When the Body Breaks but the Policy Doesn’t Listen

Welcome to Season 6, Episode 22 of Winning Isn't Easy. In this episode, we'll dive into When the Body Breaks but the Policy Doesn’t Listen.

Disability insurance claims are often presented as questions of medical evidence, but the outcome frequently depends on something else entirely: how a person's limitations are defined, classified, and translated into policy language. The gap between experience and contractual definitions can become especially significant when insurers evaluate complex occupations, subjective symptoms, or functional impairments that do not fit neatly into standardized vocational categories. In this episode, attorney Nancy Cavey examines three disability cases that illustrate how these disputes arise and why occupational definitions often play a central role in claim decisions. She discusses the challenges faced by a river pilot with long COVID symptoms, the importance of "own occupation" language in disability policies, and the difficulties of assessing chronic pain and medication-related cognitive impairments within the framework of vocational analysis. Together, these issues demonstrate that disability claims are rarely determined by medical diagnoses alone. Instead, they reveal how medical evidence, occupational duties, vocational classifications, and legal standards intersect to shape disability determinations, and why understanding that process is critical when pursuing Long-Term Disability benefits.

In this episode, we'll cover the following topics:

One - Rolling, Rolling Down the River - How the River Pilot With Long COVID Lost His Unum ERISA Disability Claim

Two - When Definitions Decide Disability - Why “Own Occupation” Is Often the Real Battleground

Three - Don’t Let a Disability Carrier or Plan Ignore How Long-Term Opioid Use and Side Effects Can Prevent You From Performing Your Own Occupation

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Navigating Your Social Security Disability Claim. Give it a listen: https://wiessdpodcast.buzzsprout.com/


Resources Mentioned in This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Transcript

Nancy Cavey [00:00:15 - 00:01:22]

What happens when your body breaks, be it an accident or a chronic medical condition, or a condition that's just gotten to the point where you have to stop work and apply for your disability benefits. In disability insurance, the answer to getting your disability benefits often has less to do with medicine and more to do with definitions, classifications and discretion. And across the stories I'm going to be telling you in this episode, a familiar pattern is going to show up. Real human limitations that are being translated into technical categories and policy terms that will decide or determine whether someone is considered disabled and get their disability benefits. I'm Nancy Cavey, national ERISA disability insurance attorney, and I want to welcome you to this episode of Winning Isn't Easy. Before we get started, I've got to give you a legal disclaimer. This podcast isn't legal advice. But now that I've said that, nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that disability carriers are, plans play, and what you need to know to get the disability benefits you deserve.

Nancy Cavey [00:01:22 - 00:02:21]

So off we go. Now this episode is going to follow three interconnected threads that reveal how disability determinations actually get made in the ERISA disability world. I'm going to tell you the story of a river pilot whose long Covid symptoms collided with a national economy job description that flattened the reality of life on the water to something that's really unrecognizable. Then I'm going to step back from a single case and talk about the broader battleground. And that's how own occupation language in a policy quite, you know, often will determine whether you're entitled to your benefits. And that language can outweigh medical evidence. Finally, we're going to turn to a case where chronic pain and opioid side effects raise a different but related questions. Whether cognitive and functional limitations are put partly accounted for when insurers will reduce complex jobs to simplified vocational labels.

Nancy Cavey [00:02:21 - 00:03:25]

So taken together, these three stories will show how disability claims are just rarely medical disputes. They translate into exercises from lived experiences, if you will, to medical records, to vocational categories and finally to legal standards. At every step of a disability claim we know and you will learn that at every step something can be emphasized, minimized, or lost entirely. And that gap between how a person experiences their limitations and how a policy will define their occupation often becomes the place where outcomes are decided. Let's dive in. Number one, I'm going to talk about rolling, rolling, rolling down the river. How a river pilot with long Covid lost his Una Marissa Disability Claim 2 When definitions decide Disability why an Own Occupation Definition of disability is often the real battleground. And number three, don't let a disability carrier plan ignore how long term opioid use and side effects can prevent you from performing your own occupation.

Nancy Cavey [00:03:25 - 00:03:30]

Before we get started, let's take a quick break before we dive into this episode.

Speaker B [00:03:31 - 00:03:49]

Have you been robbed of your peace of mind by your disability insurance carrier? You owe it to yourself to get a copy of Robbed of your peace of Mind, which provides you with everything you need to know about the long term disability claims process. Request your free copy of the book@kvlaw.com today.

