In Rouleau v. Liberty Life Assurance Company of Boston, plaintiff Michelle Rouleau, a Registered Nurse (RN) for a Hospital, had a history of intractable lower back pain dating back many years. As an employee of the Hospital, she was covered by a Group Long-Term Disability Insurance policy issued by Liberty Life (Liberty).
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 the material and substantial duties of her Own Occupation.” After 24 months of disability, the claimant must be “unable to perform, with reasonable continuity, the material and substantial duties of Any Occupation for which he is reasonably fitted by education, training, and experience.”
Initial Claim Approval and Subsequent Denial
Rouleau submitted his claim for STD benefits in March 2012. She was paid through the maximum benefit period and in September 2012 transitioned to LTD benefits. Both STD and LTD were funded and administered by Liberty. During the initial 24 months, at Liberty’s request, Rouleau applied and was approved for SSDI benefits. In September 2014, after receiving LTD benefits for 24 months her claim was reviewed under the more lenient “Any Occupation” definition of disability in the Policy.
The medical records confirm that throughout 2013 and 2014 Rouleau continued to treat with her physicians, pain specialists, and specialists, all of whom confirmed that Rouleau’s disability precluded her from working. Based solely on his review of these medical records, however, Liberty’s reviewing physician determined that Rouleau was capable of working in a sedentary occupation. Liberty also conducted surveillance of Rouleau which yielded footage of her performing a variety of basic physical activities over two days, including driving, walking, bending, and some simple yard work. In September 2014 Liberty informed Rouleau that her LTD claim was being closed because her records did not support a disability under the “Any Occupation” definition.
Rouleau’s Appeal of the Denial of Continued Benefits
After Liberty denied her claim for continuing benefits, Rouleau timely appealed the decision and submitted an Attending Physician’s Statement from her primary treatment provider stating that she could not function in a full-time occupational setting. Liberty upheld the denial. Having exhausted her administrative remedies, Rouleau filed this ERISA lawsuit.
The District Court’s Case
Finding that the administrative record includes both subjective and objective evidence that supported an award of benefits, the District Court afforded “great weight” to the Social Security Administration’s (“SSA”) determination that Rouleau was totally disabled from employment. Although it acknowledged that “[a] determination that a person meets the Social Security Administration’s uniform standards for disability benefits does not make her automatically entitled to benefits under an ERISA plan, since the plan’s disability criteria may differ from the Social Security Administration’s,” that Court also stated that that “SSA’s determination is ‘far from meaningless.’” And if the carrier (1) encourages the applicant to apply for Social Security disability payments; (2) financially benefits from the applicant’s receipt of Social Security; and then (3) fails to explain why it is taking a position different from the SSA on the question of disability, the reviewing court should weigh this in favor of a finding that the decision was arbitrary and capricious.
In assigning “no weight” the surveillance footage obtained by Liberty, the Court noted that the video is consistent with Rouleau’s own account of her condition and revealed no activity at all on most of the days surveillance took place. The activity that the video did show was limited and offers little support for Liberty’s position. Throughout most of the activities recorded Rouleau moves slowly and gingerly, takes frequent breaks, her posture is stooped, and she stands up slowly and with effort. Nothing about the activities in the video suggests she was able to maintain even a short period of activity without breaks nor do they dictate a conclusion that Rouleau was capable of employment.