In Sue Ray v. Reliance Standard Life Insurance Company, W.D. Washington, July 31, 2018, Plaintiff filed suit under the Employee Retirement Income Security Act of 1974 (“ERISA”) to recover long-term disability (“LTD”) benefits, which Reliance Standard denied on the ground that plaintiff could perform her “Regular Occupation” and was therefore not “disabled” within the meaning of the LTD policy at issue. The parties disagreed as to whether plaintiff was “Totally Disabled” and whether she submitted “satisfactory proof” of “Total Disability.”
“Totally Disabled” and “Total Disability” are defined in the LTD policy as meaning that, as a result of an injury or illness, the Insured cannot, during the “Elimination Period” and for the first 24 months during which the “Monthly Benefit” is sought, perform the material duties of his or her “Regular Occupation.” Plaintiff ceased working on August 17, 2015, and filed a claim for benefits. Reliance Standard denied her claim by letter dated November 25, 2015 and again on appeal to Reliance’s Quality Review Unit by letter dated February 4, 2016. Reliance concluded that plaintiff’s “Regular Occupation” was as a “Private Duty Nurse,” and determined that plaintiff had the capacity to work full-time as a “Private Duty Nurse,” citing to the opinion of an alleged independent peer reviewer. When formulating his opinion, the reviewer aware that plaintiff suffered from irritable bowel syndrome (“IBS”) with diarrhea symptoms, and he stated that, during the course of her workday, plaintiff “must have ready access to restroom facilities.”
Plaintiff challenged Reliance Standard’s analysis because its classification of her as a “Private Duty Nurse” disregarded the amount of travel by motor vehicle she was required to do as a “Visiting Nurse,” which was the position she held with her employer. As a “Visiting Nurse,” plaintiff provided skilled nursing care and services to patients in the home setting and she was required to frequently (34-65% of the time) operate a motor vehicle to get from one location to another. While in her car, or at patients’ homes, plaintiff experienced episodes of diarrhea, which would require her to divert from or leave a work site to attend to her hygiene and take steps to prevent infection.
In deeming plaintiff a “Private Duty Nurse,” Reliance did not properly define the scope of plaintiff’s “material duties” as a “Visiting Nurse.” Plaintiff’s doctor and Reliance’s peer reviewer agreed that, because plaintiff has “recurrent unpredictable episodes of bowel incontinence,” she must have “ready access to restroom facilities.” The material duties of plaintiff’s “Regular Occupation” as a “Visiting Nurse” include frequent travel via motor vehicle to, from, and between patients’ homes, which necessarily places her out of close range to a restroom for substantial periods of the workday. The occupational data for “Private Duty Nurse” do not include any driving or travel requirements and Reliance Standard did not properly perform an analysis of whether plaintiff could perform the “material duties” of her “Regular Occupation.”
The Court held that, because of her IBS with bowel incontinence, plaintiff could not, as of August 17, 2015, perform the “material duties” of her “Regular Occupation.” The Court further held that plaintiff submitted “satisfactory proof” of “Total Disability” and that Reliance Standard’s own reviewer’s opinion supports deeming plaintiff “Totally Disabled.” As a result of her success on the merits, the Court instructed the parties confer in an attempt to reach agreement concerning attorney’s fees and/or costs awarded to plaintiff and to incorporate the associated amount or amounts in a proposed judgment.