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Analyzing Facts in an ERISA Claim

Recent Eighth Circuit decisions underscore the importance of specific facts in ERISA benefits claims. The Eighth Circuit utilizes mainstream, conventional standards to evaluate ERISA claims, but its decisions can be very different from case to case based on its reading of the facts. In one case the court held that since the insurance company's reviewing doctors' opinions were factually inaccurate (one failed to address the evidence of debilitating pain, the other neglected to mention significant evidence tending to support the claim) the insurance company abused its discretion by terminating benefits and ordered the claim remanded to the insurance company to fully and fairly consider the claim. In another case, however, the court noted that errors in one of the reviewing doctor's reports were irrelevant, given the other evidence and the considerable discretion which the insurance company had to decide the case.

In another case the Eighth Circuit reversed a district court award of benefits to a claimant, rejecting to the district court judge's conclusion that a functional capacities examination (FCE) had limited value because the claimant's symptoms were variable, holding that the FCE provided "critical evidence" regarding how the claimant's medical conditions affected an ability to work. The court also ruled that the district court improperly rejected the medical opinions of the insurance company doctors because those opinions were based on the FCE, reasoning that the actual reports relied upon the entire medical records, and that the FCE was objective medical evidence so it was appropriate to base conclusions upon it. The Eighth Circuit also held that the district court improperly determined that a two-day video surveillance did not support the insurance company's decision to deny long-term disability benefits, reasoning that evidence of the claimant pumping gas and carrying boxes tended to contradict his claim of disability. The video evidence need not establish conclusively that a claimant can work full time, but rather provided another form of objective evidence upon which an ERISA plan administrator made a claim determination. The court also held the district court improperly rejected findings of the insurance company's labor market survey, reasoning that transferable skills and labor market studies can constitute substantial evidence supporting a denial of benefits, and the fact the insurance company revised its labor market survey and eliminated a position that the claimant was unable to perform "suggested a reasonable review of the claim".

Eighth Circuit Decision on "Own Occupation" Requirements

In another Eighth Circuit case, the claimant was injured on the job and was, therefore, unable to successfully meet the requirements of his fitness for duty evaluation. He was then terminated from his position. The insurance company evaluated the claimant's own occupation with reference to the national economy, as specified in the policy, and determined that the claimant's actual job duties included some physical demands but those physical demands were not common in the national economy. That is, even though he couldn't do his own job as it actually existed, he could do his "own job" as defined in the policy, which was the job as it commonly existed in the national economy, and therefore he wasn't entitled to benefits.

The claimant appealed, submitting a report by a vocational consultant to explain that the insurance company's evaluation was incorrect and invalid. The insurance company affirmed its previous denial of benefits and the matter proceeded to litigation. The Eighth Circuit affirmed the denial of benefits, reasoning that the policy provided the explicit definition of own occupation by explaining that it is not limited to the individual claimant's actual specific job duties but instead was based on how similar jobs are generally performed in the national economy. Therefore, it was proper to disregard the actual duties the claimant performed and instead focus on the duties generally required by employers in the national economy. Even though it was undisputed that the claimant could not perform his actual job, the court found that he was not entitled to benefits under the policy because it did not insure capacity to perform his actual job, but instead insured capacity to perform a generic job in the national economy.

Areas We Serve in the Eighth Circuit

ERISA Law Center serves the Eighth Circuit by representing claimants in the following states and cities: Arkansas: Little Rock, Fort Smith, Fayetteville, Springdale, Jonesboro, North Little Rock and Conway; Iowa: Des Moines, Cedar Rapids, Davenport, Sioux City, Waterloo, Iowa City, Council Bluffs, Ames and Dubuque; Minnesota: Minneapolis, St. Paul, Rochester, Duluth, Bloomington Brooklyn Park, Plymouth, St. Cloud and Eagan; Missouri: Kansas City, St. Louis, Springfield, Independence, Columbia, Lee's Summit, O'Fallon, St. Joseph and St. Charles; Nebraska: Omaha, Lincoln, Bellevue, Grand Island, Kearney and Hastings; North Dakota: Fargo, Grand Forks, Bismarck, Minot and West Fargo; and South Dakota: Sioux Falls, Rapid City, Aberdeen, Brookings and Watertown.

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