What happens when the claimant is "disabled" from performing her job with her current employer... but can perform that same job with another employer?
This issue highlights the importance of the "national economy" definition of disability as found in most long term disability policies.
Here's the case of Holden v. Unum Life Ins. Co. of Am., __ Fed. Appx. __, 2021 WL 2836624 (6th Cir. July 8, 2021)(This decision also provides good defense responses to criticisms of benefit denials based solely on medical record reviews rather than independent medical exams.).
FACTS: Holden sought ERISA-governed Long Term Disability (LTD) benefits due to Post Traumatic Stress Disorder arising out of alleged overwork, bullying and abuse at her law firm. Her physician also opined that she was disabled and could not work for her current, or any other, employer. But Unum concluded Holden was not disabled because: (1) her claimed disability related to "issues unique to your specific workplace"; and (2) Holden was "able to perform... her regular occupation as it is normally performed in the national economy...." Holden then sued Unum.
SIXTH CIRCUIT COURT OF APPEALS, APPLYING ABUSE OF DISCRETION STANDARD OF REVIEW, HELD:
1. "[Under the terms of the plan], what mattered to Unum's determination was not whether Holden was capable of performing her job [at her law firm] but rather whether Holden could have performed a similar job for another employer at another location." Op. at 21 (emph. added).
2. "Holden's [claim fails because the]... allegations were specific to [her law firm employer].... Her physicians concluded her "struggles were workplace-specific." Op. at 22.
3. The Court disregarded the opinions of one treater who opined that Holden would not be able to perform the same occupation for a different employer because:
a. the statement was internally inconsistent with the physician's notes/opinions; and
b. "Unum is not required to defer to [the treating physician's] opinion." "When [applying the abuse of discretion standard] we are tasked with asking whether it is possible to offer a reasoned explanation...[and] we cannot require Unum to adopt some of [the treating physician's] observations while discrediting others." Op. at 25 (underscore in original).
4. Unum's reliance merely on a medical record review (rather than an independent medical exam) was not arbitrary and capricious because Unum did not deny benefits "based on any credibility determination regarding Holden....[Unum] appears to have based its decision by crediting Holden's own statements rather than finding her not credible." Op. at 29.
5. "This Court has never held that if a psychiatric determination is at issue, it is necessarily arbitrary and capricious to fail to conduct an independent medical evaluation." Op. at 31.
6. "'Even if in-person examination is favored...reliance on a file review does not, standing alone, require the conclusion that [the administrator] acted improperly.'" Op. at 34 (citation omitted).
7. Doc-to-Doc and Peer Reviews help. The Court also was not troubled that the claim denial was based solely on a medical file review because "some of the reviewing experts here spoke directly with those who treated Holden." Op. at 34.
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