Court Rules “Superhuman Effort” Cannot Serve As The Sole Reason For The Denial Of Disability Benefits

The case of Mucciacciaro v. Hartford Life & Accident Insurance Company was filed in the United States District Court for the District of New Jersey. This legal battle centers around Sandra Mucciacciaro, the Plaintiff, and Hartford Life and Accident Insurance Company, the Defendant. The legal dispute pertains to a claim for long-term disability benefits, with the Plaintiff and the Defendant filing cross-motions for summary judgment. ERISA governs the disability plan.

Claim History

Dimensional Dental Holdings, LLC employed the Plaintiff as a dental hygienist when she began experiencing back pain in 2017. Two years later, she submitted a note from her doctor requesting that she be allowed to work thirty hours per week. The Plaintiff’s employer denied this accommodation request. She continued working for six months, but on June 3, 2020, she gave her employer two weeks’ notice of her resignation.

The Plaintiff requested an application for disability benefits on June 14, 2020, but continued to work full-time through her June 17, 2020, resignation date. She applied for benefits on July 25, 2020, but claimed June 18, 2020, as “the date on which she was first unable to work.” She also supplied the Defendant with medical records and MRI results.

However, the Defendant denied the Plaintiff’s claim, stating:

“As of the date of the disability, 06/18/20, you were not covered under the Long Term Disability (LTD) benefits plan. Because of this, we cannot consider your claim for Long Term Disability (LTD) benefits.

….

When making our decision, The Hartford had to establish what your date of Disability was. In doing so, we determined that your date of Disability was 06/18/2020. We came to this determination using the policy language you see above. In order to be considered Disabled, we select the date for which you first would be unable to perform the “Essential Duty” of Your Occupation. You can see above what defines “Essential Duty.” Per your employer, you performed your full “Essential Duty” on 06/17/2020 to include working Your Occupation, unmodified, for the duration of time expected for your shift. As such, you do not meet the policy definition of Disability as of 06/17/2020 as you were able to perform all of your “Essential Duty” for this day. Thus, the first potential day that you could be considered for Disability from Your Own occupation would be 06/18/2020. As of this date, per your employer, you were no longer an Active Employee under the policy.”

In her appeal, the Plaintiff explained that she had indicated the wrong date of disability because she misunderstood the question and that the medical evidence provided clearly demonstrated that her disability had begun in 2019. However, the Defendant upheld the decision to deny her claim, relying again on the fact that the Plaintiff was performing the essential duties of her occupation before June 18, 2020, and she did not have coverage on June 18, 2020, because she had voluntarily resigned. The Plaintiff then filed suit against the Defendant.

The Policy

To be eligible for coverage under the Policy, an employee must be a “Full-time Active Employee,” which requires working “at least 30 hours weekly” “on a regular basis.”

The Policy states, in the relevant part:

“Disability or Disabled means You are prevented from performing one or more of the Essential Duties of:

1. Your Occupation during the Elimination Period;
2. Your Occupation, for the 2 year(s) following the Elimination Period, and as a result Your Current Monthly Earnings as less than 80% of Your Indexed Predisability Earnings, and
3. after that, Any Occupation.

Essential Duty means a duty that:

1. is substantial, not incidental;
2. is fundamental or inherent to the occupation; and
3. cannot be reasonably omitted or changed.

Your ability to work the number of hours in Your regularly scheduled work week is an Essential Duty. However, working more than 45 hours per week is not an Essential Duty.

Termination: When will my coverage end?

Your coverage will end on the earliest of the following:

….

• the date You cease to be a Full-time Active Employee in an eligible class for any reason;

unless continued in accordance with any of the Continuation Provisions.

Coverage while Disabled: Does my insurance continue while I am Disabled and no longer an Active Employee? 

If You are Disabled and You cease to be an Active Employee, Your insurance will be continued:

1. during the Elimination Period while You remain Disabled by the same Disability; and
2. after the Elimination Period for as long as You are entitled to benefits under the Policy.”

