Court Rules That an Insurer Failed to Use Proper “Reasonable Continuity” Standard in Evaluating a Preexisting Condition that Disabled the Claimant

Under many long-term disability insurance policies, the insured is considered disabled if he or she is unable to perform “with reasonable continuity” the important tasks, functions, and operations of his or her occupation for a specified period of time. If a plaintiff seeks long-term disability benefits based on a claim that the insured was disabled as a result of a condition that existed before the insured stopped working, must the plaintiff demonstrate a change in the insured’s circumstances, such as a significant worsening of the preexisting condition? In Lyttle v. United of Omaha Insurance Co., No. 17-cv-01361-WHO, 2018 WL 4519949 (N.D. Cal. Sept. 19, 2018) (“Lyttle”), the court held that the plaintiff, who was the insured’s surviving spouse, did not have to demonstrate a change in the insured’s circumstances; she only needed to demonstrate that, because of the insured’s condition, he could no longer continue in his occupation. The court also held that, based on the evidence in the administrative record, the insurer, United of Omaha Insurance Co. (“United”), had incorrectly denied long-term disability benefits.

The plaintiff’s late husband, Matthew Lyttle (“Lyttle”), had been a Vice-President of Chemistry, with job duties that included lifting and walking. In 2011, Lyttle was diagnosed with liver cancer. And, in 2014, it was confirmed that the cancer had spread outside his liver.

In 2014, one of the medications prescribed for Lyttle had an unfortunate side effect known as hand-foot syndrome. Lyttle’s hand-foot syndrome caused him to have persistent pain in his feet and blisters caused by walking around at work. Lyttle tried to manage the pain by taking Norco, an opioid pain medication, but that medication impaired his ability to perform the rigorous intellectual tasks his job required.

In 2015, Lyttle was absent from work 17% of the time. And, in an e-mail dated December 28, 2015, Lyttle told his doctor that “he would like to take disability starting in 2016 because his condition had not changed and he had persistent pain in his feet and blisters caused by walking around at work.” Id. at *3. Lyttle’s doctor placed him off work from January 5, 2016 through June 5, 2016.

Under the United long-term disability policy, Lyttle was considered totally disabled if he was “unable to perform with reasonable continuity the Substantial and Material Acts necessary to pursue [his] Usual Occupation.” Id. at *6. The policy also provided that Lyttle would receive benefits after an “Elimination Period” of 90 days of disability. Id. at *6.

In March 2016, Lyttle filed a claim for long-term disability benefits. United denied Lyttle’s claim, and Lyttle appealed. After United denied Lyttle’s appeal, his widow filed a lawsuit seeking review of United’s denial of benefits.

Before the court, United pointed out that there was “no evidence . . . that Lyttle’s hand-foot syndrome became significantly worse or that that there was a sudden impairment in his intellectual functioning that necessitated his going on disability as of January 2016.” Id. at *8. And United argued that, “[a]bsent a change in circumstances, such as a significant worsening of his conditions, . . . its determination that Lyttle was not totally disabled during the Elimination Period and after must be upheld.” Id.

The court disagreed with United. It stated that the determinative question was whether, during and after the Elimination Period, Lyttle could “perform his job with ‘reasonable continuity.’” Id. at *9.

The plaintiff argued “that Lyttle was essentially barely performing his job and could not continue his actual occupation with ‘reasonable continuity’ given the record and the subjective evidence from Lyttle that his pain conditions had become worse during 2015, that his employer could not provide further accommodations for him, and that he used extensive vacation and sick leave in 2015.” Id. at *10.

In its ruling on cross-motions for summary judgment, the court noted the following language from Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 918 (7th Cir. 2003):

A desperate person might force himself to work despite an illness that everyone agreed was totally disabling . . . . Yet even a desperate person might not be able to maintain the necessary level of effort indefinitely. Hawkins may have forced himself to continue in his job for years despite severe pain and fatigue and finally have found it too much and given it up even though his condition had not worsened. A disabled person should not be punished for heroic efforts to work by being held to have forfeited his entitlement to disability benefits should he stop working.

The court determined that United had not asked its reviewers and examiners the proper question, which was “whether as of the end of December 2015 Lyttle was able to continue in his high-demands job with ‘reasonable continuity.’” Lyttle at *11. The court also noted that United had failed to: (a) analyze the significant subjective evidence of Lyttle’s pain and cognitive impairments; and (b) “consider that Lyttle was only able to continue in his job for as long as he did with the pain level he had through using leave time and, in the end, was not able to continue given his chronic, ongoing pain despite the lack of evidence of a ‘significant change’ in [Lyttle’s] condition.” Id.

Conclusion

Too many courts forget to apply the “reasonable continuity” standard when addressing whether an ERISA plan participant can collect his or her disability insurance benefits.  This Court did so correctly, explaining that after working for a while despite suffering from a chronic condition, an insured who is ultimately unable to continue performing his or her job with “reasonable continuity” is entitled to disability benefits, even if his or her chronic condition does not significantly worsen.

Share This Article

Facebooktwittergoogle_plusredditpinterestlinkedinmail

Comments are closed.