In Okuno v. Reliance Standard Life Insurance Company, the plaintiff was diagnosed with Crohn’s disease, Sjogren’s syndrome and possibly narcolepsy. Her claim for long-term disability was denied when Reliance determined she could perform the duties of her own occupation. She exhausted her administrative remedies and filed this lawsuit under the provisions of ERISA. In court, she claimed Reliance erred in determining she was not disabled from her own occupation instead of analyzing whether she was disabled from any occupation. The district court disagreed with the plaintiff holding that when Reliance determined she could perform her own occupation it “of course recognized that she could perform a job fitting within the plan definition of ‘any occupation.’”
Ability to Perform Own Occupation Encompasses Ability to Perform Any Occupation
The court agreed with the plaintiff’s argument that Reliance’s analysis of her disability focused on whether she could perform the duties of her own occupation instead of “any occupation.” The plan specifically provided for disability benefits when “an Insured cannot perform the material duties of any occupation. Any occupation is one that the Insured’s education, training or experience will reasonably allow.”
Although the court agreed that the correct analysis should have been on whether she could perform any occupation, it concluded that the sedentary nature of her own occupation “is a subset of ‘any occupation.’” When Reliance found she could perform her own occupation, the court concluded that “Reliance implicitly determined that Okuno did not meet the plan definition of “totally disabled” so as to entitle her to benefits.”
A Treating Physician’s Conclusion that a Claimant is Totally Disabled is Insufficient
Okuno also argued that since her treating physicians who diagnosed her many medical conditions claimed she was totally disabled, Reliance erred in denying her benefits. The district court relied on Sixth Circuit precedent and commented, “The mere diagnosis of any of these conditions alone is insufficient to render Okuno disabled within the meaning of the plan.” Disability is not based on a diagnosis, “but on the effect of that impairment on the life of the individual.”
The federal district court then undertook its own analysis of the medical records to see if Okuno satisfied her burden of presenting “evidence of the effect of those impairments on her life to qualify for long-term benefits.” The court found that although her doctors offered conclusory statements that she was totally disabled, and even expressed some limitations, there was no evidence of how the limitations rendered her totally disabled “within the meaning of the policy.”
In contrast to the unsupported conclusions of her treating physicians, reviewing consultants determined that she could perform sedentary work, which was the nature of her own occupation. The court concluded that Reliance denied Okuna long-term disability benefits based on a “principled and deliberative reasoning process.” Okuna’s claim for long-term benefits was denied.
The Court Repeatedly Noted that Claimant Misrepresented the Administrative Record
Of note, in reviewing the administrative record and contentions made in the district court, the district court repeatedly commented that “her contention does not match the record.” Although it determined “some of this is largely trivial,” the misrepresentations appeared to influence the court to note that, at least in one instance, “Her making such a contention now is suspect.”
This case was not handled by our office, but it may provide guidance to those who are struggling with similar issues. If you need assistance with your disability claim at any stage of the process, any of our lawyers will meet with you for a free consultation.