Federal Court Examines Vocational Reviews and ERISA Disability
Author: Attorney Stephen Jessup
What is an Occupation?
Pursuant to the vast majority of ERISA governed disability insurance policies, an Occupation is defined based on one of two standards – Own Occupation or Any Occupation. Quite often an insurance carrier will overlook the actual duties of an occupation and simply determine the ability to work based on the physical demand level associated with a particular occupation. If you are receiving disability insurance benefits or have been denied benefits you have most likely read somewhere in correspondence from the insurance carrier that they have deemed your occupation to be “sedentary” or “light duty.”
In the event of a claim denial an insurance carrier will typically indicate it has determined you can perform sedentary duty work (or any other corresponding physical demand level) and can therefore work in your “own” or “any” occupation. However, it should go without saying that the ability to perform at a particular physical demand level is by no means indicative of the ability to actually perform the material and substantial duties of an occupation. Unfortunately, insurance companies often fail to understand this logic.
An insurance company typically conducts a vocational analysis/review to determine what constitutes the material duties of a particular occupation, and in doing so typically rely on a variety of vocational resources such as the Dictionary of Occupational Titles, O*Net, Job Descriptions, etc. to complete the review. Failure to conduct such a vocational review as part of the claims determination process has been deemed by multiple Federal courts to be evidence arbitrary and capricious claims handling.
In a recent ruling from the United States District Court for the Northern District of Illinois, Eastern Division in the case of Daniel Travis v. Midwest Operating Engineers Pension Plan, the Court echoed this established opinion. In the Travis case, the Court reviewed Mr. Travis’s entitlement to Total Disability Pension benefits under an ERISA governed pension plan. In denying Mr. Travis’s claim for total disability benefits the Pension Plan relied upon its medical reviewer’s opinion that Mr. Travis could perform a sedentary demand level job and that based on that assertion alone the Pension Plan was not required to perform a vocational review. The Pension Plan argued to the Court that the Plan did not expressly state that vocational considerations had to be taken into account when determining whether Mr. Travis was totally disabled. Mr. Travis’s attorney argued that the Pension Plan could not construe the terms of the plan so strictly as to mean that if Mr. Travis could engage in any physical activity whatsoever that he could work regardless of any required vocational qualifications. The Court agreed with Mr. Travis, holding the Pension Plan abused its discretion by failing to perform a vocational analysis to determine whether Travis could work in some vocation given his physical restrictions and limitations. The Court remanded the case back to the Pension Plan to conduct a vocational analysis to determine Travis’s entitlement to benefits.
What to do if your insurance company is evaluating your claim for disability benefits using improper vocational information
If your insurance company is not properly determining vocational ability in light of the applicable definition of disability do not wait till a denial of benefits before challenging the carrier’s assertion. Please feel free to contact our office to discuss how we may be able to assist you ensuring that your insurance carrier is properly reviewing your claim.