Robert Stanford was a nurse anesthetist in a hospital in South Carolina. In his position, he was exposed to and responsible for administering anesthesia and narcotics to surgical and obstetric patients. Shortly after starting work, he began taking Fentanyl, a powerful narcotic. By September of 2003 he had become addicted to the drug, and entered rehabilitation the following month.
After release from rehabilitation, but before returning to work, Stanford relapsed, and returned to rehabilitation, where he stayed for 3 months this time. While in rehabilitation, he applied for long-term disability benefits with Continental Casualty, which provided benefits through his employer. While in rehab, his benefits were approved.
Stanford returned to work on March 12, 2004, but once again suffered a relapse, and returned to rehab on May 19, 2004. Once again, he applied for and received long-term disability benefits from Continental Casualty. However, in January of 2005, his benefits were terminated because his treating physician stated there was no impairment that prevented him from returning to work as a nurse anesthetist. Stanford appealed this decision, noting that he remained at risk for relapse if he was exposed to Fentanyl, and that his license had been restricted from having access to narcotics or working as a certified nurse anesthetist.
Continental Casualty denied the claim, stating that, “the policy does not cover potential risk.” With his administrative remedies exhausted, Stanford filed suit. The trial court determined that the decision to deny benefits was not unreasonable. Stanford appealed. The 4th District Court of Appeals reviewed the claim and determined that although Continental Casualty was a plan administrator operating with authority to interpret contract terms but under a conflict of interest because it also paid out the claims, the insurance company had not abused its discretion in denying the claim.
The reviewing court also found that it was not improper to not have a health care professional review the claim, since the main issue in this case was one of contract interpretation, and Continental Casualty had not disagreed with the Stanford’s treating physician: yes, the risk of relapse was high, but he was not currently physically or mentally impaired from returning to work. Lastly, the court noted that the risk of relapse for drug addiction differed from the risk of relapse for a heart attack victim: the drug addict has a choice about becoming relapsing, while a heart attack victim does not.
Comment: They key factor that resulted in this client being denied benefits was the fact that the claimant’s treating doctor opined that he was not disabled from returning to work in his prior occupation. Moreover, the fact this case was reviewed by the court under and arbitrary and capricious standard made it almost impossible for the court to determine that the disability carrier acted unreasonably. While risk of relapse alone is generally not enough to support a claim for disability, a claimant should always discuss and document all potentially disabling conditions with their treating doctors. See Stanford v. Continental Casualty Co., 514 F.3d 354 (4th Cir. 2008).