At our law firm, we represent disabled clients in their applications for long-term disability benefits. It is not unusual for LTD insurers to make mistakes in their decision-making processes, causing a wrongful denial of benefits. Often when an experienced lawyer carefully reviews the administrative record of medical and vocational evidence the insurance company or its administrator relied on to deny or terminate benefits, the attorney discovers errors.
In such a case, an internal appeal within the insurance company or a lawsuit, depending on the stage of the claim, gives the claimant and his or her attorney the opportunity to point out the mistake and advocate for an award of benefits.
Just this scenario occurred in the recent ERISA case of Ray v. Reliance Standard Life Insurance Company in which a federal judge in Washington State reversed the LTD claim denial because the insurer had used the wrong description of the claimant’s occupation when looking at whether she could do that work with her irritable bowel syndrome.
Ray was a nurse who developed IBS that caused uncontrollable diarrhea that required continual access to a bathroom.
Her LTD policy defined total disability as the inability to perform the material duties of the claimant’s “regular occupation” for the first 24 months of her illness. In denying Ray’s LTD application, Reliance said that her regular occupation was a “private duty nurse” and that she could work full-time in that job.
Ray argued that this job classification ignored the duties of her job as a “visiting nurse” that required her to frequently travel by car to visit patients in their homes. While in the vehicle or at patients’ homes, if she had an onset of diarrhea, she needed access to a bathroom “to attend to her hygiene and take steps to prevent infection.”
The judge agreed with the claimant that the insurer had improperly defined the material duties of her job as a visiting nurse by classifying her as a “private duty nurse” who would have no travel requirements. Her symptoms of “recurrent unpredictable episodes of bowel incontinence” are inconsistent with the duties of a visiting nurse.
The decision is available on Westlaw at 2018 WL 3630301.