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Dell & Schaefer Successfully Appeals Denial Of Benefits To Pre-School Teacher

Attorney Victor PeñaAuthor: Attorney Victor Peña

Most group employer sponsored ERISA disability policies pay disability benefits for a limited period of time if you are unable to perform the duties of your own or regular occupation. An own/regular occupation definition of disability is the most favorable to claimants when filing a disability claim. However, it is important to understand that “occupation” is not synonymous with “job” and when reviewing a disability claim the insurance carrier does not always have to review the claimant’s occupation as it is performed for a specific employer. Instead, most group ERISA policies allow the carrier to consider how the claimant’s occupation is performed in the national economy.

The distinction between occupation and job is important to understand when filing a disability claim and we are frequently contacted by claimants whose claims have been denied even though they cannot perform the duties of their own “job”.

However, insurance carriers frequently get this wrong and so an essential part of the claims process is making sure the carrier properly classifies a claimant’s occupation.

Ms. M contacted our firm when her disability carrier, Madison National Life Insurance Company, terminated her claim after concluding she is capable of performing her “regular occupation.”

Before filing a disability claim, Ms. M was working as a Pre-school Teacher for a public school when she was injured carrying one of her students in early 2015. She suffered several spinal herniations causing muscle spasms and resulting pain. Upon receiving Ms. M’s claim, Madison National ordered an Independent Medical Examination performed by Dr. C. Gregory Kang. According to Dr. Kang, Ms. M’s lumbar disk herniations were functionally impairing and reasonable functional restrictions and limitations would include the inability to sit for more than 15 minutes before having to change positions, inability to stand or walk for more than 15 minutes without having to sit down or rest, and inability to lift greater than 15 lbs.

Relying on the IME results, Madison National performed a Labor Market Survey indicating that Ms. M would be capable of performing her regular occupation as a Teacher for other employers. As a result, Ms. M’s claim was denied.

Upon contacting our firm, Ms. M spoke with Attorney Victor Peña who agreed to take on her case. Based on a review of the denial letter and a discussion with Ms. M, Attorney Peña recognized the error in Madison’s decision. Madison’s classification of Ms. M’s occupation as a Teacher was entirely too broad. There are many different types of teachers and it was unreasonable for Madison to classify Ms. M’s occupation as simply “Teacher.” According to Madison’s Labor Market Survey, a teacher is considered a sedentary occupation. Additionally, the Labor Market Survey listed several jobs that would be available for Ms. M, all of which were virtual schools and all of which provided education for grades K-12.

In preparing Ms. M’s appeal, Attorney Peña requested an independent Occupational Analysis. The analysis focused on the more specific classification of the occupation of a pre-school teacher rather than the general occupation of a teacher. Madison had failed to recognize that the US Department of Labor provides a specific classification of pre-school teacher which is classified as a Light duty occupation. Moreover, Madison failed to recognize that pre-school teacher is not an occupation that can be effectively performed online. There are therefore no viable options for Ms. M to perform her regular occupation online in a sedentary capacity.

Focusing primarily on the improper classification, Attorney Peña filed Ms. M’s appeal along with additional medical support. Madison had no choice but to reverse its decision and approve Ms. M’s claim.

This case is a perfect example of the importance of understanding how carriers review your own or regular occupation. An occupational description is not always clear cut and it is important to make sure the carrier does not misclassify your occupation when reviewing a claim.