CNA Insurance Ordered to Pay Disability Benefits to VP Injured in Motor Vehicle Accident
Feb. 20, 2023
A federal judge in Vermont recently awarded a vice president of an investment firm benefits under his long-term disability plan. In 1999, the insured was employed by Bear Stearns when he was injured in a motor vehicle collision. At the time of the accident, he was insured under his employer’s disability plan. The employee suffered head, shoulder, and back injuries. One year after the accident, the employee underwent rotator cuff surgery which led him to stop working.
Two years after the accident, the employee applied for long-term disability benefits based on his injuries from the accident. CNA approved the claim and began paying benefits. The employee received benefits for 18 years when CNA advised him that he no longer qualified for benefits. CNA denied benefits in part because the employee’s doctor stated in a record that the employee could perform sedentary work on a full-time basis. An opinion the doctor later revoked.
After undergoing shoulder surgery, the employee’s doctor concluded he could not work, specifically stating he could not lift or stand. Later, the employee underwent back surgery where he received a back fusion. Unfortunately, the fusion was unsuccessful and the employee’s pain continued. During this time, the employee’s doctors concluded he was totally disabled as a result of his injuries from the motor vehicle accident and the subsequent surgeries.
The employee’s other doctors agreed that he was totally disabled. One doctor concluded that the employee could not sit for more than one hour and could stand or walk for fifteen minutes. The same doctor concluded that the employee’s condition required he lie down or recline for three hours before he could return to continuous activities.
During the course of his treatment, the employee began to experience symptoms of depression. His doctors placed him on a plan to reduce his opioid use. By now, he had been diagnosed with herniated discs at L4-5 and L5-S1. The prior fusion surgery was performed at L3 to L5, however, x-rays showed that the fusion was unstable.
Nineteen years after the initial motor vehicle accident, the employee suffered a stroke.
One of the employee’s doctors looked at the employee’s medical history, including his stroke, cardiac issues, depression and hernia, combined with his back and shoulder injuries, and concluded the employee remained disabled and his condition was permanent.
During this same time period, one of the employee’s doctors completed a form for the disability insurer indicating the employee could work on a sedentary basis. On the same form, however, the doctor stated that the employee was unable to satisfy the definition of light or medium work. Thus, the doctor’s statements appeared to conflict with each other. Around this time, other doctors concluded the employee could only lift up to ten pounds occasionally and could not reach above his shoulders.
The employee underwent a functional capacity evaluation which confirmed he could only sit for approximately one hour at a time for a total of three to four hours in an eight hour work day. CNA hired a reviewing doctor who disagreed with the other doctors’ assessments. The CNA doctor concluded that the employee’s limitations for his ability to work were “based on self-reports,” meaning it was the employee, not the doctors, who concluded the employee was unable to work a full day.
Based on the opinions of the reviewing doctor, CNA denied disability benefits for the employee, relying in part on the conclusions of its reviewing doctor. The employee eventually sued CNA in federal court which led the court to review the medical evidence and decide whether the denial was appropriate. In reviewing the evidence, the court noted how CNA had dismissed the subjective complaints of the employee. The court noted that “courts do not dismiss the subjective self-reporting as presumptively invalid”. Instead, an employee’s subjective complaints are an “important factor to be considered in determining disability.”
Applying an “abuse of discretion” standard, the court found that CNA’s denial of benefits after 18 years of coverage needed to be based on a change in the employee’s medical condition. Considering the facts before it, the court concluded “the record does not evidence such a change,” meaning there was no evidence that the employee’s medical condition had changed. Based on this conclusion, the court found the employee was entitled to disability benefits.
The decision is Curiale v. Hartford Life & Accident Ins. Co., No. 2:21-cv-54, 2022 WL 2063261 (D.Vt June 8, 2022).