A man worked as an over-the-road truck driver, meaning he was hired to drive long distances from the place of pickup to the place of delivery. His employer provided an employee benefit plan which was governed by the Employee Retirement Income Security Act (ERISA).
The man was diagnosed with insulin-dependent diabetes mellitus. As a result of his diagnosis, he was unable to continue work as an over-the-road truck driver as certain regulations of the U.S. Department of Transportation provide that any person with insulin-dependent diabetes mellitus is not qualified to operate a commercial motor vehicle. As a result, Arkansas disqualified his commercial driver's license.
He submitted a claim for long-term disability (LTD) benefits to the plan’s insurer. In support of his claims, he submitted a statement from the doctor who had diagnosed him, stating that he could not work because he was “unable to obtain a DOT health card with this new diagnosis.” The doctor wrote a follow-up letter to the insurer repeating that he did not feel that the man would be able to obtain gainful employment noting his insulin dependent diabetes mellitus, which precluded him from operating any sort of heavy machinery or motorized vehicles based on the Department of Transportation regulations. The insurer concluded that the man was not disabled under the terms of the plan and denied the claim for LTD benefits on that basis.
To qualify as “Totally Disabled” under the LTD policy, an insured must be unable to perform the material duties of his regular occupation due to injury or sickness. The LTD policy further provided that if the insured required a license for the occupation the loss of the license for any reason did not in and of itself constitute “Total Disability.” In its denial letter, the insurer explained that although the man's submission asserted that his diagnosis of diabetes mellitus precluded him from maintaining a commercial driver's license under the federal regulations, there was no evidence that any symptoms of diabetes mellitus prevented him from performing his occupation under the terms of the LTD policy.
The man administratively appealed. He argued that the diabetes-related loss of his commercial driver's license prevented him from performing his job duties. The insurer upheld the denial, reasoning that the LTD policy explained that loss of a license did not constitute disability and that there must be evidence that one was physically or mentally incapable of performing the material duties of his occupation as a truck driver to qualify as totally disabled. The insurer maintained that the man’s doctor's submissions referred only to the federal regulations and failed to identify any specific restrictions or limitations the man suffered due to insulin-dependent diabetes, nor provided any insight as to how his symptoms were preventing him from performing his duties as a truck driver. The insurer also cited the conclusions of another doctor, who had reviewed the man's claim file and found that there was no evidence to substantiate his inability to perform the duties of a truck driver, other than the regulation set forth by the Department of Transportation.
The man sued the plan and the insurer, alleging that the insurer unreasonably denied his claim for LTD benefits in violation of ERISA. The United States District Court for the Eastern District of Arkansas granted judgment on the administrative record in favor of the man.
The Eighth Circuit United States Court of Appeals reversed. The court held that the plan required a showing that the insured was physically or mentally incapable of performing the material duties of his occupation, independent of his loss of license, in order to be eligible for LTD benefits; and substantial evidence supported the denial of benefits.
The plan required a showing that the insured was physically or mentally incapable of performing the material duties of his occupation, independent of his loss of license, in order to be eligible for LTD benefits. The LTD policy provided that plan participants were only eligible for LTD benefits upon “total disability.” “Total disability” occurred only when a participant could not perform the material duties of his regular occupation. If a plan participant required a license for such occupation, the loss of such license for any reason did not in and of itself constitute “total disability.” Based on the insurer’s reasonable interpretation of the terms of the LTD policy, the court concluded that it required a showing that the participant was physically or mentally incapable of performing the material duties of his occupation, independent of his loss of a license, in order to be eligible for LTD benefits.
Substantial evidence supported the determination that the insured was not rendered incapable of performing his regular occupation as a result of his insulin-dependent diabetes mellitus. The man’s doctor opined that he man would be unable to work as a truck driver based on a Department of Transportation's regulation. The Department of Transportation's medical advisory criteria for evaluation under 49 C.F.R. § 391.41 presumed that a person afflicted with insulin-dependent diabetes was at risk of passing out, becoming disoriented, or going into a diabetic coma or shock while working as an over-the-road truck driver. However, the doctor identified no physical limitations on the man's ability to work as a truck driver as a result of his diabetes. The court held that it was permissible for the insurer to require some evidence specific to the man, as opposed to the generalizations upon which the government sometimes must rely in its regulatory capacity to avoid significant administrative burdens. Moreover, the court noted that the insurer also asked another doctor to review the man’s claim file. That doctor found no evidence that diabetes mellitus impaired his ability to perform his occupation.
The Eighth Circuit United States Court of Appeals reversed the district court’s grant of judgment on the administrative record in favor of the insured.
See: Hampton v. Reliance Standard Life Ins. Co., 2014 WL 4977397 (C.A.8 (Ark.), October 7, 2014) (not designated for publication).
See also Medical Law Perspectives, May 2014 Report: Diabetes and Its Complications: Malpractice and Other Liability Issues
See also Medical Law Perspectives, June 2013 Report: Independent Medical Evaluations: Legal Risks and Responsibilities