In Armani v. Northwest Mutual, plaintiff Avery Armani, a Controller for an insurance agency, injured his back while lifting a heavy back-up power supply at work. As an employee of the insurance agency, he was covered by a Group Long-Term Disability Insurance policy issued by Northwest Mutual (NWM).
Under the terms of the LTD Policy, the definition of disability changed after benefits were paid for 24 months. For the first 24 months, a claimant must be “unable to perform with reasonable continuity the material duties of his Own Occupation.” After 24 months of disability, the claimant must be “unable to perform with reasonable continuity the material duties of Any Gainful Occupation for which he is reasonably fitted by education, training, and experience”.
Initial Claim Approval and Subsequent Denial
Armani submitted his claim for benefits in July 2011. He was limited to sitting for four hours, standing for two hours, and walking for two hours during an eight-hour workday. NWM’s vocational case manager confirmed that Armani’s occupation was classified as sedentary, and Armani’s disability claim was approved under the “own occupation” definition test effective July 18, 2011.
Between September 2011 and January 2012, Armani continued to visit chiropractors, pain specialists, and physicians, all of whom confirmed that Armani’s disability precluded him from working. Based solely on these medical records, however, NWM’s reviewing physician determined that Armani was capable of working in a sedentary position. In July 2013 NWM informed Armani that his LTD claim was being closed because “his records did not support a disability under the ‘own occupation’ or ‘any occupation” test.’
Armani’s Appeal of the Denial of Continued Benefits
After NWM denied his claim for continuing benefits, Armani appealed the decision and requested a review by a second doctor. NWM submitted the file to a second doctor who concluded that Armani was not precluded from sedentary work and that “[i]t would be reasonable that [Armani] would have the ability to reposition from sitting to standing occasionally as needed.” NWM upheld the denial. Having exhausted his administrative remedies, Armani filed this ERISA lawsuit.
The District Court’s Case
In the District Court Armani argued that he was “unable to perform any occupation classified as ‘sedentary,’ because, by definition, ‘sedentary’ requires an ability to sit for six hours.” The court held that NWM was not bound by this definition of “sedentary” work on the basis that it was drawn from the Social Security context. Citing “the vast differences in both form and function between Social Security law and ERISA law,” the district court concluded, without further discussion or analysis, that “the federal criteria for Social Security claims are not transferable to ERISA cases.” The 9th Circuit, however, determined this conclusion was erroneous.
The 9th Circuit’s Holding
The 9th Circuit found that the administrative record available to the district court plainly showed that, between July 25, 2011, and April 15, 2013, every physician and chiropractor who treated Armani determined that he could not sit for more than four hours a day.
The 9th Circuit concluded that an employee who cannot sit for more than four hours in an eight-hour workday cannot perform work classified as “sedentary.” The Court further noted that “sedentary work” generally requires the ability to sit for at least six hours. Thus the logical conclusion is that an employee who is unable to sit for more than half of the workday cannot consistently perform an occupation that requires sitting for “most of the time.” Based on these findings, the Court held that an employee who cannot sit for more than four hours in an eight-hour workday cannot perform “sedentary” work that requires “sitting most of the time.”
This case was not handled by our office, but it may provide claimants guidance in their pursuit of compensation under the accidental dismemberment clause of an insurance policy. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.