“Regular occupation” versus “Any occupation”
Once a court determines the claimant’s “regular occupation,” the next inquiry is what are the “material and substantial duties” of that occupation. Although no universal rule exists, the disability benefit lawyers of MyLTDbenefits.com may apply two broad general principles to determine whether an insured is “unable to perform the material and substantial duties of your regular occupation.” The measure of whether a claimant can perform his or her material and substantial duties may be determined either qualitatively or quantitatively.
In a qualitative analysis, a claimant can be totally disabled if unable to perform one “essential duty” of his regular occupation, e.g. a shortstop unable to throw, if that duty was central to the occupation. From a quantitative perspective, if a person suffers a 75% decrease in function, then this may be sufficient to sustain a total disability claim.
In contrast to occupational disability policies, general disability policies consider a claimant totally disabled only when his condition renders him unable to perform the duties of his occupation and any other occupation for which he is reasonably fitted by education, training, or experience. The any occupation standard is often employed in group insurance plans when disability continues beyond a certain time (generally twenty-four to thirty-six months).
Claims under the “any occupation” standard typically involve an analysis of the claimant’s employability. Analysis of these claims by MyLTDbenefits.com, therefore, necessarily focuses on an insured’s education and work experience.
Mental Illness Exclusion
The Seventh Circuit Court of Appeals recently ruled in favor of our client, “Paul”. Paul enjoys disability insurance as a fringe benefit of his job. He stopped working in June 2002 because of a hernia and back pain. The hernia was repaired surgically, but Paul did not return to work. After a psychiatrist diagnosed Paul with dysthymia and major depression, Prudential started sending him long-term disability payments. But “long-term” means two years, the Plan’s limit when inability to work is caused even in part by a mental illness (which the policy defines to include depression). At the end of January 2005 Prudential ended the disability benefits, citing the two-year cap. After exhausting his administrative remedies, we filed suit on Paul’s behalf under the Employee Retirement Income Security Act (ERISA).
Claimant must be allowed to submit evidence of his disability
After filing suit, we had proposed to take discovery in order to generate evidence about Paul’s medical and mental conditions, and the extent (if any) to which his mental condition affects his ability to work. Prudential opposed all discovery, contending that the suit should be resolved on the administrative record. The district court concluded that no discovery at all is appropriate and barred all discovery on medical questions. We then asked some of Paul’s physicians to provide affidavits describing his spine condition and prognosis, and we tendered these to the judge-who struck them from the record, writing:
The submission of materials outside of the administrative record contradicts the scope and intent of the Court’s protective order. While that order was directed towards future discovery, [Paul] cannot circumvent the force of the protective order by surreptitiously filing information outside of the administrative record in support of his motion papers.
Having barred us from offering any evidence, the judge then granted summary judgment to Prudential, relying on the two-year cap and the fact that the administrative record contains two medical evaluations implying that Paul is able to work. The judge did not mention the contrary evidence in the administrative record.
The Court of Appeals criticized the district court, holding that, “we cannot imagine any justification for refusing to admit evidence that one party has procured at its own expense, such as the medical affidavits that [Paul] tendered. Tellingly, the district judge did not cite authority for throwing out the affidavits, and Prudential’s brief does not supply any.”
This case makes clear the importance of submitting evidence of disability in the form of affidavits and to request the court to allow discovery for purposes of challenging the opinions of the insurance carrier’s reviewing doctors. If the district court will not listen to reason, the Court of Appeals may come to the rescue, as it did in this case.
Contact Alan C. Olson & Associates for assistance with long term disability benefits in Wisconsin, Illinois, Indiana, and nationwide in obtaining your long-term disability (ERISA) benefits. We pride ourselves on providing cost-effective solutions.