In Aisenberg v. Reliance Standard Life Ins. Co., the United States District Court for the Eastern District of Virginia has ruled that a long term disability (“LTD”) plan must take into account potential future harm from continued employment when making an LTD benefits determination.
Facts. An attorney, who worked at what he called a “high stress” occupation involving national security, received double-bypass heart surgery. His doctors advised him to stop working, saying he should not return to his job because the stress would cause his heart condition to worsen over time and potentially cause a fatal heart attack. Based on this recommendation, the employee applied for LTD benefits.
The plan rejected his claim for LTD benefits, stating, among other things, that under the LTD plan’s provisions and prior court rulings, one’s “regular occupation” is not the specific job that the claimant is currently working at, but instead any jobs “of the same general character as the insured’s previous job, requiring similar skills and training, and involving comparable duties.” It also said that “[t]here is no randomized controlled study that shows relieving chronic job stress results in the secondary prevention of cardiovascular events.”
The attorney then sued the plan for benefits in federal court.
District Court. With regards to LTD benefits, the court said that once an employee’s regular occupation and its material duties are defined, the plan must use “a reasoned and principled process” to determine whether the claimant’s disability renders him unable to complete the job’s determined material duties. As a general rule, participants are entitled to LTD benefits if they are capable of working full-time but are only able to complete some of the material duties of their regular occupation due to the claimed disability. In other words, to support a denial of disability, the plan must find that a claimant can complete all material duties of their regular occupation on a full-time basis.
However, the court determined that in this case the plan had abused its discretion by not considering the risk of future harm the attorney would suffer by returning to a high-stress work environment, and improperly failed to consider whether other “less stressful” attorney positions existed in the national economy.
Specifically, the court found that the plan did not provide evidence to demonstrate that its examining doctors knew the material duties of the attorney’s current occupation or the stress levels of those duties. Thus, there was no basis for its opinion that he was not disabled despite the harm that stressful working conditions might impose. Furthermore, even if the plan’s doctors did know what constituted the attorney’s material duties, the plan’s failures to both assess the risk of harm that stress might cause for a patient recovering from cardiac surgery and address conflicting evidence from the attorney’s own doctors on that issue “underscores the insufficiency of the materials used in the plan’s denial of LTD benefits.”
Therefore, the court ruled that the plan’s failure to assess the risk of future harm that undertaking the material duties of the attorney’s job, or other comparable jobs, might impose was an abuse of discretion rather than “the result of a deliberate, principled reasoning process.” The court then ruled that because of this abuse of discretion, the attorney was entitled to retroactive LTD benefits.