TOM S. LEE, District Judge.
This case arises out of the termination of plaintiff John R. Kavanay's long-term disability benefits under an insurance policy issued by defendant Liberty Life Assurance Company of Boston (Liberty) to plaintiff's former employer Allstate Insurance Company (Allstate). Plaintiff brought this action under 29 U.S.C. § 1132(a)(1)(B), the civil enforcement section of the Employee Retirement Income Security Act of 1974 (ERISA), alleging wrongful termination of long-term disability benefits payable under Liberty's policy. The case is presently before the court on the parties' cross-motions for summary judgment. The court, having considered the memoranda of authorities submitted by the parties, and the administrative record, concludes for reasons which follow that Liberty's motion should be denied and plaintiff's motion should be granted as set forth herein.
During his employment with Allstate as a Claim Service Adjuster, plaintiff Kavanay was a participant in a group long-term disability plan sponsored by Allstate. The plan was funded by a policy of insurance issued and administered by Liberty. Under the terms of the policy, a participant is eligible for long-term disability benefits if during the initial twenty-four months of the claim life, the participant suffers from an injury or sickness that renders him "unable to perform the Material and Substantial duties of his Own Occupation." "Own Occupation" is defined as the occupation performed when the "Disability" began. The plan states, "For the purposes of determining disability under this policy, Liberty will consider the Covered Person's occupation as it is normally performed in the national economy."
On April 24, 2009, Kavanay sustained an injury to his knee while climbing a ladder at work. Claiming the injury rendered him unable to return to his job, Kavanay initially filed a claim for benefits under Allstate's short-term disability (STD) benefit plan, which was denied because Allstate's STD plan did not cover on-the-job injuries. Eventually, on September 20, 2009, his claim was converted to a claim for long-term disability (LTD) benefits.
An MRI taken a few days after plaintiff's injury indicated a "small horizontal tear of the medial meniscus and mild mucinous degeneration of the anterior cruciate ligament (ACL) in his right knee." Plaintiff underwent surgery by Dr. Theodore Jordan, M.D. on June 29, 2009 to repair his ACL, which was followed by physical therapy. A post-operative MRI on September 4, 2009 reflected that the ACL graft was intact, but the tear in the medial
However, on March 26, 2010, Liberty informed Kavanay by letter that it was terminating his LTD benefits effective that date because it had concluded that Kavanay no longer met the policy definition of disability. Liberty wrote that it had determined, based on an occupational analysis conducted November 3, 2009, that Kavanay's "own occupation" could be performed within a sedentary category, and since the available medical evidence did not support an impairment which would physically preclude Kavanay from performing full-time sedentary work activities, he was no longer disabled under the policy. The medical evidence to which Liberty alluded included the results of a March 11, 2010 independent medical examination by Robert S. Levine, M.D., who determined, after reviewing plaintiff's medical records and contacting Dr. Shelton, that Kavanay should avoid climbing, kneeling and crawling but could do a "desk job" that would allow him to sit at a desk and use his upper extremities.
Where, as here, a plan governed by ERISA grants the administrator "`discretionary authority with respect to the decision at issue,'" the court reviews a denial of benefits for abuse of discretion.
The record reflects that in October 2010, Liberty assigned plaintiff's claim to a vocational consultant for an "own occupation" analysis. Using the U.S. Department of Labor's Dictionary of Occupational Titles (D.O.T.), the vocational consultant determined that the job of Outside Adjuster at Allstate is part of the occupation of Claims Examiner/Adjuster/ Investigator, and concluded that the most closely related
It is undisputed that Liberty terminated plaintiff's LTD benefits under the policy after finding that the medical evidence did not prevent his performing sedentary work as an Inside Claims Examiner;
Here, it is apparent that in selecting the sedentary position of Inside Claims Examiner from the D.O.T. as establishing the requirements of Kavanay's "own occupation," Liberty arbitrarily disregarded the nature of Kavanay's position with Allstate and the specific tasks he was required to perform as an Outside Claims Adjuster. Its consequent determination that Kavanay was not disabled because he was not medically precluded from performing the sedentary occupation of Inside Claims Examiner amounts to an abuse of discretion and cannot stand. It follows that Liberty's motion for summary judgment must be denied.
Plaintiff has filed his own motion for summary judgment, in which he contends the vocational and medical evidence in the administrative record establishes beyond reasonable dispute that he was unable to perform the material and substantial duties of the occupation of an Outside Claims Examiner—Catastrophic. The medical evidence establishes without contradiction from any source that plaintiff was restricted from climbing, kneeling, squatting and crawling. The evidence in the administrative record also reflects that plaintiff's job with Allstate involved examining roofs, attics, basements and collapsed buildings, and that persons performing such jobs need to have "good flexibility, balance, strength to carry equipment while safely walking and/or crawling." The nature of the job, as performed at Allstate, required a substantial amount of squatting, bending, climbing ladders, kneeling and climbing stairs—none of which plaintiff was able to do.
The evidence in the administrative record which relates to the requirements of the occupation of a catastrophic claims examiner/adjuster/investigator, as the position is performed in the national economy, suggests that the nature of the job, and consequent physical demands of the job, as it is performed in the national economy, are comparable to the position as it is performed at Allstate since the position involves inspection of damaged buildings, which cannot be done without the ability to access all parts of the structure, including parts above and below ground level, an ability which plaintiff lacks.