Charlie Craig Hounihan (“Hounihan”) was a technician who was employed by Proctor and Gamble (“P&G”) on the Bounty paper towel line at a plant in Cape Girardeau, Missouri. Through his employment with P&G, Hounihan was covered under both short term and long term disability benefit plans with Aetna. The Proctor & Gamble Disability Committee (“Disability Committee”) is the fiduciary of the plan and has the final say for reviewing and making appeal decisions related to claims made under the plan. The plan’s requirements include the possibility of having to participate in an independent medical examination and/or a functional capacity evaluation.
The plan further states that the claimant has the burden of proving he is disabled. If there is a period during which the claimant does not submit sufficient proof of disability, he will not be paid for that time period. Additionally, “partial disability” and “total disability” must also be supported by objective evidence. The plan itself defines the following:
“‘Total Disability’ means a mental or physical condition resulting from an illness or injury which is generally considered totally disabling by the medical profession and for which the participant is receiving regular recognizable treatment by a qualified medical professional. Usually, total disability involves a condition of such severity as to require care in a hospital or restriction to the immediate confines of the home.”
The plan goes on to explain:
“‘Partial Disability’ means a mental or physical condition resulting from an illness or injury because of which the participant is receiving medical treatment and cannot perform the regular duties of his or her job, but can perform other roles at the same site or other jobs outside the Company. Thus, a partially disabled participant is not necessarily prevented from performing useful tasks, utilizing public or private transportation, or taking part in social or business activities outside the home.”
Partial disability is further limited to a maximum of 52 weeks under the plan’s provisions.
During 2012, Hounihan started to develop severe pain in his hip and knee. Soon after, Robert Tipton, M.D., prevented Hounihan from returning to work. On September 19, 2012, Hounihan began to receive total disability benefits. Jimmy Bowen, M.D., began treating Hounihan for pain radiating in the right hip, lower back, and buttocks. By January 2013, Dr. Bowen allowed Hounihan to return to work with light work restrictions. However, the department that Hounihan was employed in did not have work that could accommodate his restrictions. This led to the receipt of partial disability payments starting on January 10, 2013. By February 2013, Hounihan was classified as totally disabled.
The following May, David King, M.D., diagnosed Hounihan with a labral tear with parent label cyst and a femoral acetabular impingement. Hounihan then had an acetabulosplasty for impingement with labral tear repair and a right hip arthroscopic femoroplasty. On June 22, he was brought to the hospital with a right hip infection. This required Kurt Merkel, M.D. to perform an emergency irrigation and debridement of the right hip. After this surgery, Hounihan still had pain in his right hip area. He then had aspirations of the hip and additional irrigation and debridement procedures.
In April of 2015, Hounihan had a total hip replacement and began seeing Christopher Mudd, M.D. Dr. Mudd believed that the original hip surgery’s infection had never been resolved and that Hounihan would need to have his hip implant taken out. On May 6, he had this implant removed and had further irrigation and debridement. By December, Hounihan had another total right hip replacement done. The final count for procedures on his hip was 17 over the period of 2013 to 2016.
Six months after the final surgery, Dr. Merkel stated that Hounihan “seem[ed] to be getting along well.” Based on this, a nurse case manager asked Hounihan to participate in an independent medical examination. Matthew W. Karshner, M.D., performed the examination and opined that Hounihan be put on a transitional work schedule. At this point, P&G provided that Hounihan was partially disabled and that he had already used 17 of his 52 available weeks of benefits.
Hounihan chose to appeal this decision regarding partial disability, and in the meantime, was notified that his partial disability benefits would end on May 25, 2017, because that was when the 52-week maximum would be reached. By July, the Disability Committee notified Hounihan that the partial disability determination was proper, and subsequently denied his claim for total disability benefits. It’s reasoning for denial was because “total disability involves a condition of such severity as to require care in a hospital or restriction to the immediate confines of the home.” The Committee further supported this with the evidence that “while [Hounihan] has an inability to work 8 hours a day, 5 days a week, he does retain the abilities of lifting, carrying, pushing, pulling, walking, stopping, kneeling, sitting, standing, and upper extremity function […]”
On January of 2018, Hounihan filed the instant suit. He alleged that P&G’s application of the term “total disability” caused him inadequate notice of the reasons for his claim’s denial. After review, the court believed that P&G’s definition of “the inability to perform any job at the company or elsewhere” was consistent with its definition of both partial disability and the goals of the plan. Therefore, it believed that the definition was consistently and reasonably applied in Houlihan’s case.
Further, the court had to determine whether P&G’s decision was both reasonable and supported by sufficient evidence. Because Dr. Merkel’s medical records indicated that Hounihan could work with restrictions, including lifting, standing, sitting, pushing, carrying, kneeling, stooping, walking, and pulling, the court agreed that the Committee’s decision was reasonable. Therefore, the court decided that overall, the evidence supported the Disability Committee’s decision to deny Hounihan’s claim and that “a reasonable person could have reached a similar decision.” This resulted in the court ruling in favor of P&G and against Hounihan.[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: Hounihan v. Proctor & Gamble