The plaintiff in the ERISA disability case we will learn from was a public relations executive for a national advertising agency supervising 20 employees in the public relations group and was responsible for business development and client relationships. These responsibilities involved strategic planning and crisis management and frequent travel, often weekly, to meet with key clients. He participated in his employer's group disability insurance plan, which is funded by the insurance company.
In the summer, the plaintiff began to experience significant fainting episodes and was diagnosed with neurocardiogenic syncope, a condition involving a miscommunication between the heart and nervous system. He had a pacemaker implanted and returned to work on a modified schedule. He worked 20-25 hours a week upon his return, but his health continued to fluctuate. He began experiencing medical difficulties including sleeping problems, dizziness and headaches due to blood vessel dilation. He began to report a significant deterioration in his health that included the return of frequent migraine headaches, at least one syncopal episode, and complaints of blurred vision.
His cardiologist believed that he would not control the syncope episodes and its associated symptoms without removing as much physical and emotional stress from his life as possible. At his doctors' recommendations, plaintiff left his employment, but sought and planned to return to work on a modified schedule if possible. Three weeks later, his position at his employer was filled and three months later he was terminated.
The plaintiff applied for short-term disability. His physicians recommended that he stop working for 90-120 days to improve his condition. At that time, it was believed his prognosis was good with reduced stress.
The insurance company approved plaintiff's short-term disability benefits and later approved long-term disability benefits.
After leaving his employment, the plaintiff developed a daily routine of light exercise, household chores, and rest. However, after a few months, he was reporting a rise in number of syncope episodes that included blackouts and prolonged periods of dizziness.
Insurance Company Terminates Benefits
Roughly 17 months after plaintiff left employment, the insurance company terminated benefits and requested additional information from his treating physicians. They reported that he should not engage in any activity that increases mental stress or requires prolonged sitting or standing, and that he could not sit or stand in one position stationary due to neurocardiogenic syncope. His cardiologist reported that he could not safely and without threat to his health perform the duties of his previous job.
The insurance company denied the plaintiff's various administrative appeals, even though his cardiologist reported that the effect of long-term stress on individuals with his condition could result in some degree of permanent impairment of cerebral function.
The court reviewed the matter on a "sliding abuse of discretion" standard. The court stated that the review of the insurance company's benefit denial decision should begin with a precise and detailed listing of the essential duties of his former employment. Thus, the insurance company's disability determination should properly have commenced with a listing of the "material and substantial duties" of plaintiff's "regular occupation" so that it might then make a "deliberate and principled" analysis and judgment as to whether he was limited by his neurocardiogenic syncope from performing each of these occupational duties.
The court noted that none of the insurance company's denial letters included neither a sufficiently precise and detailed listing of his occupational duties or the requisite deliberate and principled analysis of his ability to perform those duties. In the absence of such analysis, any analysis of the claimant's self-reported activities or his lack of frequent syncope episodes can not be relied upon as dispositive.
The court remanded the case to the insurance company because the current record was inadequate to assess whether the insurance company appropriately exercised its limited discretion in denying plaintiff's application for disability benefits. The court instructed the insurance company to detail each "material and substantial" duty of his former position and then conduct a "deliberate principled reasoning process" to determine whether the fact that he suffers from neurocardiogenic syncope limits his ability to perform each of these activities.
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