Disability Case Won on Appeal Illustrates Importance of Medical Records

If you’re facing a denial of disability benefits based on unclear or conflicting definitions of work requirements, the following case outlines how consulting a Louisiana long-term disability lawyer can help you navigate the complexities of your claim.

Disability benefits depend on a “frequently” used word. At least that was the decision of the United States Fifth Circuit Court of Appeal in the case of Robert R. Burtch v. Hartford Life and Accident Insurance Company (Case No. 08-30513, filed March 19, 2009). The decision was reached and Mr. Burtch obtained his benefits because Mr. Burtch was required to walk “frequently” in his job, but the Hartford’s consulting doctors said he could walk “occasionally.”

The Court stated, “Frequent walking was an essential duty of Burtch’s employment and not a single doctor – including two hired by Hartford-reported that Burtch was capable of that degree of walking. Dr. Vasquez’s conclusion that he could do ‘occasional walking of short distances’ is not compatible with a requirement of frequent walking”

Mr. Burtch was diagnosed with emphysema in February 2004. Interestingly, Burtch was an insurance underwriter for AIG at the time of his diagnosis. He had long-term disability benefits through his employer which were provided under ERISA. Upon his doctor’s recommendation, Burtch stopped working and moved to Big Sky country – Montana.

In reviewing Burtch’s claim, Hartford sent AIG a form asking what the physical aspects of Burtch’s job were. AIG replied that Burtch was required to walk frequently, sit and use a keyboard continuously, and stand, stoop, kneel, crouch, and reach occasionally.

Burtch’s doctor opined that he was not capable of working full-time. He stated that Burtch could only walk short distances.

Hartford hired a doctor to perform an independent medical examination (IME) of Burtch. The IME doctor stated that Burtch was partially disabled, but could work part-time in a sedentary job in a room with air-conditioning.

Based on the IME’s opinion, Hartford denied the disability benefits. In denying the benefits, Hartford stated that Burtch was required to walk frequently. Nevertheless, Hartford stated that while Burtch may have symptoms of emphysema and some limitations, he was not prevented from performing the essential duties of his occupation, which was classified as sedentary.

Burtch appealed the decision through the appropriate administrative procedures. On the appeal, Hartford hired three additional doctors to review Burtch’s condition. Only one of the doctors commented on Burtch’s emphysema, however. This doctor noted that Burtch was required to walk frequently in his job.

In her final opinion, Hartford’s doctor stated that Burtch could work full time in a sedentary to light occupation provided it was limited to occasional walking of short distances.

Hartford then denied Burtch’s appeal based on this opinion. He then filed suit in federal court. The district court granted summary judgment to Hartford finding that Hartford did not abuse its discretion in denying disability benefits to Burtch. Burtch appealed to the Fifth Circuit.

While he advanced three arguments on appeal, the Fifth Circuit only found one compelling – that Hartford abused its discretion in determining Burtch was capable of performing his occupation. In deciding that Hartford abused its discretion, the Fifth Circuit stated that “there is no rational connection between the found facts (Burtch’s inability to walk frequently) and the evidence (no doctor finding that Burtch could walk more than occasionally).

Thus, the decision came down to one word – frequently. If any of Hartford’s doctors would have stated that Burtch could walk frequently, chances are Hartford’s denial would have been upheld. Instead, Hartford is left to pay the benefits.

Does your job require you do tasks frequently, occasionally, or constantly? Does your doctor know that? Has your doctor rendered an opinion that you cannot do that task as required?

As the Burtch opinion shows, one word can mean the difference between obtaining disability benefits or not. Have you checked your medical records to make sure they support what you told your doctor, or what your doctor told you? Get your medical records and work out the inconsistencies or holes before your disability benefits claim is denied.

The Burtch court discussed how his disability benefits plan defined disability. The Court then related that definition of disability to the evidence before it. Definitions of disability are often different from policy to policy. Make sure you know yours before filing for disability benefits.