Facts

Plaintiff Juree Kim was traveling in a taxicab on business, when she was struck by an SUV on the freeway, and sustained a herniated disc in her lower back. She submitted a disability benefits claim to her group long-term disability insurer, defendant Life Insurance Company of North America. Defendant denied her claim.

Plaintiff sued defendant for recovery of her policy benefits and alternatively sought a remand to the plan administrator to fairly review her claim. Since the policy was part of an employee welfare benefit plan, the lawsuit was governed by ERISA.

PLAINTIFF'S CONTENTIONS:
Plaintiff claimed that the injuries she sustained from her car accident prevented her from performing the material duties of her "regular occupation" as the Vice President of Retail and Fashion at a global, five-billion dollar publicly traded, logistics company. She was therefore disabled as defined by the policy. Her position required extensive domestic and international travel to promote the company's warehousing services, sitting in airplanes and in traffic for hours at a time, dragging luggage through airports and then, upon arriving, walking endlessly through gigantic, 900,000 square foot warehouses. Her debilitating back pain prevented her from sitting, standing or walking for extended periods and carrying moderately heavy items, all as documented by her treating physicians and each of which is required by her job.

Plaintiff alleged that defendant failed to consider the plaintiff's travel duties when evaluating whether she was disabled from performing her "regular occupation." It could not take a generic vice president position from the Department of Labor's Dictionary of Occupational Titles to determine her occupational duties when it does not include her actual job duties.

Alternatively, plaintiff could not perform even the dissimilar vice president occupation defendant advocated, mostly involving sitting at a desk all day, because her herniated disc prevented it. The medical consultant hired by defendant to review plaintiff's medical records was biased and arrived at the wrong conclusion, namely, that plaintiff could sit, stand and walk for eight hours of the workday, as long as she took breaks every 30 minutes. His opinion was flawed and lacked foundation because he never examined plaintiff and made wholly conclusory statements without analyzing the evidence or explaining why he disagreed with plaintiff's treating physicians, who arrived at the opposite conclusion after treating her for years based upon objective MRI films.

DEFENDANT'S CONTENTIONS:
Defendant claimed that plaintiff could perform a vice president desk job despite her accident because her exaggerated injuries have mostly healed. Defendant hired a board-certified neurologist to review plaintiff's medical records that determined that plaintiff could perform a "sedentary" occupation that involved mostly sitting, and that she could sit up to 8 hours per day at work by taking rest breaks every 30 minutes. Defendant did not have to take into account plaintiff's actual job duties requiring heavy travel when evaluating whether she is disabled within the meaning of the policy. The policy defined "disabled" as the inability "to perform . . . the material and substantial duties of . . . her regular occupation." It defined "regular occupation" as, "The occupation the Employee routinely performs at the time the Disability begins. In evaluating the Disability, the Insurance Company will consider the duties of the occupation as it is normally performed in the general labor market in the national economy." Based on the last sentence, defendant contended that plaintiff's actual travel job duties need not be considered because how a vice president occupation is normally performed nationally is the correct occupational standard, not plaintiff's specific job. The Dictionary of Occupational Titles stated a vice president has purely sedentary duties, does not travel, and sits most of the day. Therefore, while plaintiff may not be able to perform the material duties of her own job, admittedly including travel that was irrelevant to whether she is disabled under the policy.

Result

The court following a bench trial entered judgment in favor of plaintiff and against defendant. The court reversed and overturned defendant's denial of plaintiff's claim for long-term disability benefits and remanded the claim back to defendant for additional review in light of the proper occupational standard and additional evidence submitted by plaintiff at trial. The court concluded defendant had to consider plaintiff's travel duties as part of "her regular occupation" when deciding whether she is disabled within the meaning of the policy. It also concluded that defendant failed to conduct a full and fair review of her disability claim. The court ruled that the opinion of defendant's medical consultant was confusing, unpersuasive, conclusory, "hardly amounts to an analysis of [plaintiff's] claim at all and the court will not afford it any weight." Following defendant's administrative review of the claim ordered by the court, defendant determined plaintiff was disabled, paid her all past due benefits plus prejudgment interest, and is continuing to pay her ongoing disability benefits.

Other Information

The court granted plaintiff's motion for attorney fees and costs in part, finding plaintiff was entitled to attorney fees in the amount of $263,943. FILING DATE: March 16, 2015.