Injured Employee’s Functional Capacity Evaluation Helps Employee Win Long-Term Disability Benefits in Court
Feb. 22, 2023
A Functional Capacity Evaluation (“FCE”) evaluates an individual’s capacity to perform work-related activities. FCE’s can play an important role in establishing that an employee qualifies for disability coverage under a long-term disability plan as they can provide a thorough analysis of the employee’s inability to return to work. To do this, the FCE takes the health status and body function of the employee and compares that to the demands of the employee’s job and their work environment.
Recently, an employee who was unable to work as an investment advisor for a Wall Street firm sued his disability insurer due to its denial of the employee’s disability benefits. The court, after considering all the evidence, ruled in the employee’s favor and awarded him benefits. In doing so, the court considered the employee’s Functional Capacity Evaluation which ultimately supported the employee’s disability claim.
Functional Capacity Evaluations typically include a battery of standardized assessments that offer performance-based measurements. Components of the exams include interviewing the employee, reviewing the employee’s medical records, assessing the material handling activities the employee can perform, assessing the employee’s level of pain and comparing these components to the job specific functions required of the employee at work.
In the case of the disabled investment advisor, the employee’s injuries date back to a 1999 motor vehicle collision which caused the employee to sustain a torn rotator cuff and herniated discs in the lower back. The employee underwent a fusion of discs in his lumbar spine; however, the procedure did not relieve his pain. Virtually all of the employee’s doctors concluded he was disabled and unable to perform the requirements of his job.
After the insurer denied the employee’s disability benefits, the employee underwent an FCE. The evaluation was performed by a licensed occupational therapist who found the employee could sit for approximately one hour at a time for a total of three to four hours in an eight-hour workday. The FCE also showed he could occasionally bend or stoop but he could rarely kneel, crouch or climb stairs. Worse still, due to his shoulder injury the employee was unable to reach greater than 15 inches over his head. His stamina was for two or three hours per day.
The insurer that denied the employee’s disability claim, Hartford, hired a doctor to review the claim. That doctor failed to reference several of the records and conclusions of the employee’s treating doctors. One of the employee’s doctors agreed with the conclusions in the FCE report that outlined the employee’s limitations. Ignoring the evidence, Hartford’s doctor found that the employee could climb stairs, kneel, crouch, and reach overhead. Based on the opinions of the Hartford doctor, the insurer upheld its denial of the claim.
The judge considering the employee’s disability claim found that the insurer’s attacks on the employee’s Functional Capacity Evaluation “are thin at best.” The court explained that the FCE “reflects a thorough examination performed over a period of four to five hours using a variety of assessment tools.” The court noted how the consistency of the employee’s effort in completing the FCE was tested several times. The consistency of the employee’s reporting of symptoms over a twenty year period (since the motor vehicle collision in 1999) suggested the employee was not exaggerating his limitations.
Taking all the evidence into consideration, the court found that the employee had received long-term disability benefits for 18 years. The court found that the employee’s medical condition had not changed over this period. Further, the employee’s medical providers consistently found he was disabled. ERISA prohibits plan administrators like Hartford from arbitrarily refusing to give credit to a claimant’s reliable medical evidence, including the opinions of the claimant’s treating physicians. Taking all of this into consideration, the court concluded “the overwhelming medical evidence favors coverage.”
The decision is Curiale v. Hartford Life & Accident Ins. Co., No. 2:21-cv-54, 2022 WL 2063261 (D.Vt June 8, 2022).