The Plaintiff in Ricky D. Hayes v. Dearborn National Life Insurance Company worked for F.A. Richards & Associates Incorporated as an adjuster for approximately 11 years when he became unable to perform the duties of his own occupation. He was awarded long-term disability benefits based on his diagnoses of depression, anxiety, and a sleep disorder.

Dearborn informed Plaintiff on several occasions, in writing, that since his disabling conditions were mental disorders, he was only eligible for 24 months of benefits. They gave him the opportunity to present evidence of a physical disability.

Most reports from treating and reviewing physicians stated Plaintiff had no physical disabling condition. However, he received Social Security disability benefits for a physical condition, so Dearborn gave him the opportunity to submit evidence of a disabling condition. He did not do so. He refused to take a Functional Capacity Exam (FCE) at Dearborn’s expense.

Finally, one reviewing physician found physical disabling conditions, but according to Dearborn, there were still seven occupations that Plaintiff could perform under the “any occupation” terms of the policy. It denied him long-term disability benefits on this basis. He filed an ERISA lawsuit, but the Louisiana Federal district court agreed with Dearborn, so he filed this appeal to the U.S. Court of Appeals for the Fifth Circuit.

Dearborn’s Evaluation was not Procedurally Unreasonable

Plaintiff argued that Dearborn’s evaluation was procedurally unreasonable. The Court ruled for Dearborn on every issue raised.

  1. Dearborn did not ignore Hayes SS benefits award and, in fact, based on the award, it gave Plaintiff extra time to present evidence of a physical disability, which he failed to do.
  2. Dearborn’s inconsistent reasons for denial of benefits actually worked in Plaintiff’s favor by allowing him to provide further evidence of a physical disability. When Dearborn finally accepted proof of his physical disability, it was not error for it to ultimately conclude that even with his physical limitations, there were seven other occupations for which he could perform the job duties.
  3. Dearborn did not “cherry-pick” the record to only find evidence to support its denial. Even if substantial evidence supported a finding that Hayes was entitled to benefits, it did not matter. The Court ruled that so long as “substantial evidence supports Dearborn National’s decision, it must be upheld.”

Substantial Evidence Supports Dearborn’s Denial of Long-Term Disability Benefits

According to the terms of the disability insurance policy, even if Hayes was physically disabled, he was only entitled “to a continuation of benefits if those physical problems rendered him incapable of performing any gainful occupation.” Since an independent rehabilitation specialist found seven different jobs Hayes could perform “given his education, training, and experience…” The appellate court concluded that “there was substantial evidence to support the denial of benefits.”

This case was not handled by our office, but it may be helpful to claimant’s who need to prove they are disabled from performing the job duties of any gainful employment for which they are qualified. If you have any questions about any aspect of your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.