Nancy Cavey [00:04:06 - 00:05:12]

Welcome back to Winning Isn't Easy. Rolling, rolling, rolling down the river how one river pilot with long covet Lost his Una Marissa Disability Claim how many of you have heard that song Proud Mary, written by John Fogarty and sung by Ike and Tina Turner? The lyrics go something like this Big wheel keep on turning Proud Mary keep on burning Rolling, rolling, rolling on the river. Every time I hear that song, I think of Mark Twain's stories about the Mississippi river pilots and the difficult job they had navigating down the mighty Mississippi. Those lyrics in Mark Twain's story came to mind when I read the recent case of Hans versus Unum Life. It's a case out of Pennsylvania, so let me tell you the misadventure that Mr. Hans had with Unum. Now, Ryan Hans was a river pilot who navigated commercial vessels on the Delaware river and Bay and he was covered under an ERISA disability plan offered by the Pilots association for the Bay and River Delaware. The plan was unfortunately insured and administered by Unum, who was given the discretion to make a benefit determination.

Nancy Cavey [00:05:12 - 00:06:02]

Now, while the Pilots association was probably well intended, having a plan insured and administered by Unum was a crucial mistake. Unum is very, very, very, very happy to collect premiums and very reluctant to pay benefits. Now, Mr. Hans began experiencing long Covid symptoms and was seen by a multitude of health providers including a Covid specialist, a cardiologist and a primary care physician. He had a rapid heart rate, left auxiliary pain, and even had neurological symptoms. He did not have significant improvement. Notwithstanding his treatment, he applied for his long term benefits on the basis that he was unable to safely pilot vessels because of his physical and mental limitations. Now that sounds pretty obvious, doesn't it? So let me tell you about the what was your occupation? Game that Unum played rather, in an effort to defeat this claim.

Nancy Cavey [00:06:03 - 00:07:00]

One of the most important terms in a disability policy or plan is the definition of occupation. Now normally what you'll see is that there's no uniform definition. And it can range from how your occupation is performed for your specific employer, how your occupation is performed in the local economy, how how your occupation is performed in the national economy, or even how your occupation is performed pursuant to the outdated Dictionary of Occupational Titles. And in this particular plan, the definition of occupation was based on how the occupation was performed in the national economy, not in the Delaware Bay. So Unum concluded that his occupation in the national economy was a pilot ship with physical demands classified as light. Now, I live in the Tampa Bay area and I see ship pilots all the time. And I've seen film of them having to climb the ladder to get onto the ship. From the pilot ship to the ship that they are working with.

Nancy Cavey [00:07:00 - 00:07:47]

I have seen them video doing all sorts of physical activity that is certainly not light and clearly very dangerous. But Unum's medical reviewers concluded that the evidence didn't support restrictions or limitations that precluded him from full time employment as a ship pilot. So on appeal he said, look, my job is really a composite. I'm a ship pilot, but I'm also a deckhand. And I get that, having seen what it is they do. But the court disagreed. They found that Unum's determination of the material and substantial duties of his regular occupation was not arbitrary and capricious. And in this instance, the definition of occupation and the fact that the plan gave Unum discretion to interpret the terms of the policy resulted in the judge finding in favor of Unum.

Nancy Cavey [00:07:47 - 00:09:06]

Hopefully the union rather has learned its lesson and found a new insurer and an administrator for its policy and plan. But also have clarified that the definition of occupation is how it's performed for this particular organization and this particular body of water. Unfortunately for Ryan Hans, he's no longer rolling on the river. Let's take a break. Welcome back to Winning isn't Easy when definitions decide Disability why own occupation is often the real battleground in a disability claim. Now, in long term disability cases, the most important fight is not about whether somebody's sick, injured, or really ever really disabled. And I know that sounds weird, it's about what their occupation is legally defined to be. Now, under ERISA governed plans, the term own occupation can be interpreted in very different ways depending on the terms of the policy.

Nancy Cavey [00:09:07 - 00:10:06]

Some plans will define it as it's performed for the specific employer, which I think is the best definition. Others will define it how it's performed in the national economy. And others will use a national economy definition that is also based on what's called the Dictionary of Occupational Titles. Now the Dictionary of Occupational Titles hasn't been updated in probably 50 years. And it in my view, doesn't really reflect how an occupation is performed today, much less in the national economy. I think that's one of the worst definitions that you can have. But unfortunately what you're going to see is that many disability policies or plans use this type of definition, either national economy or the dot. What happens is that the claimants real world occupational duties are are stripped down into a vocational category that's standardized and physical demands are generalized.

