Long-term disability? He said/she said fight leads to this result

There was evidence to support both sides. Here’s why the scales tipped in favor of an employee seeking long-term disability benefits. 

A maintenance supervisor had long-term disability insurance. His employer provided the insurance.

The policy provided two years of benefits for claimants who could not perform their current jobs.

Benefits continued beyond two years for claimants who could not perform any job.

The employee left his job in July of 2016 due to lower back pain.

He had back surgery two months later.

The insurer cut benefits under the policy after two years. It said the employee could perform sedentary work.

Test Results Were ‘Relatively Mild’

MRI results were “relatively mild,” the court said. But the employee’s doctor said he needed to avoid lifting, bending and prolonged sitting.

The employee further noted that he successfully applied for Social Security disability benefits. Those benefits are available only to those who are not able “to engage in any substantial gainful activity.”

The insurer hired a doctor. The doctor said the employee could do sedentary work. And the insurer stood by its decision to deny the claim for extended benefits.

The employee sued. He claimed that the denial violated ERISA. A lower court ruled in his favor. The insurer appealed.

The U.S. Court of Appeals for the Eighth Circuit affirmed the lower court’s ruling.

It upheld the finding that the employee could not work.

Insurer Points to Evidence

The insurer pointed to evidence indicating an ability to work. That included its examining physician’s opinion that the employee could do sedentary work. The physician also said the employee engaged in “symptom magnification.” The insurer also noted that the MRI results were mild.

But that evidence had to be balanced against other evidence indicating that the employee could not do even sedentary work, the appeals court said.

That evidence included the fact that the employee had successfully applied for Social Security disability benefits. Also, evidence from other health care professionals indicated he could not work. The employee’s own accounts of debilitating pain were also probative, the appeals court explained.

There was evidence that the employee was not disabled. But there was also enough evidence to permit the lower court’s decision that he was, the appeals court ruled.

The appeals court affirmed the lower court’s decision.

Avenoso v. Reliance Standard Life Insurance Co., No. 21-1772, 2021 WL 5570816 (8th Cir. 11/30/21).