Two recent “own occupation” versus “any occupation” judgments, in addition to cases from late last year, while not resounding successes, seem to indicate a trend of the courts favoring claimants over insurers.
An insurer’s conflicting determinations
In Robinson v. Aetna Life Ins. Co., No. 20-CV-4670, 2023 WL 2058310 (N.D. Ill. Feb. 16, 2023), the plaintiff was awarded long-term disability benefits for a disabling heart condition after lengthy legal efforts. The first shoe to fall was winning her Social Security Disability Insurance (SSDI) benefits in March of 2020, with a retroactive effective date going back to October 2016.
Per Aetna’s plan, being awarded SSDI benefits was a precondition to being granted their long-term disability benefits. However, Aetna seemingly ignored the plaintiff’s SSDI success, instead ruling that she was ineligible because she was, in their judgment, capable of returning to work under their definition of “any occupation.”
Aetna’s ultimate folly was attempting to recoup so-called “overpayment of benefits,” using her newly awarded, retroactive SSDI benefits as a pretext. It didn’t take a legal expert to recognize Aetna’s tandem, incongruent determinations. A lawsuit ensued, and the court ruled against Aetna.
As for the “any occupation” portion of the case, temporarily lost in the parallel dispute, the court asked Aetna to take another pass at the claim. Though it would be a safe bet to expect yet another denial of benefits from Aetna, the momentum from the following case, also involving a disabling heart condition, may weaken Aetna’s position.
Backing up “any occupation” evaluations
In Aisenberg v. Reliance Standard Life Ins. Co., No. 1:22-cv-125, 2023 WL 2145499 (E.D. Va. Feb. 21, 2023), a former attorney engaged in “demanding and stressful” cyber security work, submitted a long-term benefits claim after undergoing open heart surgery involving a double coronary artery bypass graft.
His argument, supported by precedent, led the court to rule that “the risk of future harm from work-related stress for a plaintiff with heart conditions may qualify as a disability for the purposes of LTD benefits.” This point, however, did not necessarily annul Reliance’s “any occupation” argument.
Nevertheless, the court again ruled in favor of the plaintiff because Reliance had failed to prove that the plaintiff could safely perform similar work or offer reasonably suitable alternative positions, real or hypothetical. However, the court has granted Reliance another attempt at providing “regular occupation” options with non-threatening stress levels.
This mixed bag of rulings is nonetheless a sign that courts are becoming more demanding of insurers’ “own occupation” and “any occupation” evaluations. Such judgments put the onus on insurers to justify their decisions and back up their claims with actionable, substitute work opportunities. If rulings of this nature continue, they may rebalance the strength of challenges to comparable long-term disability denials in favor of claimants.