Disability plan administrator cannot use theoretical job as basis to deny claim
In an unpublished opinion summarizing a decision of the Sixth Circuit Court of Appeals the court awarded benefits to a Michigan machine operator finding the plan administrator’s decision that the claimant could perform a job, which the court described as “[existing] only in theory,” to be arbitrary and capricious.
Mr. Kennard operated machines for Means Industries, Inc. until 1990 when he inhaled fumes from a chemical spill, severely injuring his lungs and rendering him ultra-sensitive to fumes. As a result, his treating physician imposed a lifelong restriction that he work only in a clean-air environment.
Mr. Kennard was fortunate to have an employer that provided him with a clean-air environment to perform clerical work from March 1992 until 2006. Needless to say, his employer could only do so much; though it warned other employees in Mr. Kennard’s work area against wearing perfume or lighting candles, various fumes would cause Mr. Kennard to suffer shortness of breath requiring him to leave work.
Social Security Administrative Law Judge finds Kennard unable to engage in any substantial gainful activity and there are no jobs in the national economy that he can perform
In 2006 Kennard stopped working and the same year successfully applied for Social Security Disability Benefits. According to the SSA’s decision, medical evidence showed that “even extremely low levels of airborne dusts, mists, fumes, vapors, perfumes, cleaning fluids, etc.” gave Mr. Kennard “severe cough variant asthma and angioedema.” More importantly, a vocational expert testified that, based on Mr. Kennard’s pulmonary restrictions and age, education, and work experience, “there are no jobs in the national economy that he could perform.”
Kennard Seeks Disability Retirement Benefits Under His Employer’s ERISA-Governed Group Insurance Policy
As an eligible employee under his employer sponsored group disability plan Mr. Kennard was entitled to benefits if “he has been totally disabled by bodily injury or disease so as to be prevented from engaging in any occupation or employment for [pay] and which condition constitutes total disability under the federal Social Security Act.”
The disability plan further conditioned benefits on an assessment by physicians chosen by the employer that the disability be permanent.
Plan Administrator denies Mr. Kennard’s Request for Benefits
After having Mr. Kennard examined by two physicians, the Plan Administrator denied Mr. Kennard’s claim concluding, without discussion, that Mr. Kennard was “not permanently disabled within the meaning of the plan”. The denial cited an opinion by one of the hired physicians that: “Kennard is employable as long as he could be guaranteed that he would be placed in an absolute clean air environment with absolutely no noxious fumes or inhalants, as he is extremely sensitive to this.”
Kennard’s ERISA lawsuit
Mr. Kennard filed a lawsuit in federal court seeking to enforce his rights under the Plan. Although the district court sided with the administrator, the U.S. Court of Appeals for the Sixth Circuit, reviewing the district court’s decision, ultimately awarded Mr. Kennard benefits.
The Court of Appeals rejected the district court’s conclusion that the doctors’ reports support the administrator’s decision that Kennard can “engage in any occupation or employment” explaining that “bare recitations of medical data, without reasoning, cannot produce a logical judgment about a claimant’s work ability.”
As the court further explained:
“A valid denial of benefits premised on Dr. Levinson’s opinion would need to include evidence of the existence of absolute-clean air jobs available to Kennard.”
The court pointed out that the SSA found that there are no jobs in the national economy that Kennard could perform. Although the plan administrator is not required to seek out vocational evidence it does need to ground its decision on a reasoned explanation and in failing to tackle the implicit non-existence of jobs compliant with the strict condition of being “guaranteed that he would be placed in an absolute clean air environment” the plan administrator’s decision was not “the result of a detailed, principled reasoning process and… supported by substantial evidence.”
Finding no evidence in the record to support a denial of benefits, the court awarded benefits to Mr. Kennard.
Why does this decision matter?
This case discussed the standard employed in the sixth circuit when courts review ERISA governed disability plan denials. While the claimant generally faces the high burden of convincing the court to disturb the administrator’s decision by showing that the administrator’s judgment was “arbitrary and capricious” the court explains in this case that a reviewing court nevertheless must ensure that the administrator can offer a reasoned explanation for its judgment that a claimant was not “disabled” within the plan’s terms. The court therefore focused on what the administrator is required to do.
This decision will encourage ERISA plan administrators to offer more reasoned explanations for their decisions. It may also cause administrators to perform more careful vocational analyses when reviewing claims.
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Who are Dell Disability Lawyers?
We are disability insurance attorneys that know how to get your short or long term disability benefits paid. As a nationwide law firm we have helped thousands of disability insurance claimants throughout the United States to collect hundreds of millions of dollars of disability insurance benefits from every major disability insurance company.
Our attorneys have been able to either get our clients paid monthly disability benefits or obtain a one-time lump-sum settlement in more than 98% of our cases. Our disability insurance lawyers have seen it all when it comes to disability insurance claims and we know exactly what it takes for your disability claim to be approved.
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Our disability insurance attorneys help individuals that have either purchased a long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer. We have helped individuals in almost every type of occupation with monthly disability benefit payments ranging from $1,500 to $50,000.
Our clients include all types of employees ranging from retail associates, sales representatives, government employees, police officers, teachers, janitors, nurses, pilots, truck drivers, financial advisors, doctors, dentists, veterinarians, lawyers, consultants, IT professionals, engineers, professional athletes, business owners, and high level executives.
A strong understanding and presentation of the duties of your occupation is essential for securing disability insurance benefits.
Do you work in my state?
Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability insurance lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.
What are your fees?
Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.
The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.
In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.
Do I have to come to your office to work with your law firm?
No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via phone, email, fax, or video conferencing sessions. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.
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When you call us during normal business hours you will immediately speak with a disability insurance attorney. We can be reached at 800-698-9159 or by email. Lawyers and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.