Long-term disability insurance policies are an important safety net for employees. In the event of an accident, long-term disability helps to bridge the gap in income when an employee is no longer able to work. But to what extent does it mean for an employee to be no longer able to work? While insureds may be unable to continue fully working in their usual occupation, insurers often argue an insured can perform some other sedentary occupation to account for claimed disability, allowing them to deny the benefit claim.
In the 2003 Northern District of California case, Bruce v. New York Life Ins. Co., 2003 WL 21005313 (N.D. Cal. 2003), the court addressed this very issue. In Bruce, the plan participant Mary Bruce brought suit challenging defendant Aetna Life Insurance Company’s decision to deny her claim for disability benefits in a group insurance policy subject to the Employee Retirement Income Security Act (“ERISA”). ERISA, a 1974 federal law, sets minimum standards for many long-term disability plans and serves to provide protection for individuals in these plans.
The court in Bruce considered a disability policy in which a plan participant is initially eligible for benefits if she cannot perform her “usual occupation” and thereafter only if she cannot perform “another occupation in which he could reasonably be expected to perform satisfactorily in light of his age, education, training, experience, station in life, physical and mental capacity.” Relying upon the Webster’s Dictionary definition of “occupation,” the district court in Bruce held the plain meaning of “another occupation” was performing full-time work in another occupation. The court stated:
Moreover, where, as here, the plan participant’s occupation, prior to injury, was in fact full-time, the phrase “usual occupation” would be understood to mean “usual full-time occupation.” Given the juxtaposition of the terms “usual occupation” and “another occupation,” the latter term ordinarily would be understood to mean “another full-time occupation.”
Interpreting the term “another occupation” to refer to a full-time position is also consistent with New York Life’s practices. In its Physical Capacities form, on which New York Life requests that physicians provide information to assist “in determining the work potential” of a plan participant, New York Life seeks information with respect to the participant’s ability to perform tasks “in an 8–hour workday.” (See, e.g., AR at 56.) Finally, even if the term “another occupation” were ambiguous as to whether it refers to full-time or part-time employment, the term must be interpreted to refer to full-time work because ambiguous terms in policies subject to ERISA are “construed against the insurance company.” See Lang v. Long–Term Disability Plan, 125 F.3d 794, 799 (9th Cir.1997) (holding, in ERISA action where denial of benefits was subject to de novo review, ambiguous language in policy was properly construed in favor of insured). Consequently, the Court finds the term “another occupation,” as used in the policy at issue, is properly construed to encompass only full-time employment.
Accordingly, the court held that the opinion that Bruce could perform limited part-time work out of her home did not support a finding that she could perform “another occupation” within the meaning of the subject policy.
More recently, the Ninth Circuit Court of Appeals further examined the meaning of disability under ERISA as it relates to sedentary work. In Armani v. Northwestern Mutual Life Ins. Co., 840 F.3d 1159 (9th Cir. 2016), the court addressed the definition of sedentary work and the required time one must be physically able to sit to perform such work. Reversing the district court’s order, the court held that an employee who cannot sit for more than four hours in an eight-hour workday cannot perform “sedentary” work.
The participant Avery Armani was insured under a group long-term disability policy issued by Northwestern Mutual that provided a more-inclusive meaning of disability in the first 24 months of benefits. Under the policy, after 24 months of disability benefits, the claimant must then be “Disabled from all occupations” to be eligible for benefits. Upon injuring his back, Armani was not able to sit continuously without the ability to change position. Armani’s disability claim was initially approved and then denied after further review nearly two years after his initial claim, in July of 2013. After further medical record indicated Armani could sit for four hours a day, Northwestern Mutual closed Armani’s claim asserting he was not precluded from sedentary work.
Armani filed suit under ERISA seeking judicial review of Northwestern Mutual’s claim decision. Following a bench trial, the district court ultimately held that Armani failed to show he was disabled from “all occupations” with the reasoning that Armani failed to demonstrate his disability prevented him from performing some sedentary occupations.
After timely appeal, the court held that an employee who cannot sit for more than four hours in an eight-hour workday cannot perform “sedentary” work that requires “sitting most of the time.” The court explained that the district court’s rejection of Armani’s definition of “sedentary” was based upon an erroneous application of Social Security law and ERISA law. The court based its ruling on several decisions evaluating ERISA claims that found “sedentary work” generally requires a sitting tolerance of at least 6 hours of an eight-hour work day. This four-hour standard is applicable in assessing the extent to which an employee can claim disability benefits after an injury in occupations where sitting for long periods of time is an essential component of the job.
While factually dissimilar, the court’s ruling in Armani is consistent with the 2003 Bruce district court opinion. Under the Armani four-hour bright line rule, Mary Bruce would have been unable to perform sedentary work, since Bruce’s administrative record indicated she was only able to sit for roughly four hours per day. Conversely, Avery Armani would have been limited to part-time work, as he also was only physically able to sit for four hours.
Even though the district court and the Ninth Circuit reached the same destinations, the courts took different paths of analysis. On the one hand, Bruce considered the plain meaning of “occupation” and the Webster’s Dictionary definition of occupation meaning a full-time job. Thus, part-time work was not a sufficient replacement for “another occupation” in the “any occupation” analysis. On the other hand, Armani considered the analysis from other courts which consistently found that the standard of work from the Department of Labor and Dictionary of Occupational Titles defined sedentary work as requiring the ability to sit for at least six hours.
These tests may seem arbitrary, but they help to provide guidance and protection for a disabled worker with coverage from a disability plan. As disability claimants are often only able to perform sedentary work after injury, insurers now cannot argue that part-time, sedentary work is a sufficient to deny a disability insurance claim under the “any occupation” standard.