In Part 1 of this post, we told readers about a recent Third Circuit Court of Appeals case called McCann v. Unum Provident in which a doctor appealed his long-term disability insurer’s termination of his benefits. In that post, we explained how the Third Circuit Court of Appeals determined that the federal law called ERISA applied to the dispute.
Today, we talk about the court’s determination of exactly what Dr. McCann’s “occupation” was for purposes of whether he was disabled under his LTD policy from performing that occupation. The court’s review was de novo, meaning it examined whether the administrator’s decision was correct under the “plain terms” of the policy.Own Occupation
Under Provident’s policy, “occupation” meant the occupation in which the insured was “regularly engaged” when he became disabled. If the occupation was a “recognized specialty” within the insured’s “degree or license,” the specialty is the occupation.
Provident and the trial court said that McCann’s occupation was diagnostic radiology, but he maintained it was instead interventional radiology, a specialty that requires “stressful, intrusive medical procedures and weekend and night calls.”Generalist or Specialist
The Third Circuit disagreed, holding that the doctor’s occupation was his specialty of interventional radiology and that his diagnostic duties were a component of his work as a specialist. The court also explained that while the doctor did more diagnostic than interventional procedures, his interventional tasks took much more time, so the comparison of number of tasks was not meaningful.
Further, Dr. McGann did some duties of an interventional radiologist, even if he also did diagnostic radiology, which he could not have done unless he was an interventional specialist.
The court found the evidence conflicting on whether the doctor could perform the substantial duties of his specialty, so it remanded the case back to the lower court to reexamine this question.
This case is a good example of the crucial importance that the decisionmaker, when deciding an LTD claim, carefully examines the evidence of what the claimant’s “own occupation” is. Without an accurate assignment of the proper occupation, the answer to the question of whether the claimant can still perform the duties of his or her own occupation will likely be inaccurate.