Does a claimant seeking disability need to prove the cause of disability to qualify for benefits? According to a recent federal decision from Georgia, the answer is no.

Arthur Lesser IV, the plaintiff in Lesser v. Reliance Standard Life Insurance Co., 2019 WL 2416926 (N.D. Ga. June 4, 2019), worked as a software engineer for Johnson Outdoor Inc. between May 2011 and February 2016 until he had to cease working due to multiple diagnoses: (1) severe daytime hypersomnolence, (2) memory loss, (3) obstructive sleep apnea, (4) male hypogonadism, (5) pituitary dysfunction, (6) hypothyroidism, (7) mild brain atrophy and (8) multifactorial generalized fatigue.

Lesser’s primary care physician certified that he “should not work due to inability to stay awake and inability to perform mental functions [that the] job requires.”

Lesser’s ensuing disability benefit claim was initially approved and Reliance began paying benefits as of Aug. 13, 2016. However, payments ceased the following Oct. 13 after a nurse’s review concluded there was a lack of adequate medical evidence to support a disability finding. A pre-litigation appeal failed to overturn the denial and litigation followed.

The court began its analysis by looking at the highly technical work performed by software engineers, finding the “physical demands of the job are light, but the cognitive demands are heavy.”

The record showed that Lesser complained of bouts of daytime sleepiness and fatigue that require him to take lengthy naps each day. The bouts of sleepiness cause lapses in concentration and memory. Lesser’s primary care doctor reported he was “extremely limited in his ability to follow instructions, to perform simple and repetitive tasks and his ability to perform complex and varied tasks”

The court concluded that Lesser presented sufficient evidence substantiating his symptoms and limitations. Although his complaints were self-reported, they were corroborated by multiple objective tests.

One physician administered a psychomotor vigilance test that demonstrated “profound decrements in psychomotor vigilance.” A wrist actigraphy study that recorded multiple lengthy naps on multiple days over the course of a week further confirmed Lesser’s complaints, as did a functional capacity evaluation containing built-in validity measures showing “full and consistent effort” during testing, thus establishing the plaintiff’s inability to perform sedentary work.

A neuropsychological evaluation also showed lower cognitive and intellectual abilities than would be necessary to work as a software engineer.

Although Reliance obtained an independent medical evaluation during the course of the claim, the court found the results did not support the benefit denial since the examiner did not render an opinion as to whether Lesser was capable of working as a software engineer.

Instead, the examiner reported, “[i]t may be that his former occupation of being a software engineer would be impossible to him, but I suspect that there are many other sorts of occupations that he could do.”

The definition of “disabled” was occupation-specific, though, which led the court to conclude: “The [p]laintiff’s hypothetical ability to work at some other occupation has no bearing on whether he can perform the duties of a software engineer.”

The court also found Reliance misapplied plan requirements by rejecting Lesser’s claim due to the absence of a determination as to the etiology of his symptoms. The court explained: “But the [p]lan requires satisfactory proof of disability, not etiology. A claimant establishes eligibility under the [p]lan terms by proving that he cannot perform the material duties of his regular occupation, not by identifying the root cause of his illness.”

The court went even further by observing: “It is neither wrong nor unreasonable for a plan administrator to require objective medical evidence of disability, even where the plan documents do not specifically require it. It is wrong and unreasonable, however, to require the claimant to furnish proof of the root cause of his illness when it is not one that is easily diagnosed by objective tests and where there is no evidence that the claimant is malingering.”

“It is clear from the numerous diagnostic tests conducted by the [p]laintiff’s medical providers that hypersomnolence is a condition with many possible physiological causes- or, in the case of idiopathic hypersomnolence, no clear root cause at all. Moreover, there is no evidence in the record to suggest that the [p]laintiff was malingering. The [d]efendant’s inappropriate focus on etiology was therefore arbitrary and capricious.”

The court also held that Reliance Standard’s arbitrariness was demonstrated by its selective review of the evidence and due to either misinterpretation or mischaracterization of medical findings. The court explained a plan administrator’s discretion is not unfettered and plan administrators “are not free to rely on selective or self-serving interpretations of the medical evidence that are not supported by the record.”

On a similar note, the court faulted Reliance for disregarding critical objective evidence such as the functional capacity evaluation.

Based on its assessment of the case, the court ordered Reliance Standard to pay benefits through the date of the judgment since “the record is complete and neither party has put forward evidence that was unavailable to the [d]efendant at the time that it made its benefits determination.”

This is an important case to keep at hand. The court made two key points that, while not original, bear repeating. First, the nonphysical aspects of a claimant’s occupation have to be taken into consideration; and second, a claimant is not required to prove the etiology of his or her impairment.

Obviously, for a policy that measures disability against a claimant’s ability to perform the duties of a particular job, especially one that is cognitively demanding, an insurer disregards its obligations under the policy when it ignores all of the occupational requirements.

Nor is it fair to an insured to require a precise diagnosis. By its very nature, idiopathic hypersomnolence is a condition whose cause is unknown. Further, the evidence presented leaves no doubt that Lesser was indeed disabled.

This article was initially published in the Chicago Daily Law Bulletin. 

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