In Hopper v. Aetna Life Insurance Company, a machinist with 11 separate medical diagnoses was initially granted short term disability benefits. When those benefits were exhausted, Aetna granted him 24 months of long term disability benefits when Aetna determined he was disabled from performing the duties of his own occupation. Due to his respiratory problems and skin rashes and visual problems, it was not difficult for Aetna to determine that he would never be able to return to work in the “dusty or dirty environment” of his own occupation of being a machinist. Also, due to his visual problems, it would not be safe for him to work as a machinist.
After 24 months of receiving long term disability benefits, the definition of “disabled” under the Aetna policy changed from being unable to work in a claimant’s own occupation, to “unable to work at any reasonable occupation” due to the disabling condition. As a result, Aetna terminated his benefits when it determined he could work in a clean office environment as an assignment clerk even though that position would require accommodations for his visual impairment problems. Hopper’s administrative appeal was denied and he filed the ERISA lawsuit.
Federal Court Upholds Aetna’s Termination of Benefits Even Though Employment Would Require Accommodations
At Aetna’s request, an ophthalmologist and a dermatologist reviewed Hopper’s medical records. A vocational rehabilitation counselor was consulted. All determined that Hopper’s visual acuity problems prevented him from working in an occupation that required “the ability to see small print or find detail without the use of a magnifying device.” Aetna then determined that Hopper could work as an assignment clerk even though he would have to use a magnifying device.
Hopper complained that Aetna should not be allowed to terminate his benefits when the job Aetna said he could perform would require “accommodations for his visual impairment.” The New Hampshire federal court disagreed and, relying on first circuit precedent, concluded, “it was permissible for a benefits committee to factor in a claimant’s ability to work with accommodations when determining that the claimant was ‘no longer unable to perform any job for which [he was] qualified by education, training or experience.'”
Claimant Also Failed to Meet His Burden of Proof
Hopper claimed his medical record was “replete with medical opinions that he is disabled from any work.” The court found the problem with that claim is that Hopper did not include any citations to the administrative record to support that claim and the court found none of the favorable opinions he mentioned in the Joint Statement of Material Facts filed in support of the ERISA lawsuit. The burden is on the claimant to prove he is disabled. In this case, since he failed to provide records to support his claim, he failed to carry his burden and Aetna was reasonable in finding he was not disabled under the “any reasonable occupation” clause of the benefits policy.
This case was not handled by our office, but it may provide claimants guidance in their pursuit of long term disability benefits when the definition of disabled changes from “unable to work in claimant’s own occupation” to “unable to work at any reasonable occupation.” If you need assistance with a similar matter please contact any of our lawyers for a free consultation.