inability to perform his regular occupation’s substantial and material duties due solely to his sickness or injury.
Geiger challenged this determination, arguing that Zurich failed to consider the specific stress related to his job that could impact his cardiac condition and did not adequately evaluate his job responsibilities when determining his disability status.
The district court reviewed Zurich’s decision de novo but was bound by the standard of review applicable to the plan administrator’s decision. The administrator’s decision must be affirmed if the decision is reasonable and supported by substantial evidence. The court concluded that Zurich’s decision-making process was reasonable and supported by evidence and that Zurich had not abused its discretion in denying LTD benefits to Geiger. Geiger then appealed that decision to the United States Court of Appeals, Fourth Circuit.
Standard of Review
The standard of review for such a case is de novo, which means the appellate court examines the evidence and the decision of the ERISA plan administrator without deference to the district court’s previous decision. In this case, because the ERISA benefit plan gave the plan administrator discretionary authority to make eligibility determinations, the court evaluated the administrator’s decision as an “abuse of discretion.”
Zurich’s position, as upheld by the district court and affirmed on appeal, centered on the following points:
- Decision-Making Process: Zurich argued that its decision-making process was reasonable. It initially approved short-term disability benefits and long-term disability (LTD) benefits for Geiger, but it also required ongoing updates on his medical condition.
- Medical Evidence: The insurer relied on medical records from Dr. Izzo, which indicated that Geiger’s condition had improved—evidenced by a normal echocardiogram, no heart symptoms, walking three miles daily, and significant weight loss. Based on this information, Zurich determined that Geiger did not meet the plan’s definition of disabled, which requires an inability to perform his regular occupation’s material and substantial duties due solely to sickness or injury.
- Independent Review: Zurich had Dr. Sims conduct a peer-review analysis of Geiger’s medical information, which included a discussion with Dr. Izzo. Dr. Sims concluded that Geiger could work with certain physical restrictions, and Dr. Izzo did not seem to disagree with the capacity for full-time work.
- Plan’s Definition and Analysis: Zurich argued that it correctly applied the Plan’s definition of “Regular Occupation,” which looks at how the occupation is typically performed in the national economy rather than how it is performed for a specific employer or at a specific location. They conducted a “Physical Requirements and Job Demand Analysis” of Geiger’s position, concluding it was sedentary and required minimal physical exertion.
- Burden of Proof: Zurich contended that it was Geiger’s burden to provide written proof of his claim for disability benefits. Zurich’s role was to assess his ability to work by considering facts and opinions from his and their physicians or vocational experts. Zurich maintained that it fulfilled its responsibilities without obtaining additional vocational evidence.
Geiger raised two primary arguments against Zurich in his appeal:
- Evaluation of Job Responsibilities: Geiger argued that Zurich abused its discretion by not correctly evaluating his job responsibilities when determining his disability status. He contended that his job analysis should have been more personalized and specific, possibly including a vocational review or a consultation of the Department of Labor’s Dictionary of Vocational Titles.
- Consideration of Job-Related Stress: Geiger also claimed that Zurich failed to consider the amount of stress involved in his job and how that stress might impact his cardiac conditions. He seemed to suggest that stress should have been factored into the assessment of his ability to perform his regular occupation, given his history of heart problems.
The court, however, did not find these arguments persuasive.
The Court’s Decision
The court considered several factors, including the plan’s language and goals, the consistency and supportiveness of the materials used to make the decision, the process’s reasoning and principles, and whether it followed ERISA’s procedural and substantive requirements.
The court affirmed the district court’s decision, finding that Zurich, the plan administrator, did not abuse its discretion in denying Geiger’s LTD benefits. Zurich approved Geiger’s short-term disability and, initially, his LTD benefits, with a caution that medical updates were required. When Geiger’s condition appeared to improve based on medical records and assessments, Zurich determined he no longer met the plan’s definition of disabled.
Geiger contended on appeal that Zurich failed to properly assess his specific job responsibilities and the stress associated with his job in determining his disability. However, the court noted that the plan defined “Regular Occupation” in a general sense rather than specific to the employer and found that the administrator did analyze Geiger’s job demands, concluding it was a sedentary position.
The court held that it was Geiger’s responsibility to provide proof of his disability and that Zurich’s responsibility was to assess his work capacity based on the available information, which it did. Neither the plan nor case law required Zurich to obtain additional vocational evidence.
Lastly, regarding the stress of Geiger’s job and its impact on his cardiac conditions, the court found no physician had stated that Geiger’s stress from his job was the reason he could not perform his duties. Thus, the court concluded that Zurich’s decision was based on reasoned process and substantial evidence.
In conclusion, the court affirmed that Zurich’s decision to deny Geiger LTD benefits was reasonable and supported by substantial evidence, and therefore, there was no abuse of discretion.
Disclaimer: This case was not handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.
Here is a PDF copy of the decision: Geiger v. Zurich