The Issues

The main issue raised by the parties’ cross-motions is simple: Did the Defendant act arbitrarily and capriciously by deciding that the Plaintiff wasn’t disabled before June 18, 2020, just because she was working full-time and performing all her job duties, without thoroughly reviewing the medical evidence she provided?

The Plaintiff argues that the Defendant’s decision was arbitrary and capricious because it was solely based on her working full-time. She adds that her complaints of pain and her doctor’s request for accommodation prove she was disabled even before she resigned. The Defendant argues its decision is backed by solid evidence because, per the Policy’s strict terms, the Plaintiff worked full-time and performed all her essential duties until she resigned, making her ineligible for benefits.

The Judge’s Decision

First, the judge considered previous court rulings. The Third Circuit hadn’t tackled this exact issue before, but other circuits have hinted that being able to work full-time shouldn’t automatically rule out a finding of disability.

It is worth noting that legal research failed to turn up a case where a claim administrator based a decision solely on attendance or work capacity to decide someone was not disabled. In all the relevant cases, plan administrators assessed the medical evidence provided, with job attendance being just one factor among many they considered.

The judge also considered the Plaintiff’s request for accommodation from her employer. However, both parties had differing views on this fact. The Plaintiff asserted it shows she could not work full-time due to a disability. The Defendant disagrees, pointing out that the Plaintiff continued working full-time after her request was denied, proving she could handle full-time work.

However, the judge sided with the Plaintiff, finding that the accommodation request substantiated that the claimant struggled to continue working. If nothing else, it cast doubt on the Defendant’s decision not to consider the medical evidence. Specifically, the judge stated:

“Defendant’s decision, finding Plaintiff was not disabled before June 18, 2020, for the sole reason that she was working full-time without conducting a substantive review of the medical evidence provided in her claim, was arbitrary and capricious. To find otherwise would fail to recognize the ability of many persons with disabilities to persevere despite their disability, often at great cost to their physical and mental health. There are innumerable reasons a person would attempt to maintain their employment despite these costs, one very obvious one being the continuance of health insurance. This “superhuman effort” cannot serve as the sole reason for the denial of disability benefits. Perlman, 195 F.3d at 983. This is especially true where individuals like Plaintiff request accommodations to allow them to continue their employment.

….

If Defendant could lawfully deny an employee’s disability claim simply because they are working full-time and thus per se not disabled then the employee would necessarily be forced to reduce their hours or leave employment to establish a disability. Reducing hours or leaving could, however, have the effect of terminating the employee’s coverage for failure to maintain their status as a Full-time Active Employee. This is not a hypothetical or speculative result. It is the exact circumstances in which Plaintiff found herself. If Defendant’s interpretation was correct, Plaintiff was presented with a catch-22: continue working full-time and never be able to prove herself disabled under the Policy or stop working and lose coverage. Under this theory, no employee could qualify for disability, and that simply cannot be how the Policy is interpreted.”

After finding that the Defendant’s decision was not supported, the Court considered the Plaintiff’s request that her benefits be granted. The Court decided not to grant her benefits but instead opted for a remand. This would allow the Defendant to properly analyze and fully consider the Plaintiff’s claim and all the relevant medical evidence provided, leading to a well-thought-out decision.

In their Motions, both parties focused on whether the Defendant could reject the claim based on the Plaintiff’s full-time work status. They did not discuss the merits of the Plaintiff’s medical evidence. Therefore, the Court found that a remand was more suitable than a de novo review of the medical evidence. The Defendant’s Motion for Summary Judgment was denied, the Plaintiff’s Motion for Summary Judgment was granted and denied in part, and the claim was remanded to Hartford for further review.

Disclaimer: Disability attorney Nick A. Ortiz did not handle this case. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.

Here is a PDF copy of the decision: Mucciacciaro v. Hartford