Nancy Cavey [00:10:06 - 00:11:08]

Cognitive complexity can be reduced to baseline activity and unique aspects of the occupation. Irregular hours, high stakes decision making, travel, multitasking under pressure. They are generally not fully reflected in the vocational profile that is used to evaluate the claim. And in my view, that's where many disputes begin and many claims die. Now, you might describe your occupation as highly demanding in practice, but the disability carrier plan is going to have a vocational review of your occupational duties. And they may classify it as sedentary or light, and they may classify the cognitive requirements as being minimal. And once that classification is made, often incorrectly, then the medical question becomes narrower, not whether you can perform their actual work, but whether you can perform the classified occupational version of the occupation. Now medical evidence then gets filtered through this framework.

Nancy Cavey [00:11:08 - 00:12:28]

Treating physicians may describe fatigue, pain, cognitive slowing, medication side effects that can limit sustained function. Often this is why carrier plans reviewing physicians working from records alone can interpret the same information differently and conclude that the restrictions your doctor assigned are really not supported at a level that would prevent full time work. Here's the problem. Courts reviewing these decisions under ERISA are generally not deciding the disability issue. What they're deciding is and asking is, is the plan or policy decision reasonable based on the administrative record and the discretion granted by the policy of the plan. This that means under the discretionary standard of review or arbitrary and capricious standard of review, that even when there's conflicting medical evidence, the plan's interpretation can stand if it's supported by substantial evidence. And as a result, disability cases often turn less on whether the symptoms exist and more on how your symptoms translate into functional limitations and then refined, if you will, or filtered through a defined occupational label. In that gap between your lived experience based on your occupational duties and the vocational classification is where the outcome of many claims are decided.

Nancy Cavey [00:12:28 - 00:13:54]

And if your claim has been denied or benefits terminated, you're going to have 180 days in which to file an appeal. What you need to do, in my view obviously is to hire an experienced ERISA disability attorney because you want to get a copy of that claims file. You want to understand how the disability carrier plan interpreted the definition of occupation, own occupation. You want to understand how their vocational evaluator took a job description and created an occupational classification. You want to understand what that definition of occupation is and whether that vocational analysis was flawed as it is many times. You also want to look at that vocational analysis to see whether all of the actual functional, physical and cognitive restrictions and limitations were considered. And then of course, you want to have your own vocational evaluator, through the assistance of your attorney, create a report that will rebut the definition that they're applying, how they apply the definition, how they did the analysis of your occupation, and rebut the conclusion that the carrier or plan is made that you could do your own occupation. And you can see that takes a lot of teamwork and understanding of not only medical and vocational issues, but the legal standard and the legal case law interpreting that particular standard in the circuit in which you live.

Nancy Cavey [00:13:54 - 00:13:56]

Got it. Let's take a break.

Speaker B [00:13:57 - 00:14:31]

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Nancy Cavey [00:14:46 - 00:16:01]

Welcome back to Winning isn't Easy. Don't let a disability carrier or plan ignore long term opioid use and the side effects that can prevent you from performing your own occupation. In many instances, I find that disability carriers either ignore or minimize the long term use of opioids for pain relief. For example, in cases where people have severe low back pain or leg pain, we know that they're going to be prescribed opioid medication to reduce their pain. Other medications like muscle relaxers to reduce spasmodic, other medication like gabapentin to reduce the transmission of the pain impulses and that opioid use, either individually or in combination can make it impossible to concentrate in a high demand information technology occupation or quite frankly, any occupation. Let me tell you the story of Jesse Bruton found in Bruton versus American United Life Insurance Company. It's out of the sixth Circuit. He was employed at by Resource Management which had contracted with American United Life to provide both short and long term disability benefits AUL in turn contracted to Disability Mrs.

Nancy Cavey [00:16:02 - 00:17:06]

To manage the disability claims by having their physicians and vocational providers review the claim, make a decision to pay the claim or deny it, and basically manage the claim and interpret the policy. I will tell you that DRMS is notorious in the ERISA world for its claims denials and terminations and when we see them involved we know that games are afoot. So let me tell you what DRMS did in this case in determining Bruton's rather occupational duties. His occupation was a technology development manager and to win his case he had to establish that he couldn't do the material and substantial duties of his occupation. Now he his occupation had both technical and client facing elements including business development. He managed the technical project team. He interacted with a variety of resources within the organization including application architects, designers, information architects, and client service managers. Obviously, the goal here was to help ensure the successful delivery of the project and he traveled 20% of the time.

Nancy Cavey [00:17:06 - 00:18:25]

He had specific pro significant problems with spinal stenosis. He had undergone multiple unsuccessful treatments with different medication trials and when his pain progressed and he got to the point where he had to stop work and apply for his benefits, he continued with his treatment, but he was still bedridden because of his pain. Now it was noted that his opioid medication was prescribed and that it was affecting his memory and processing which would impact his productivity at work. Disability rms, the claims management company had their vocational rehabilitation counselor review his occupational description and guess what? They concluded his occupation was sedentary in terms of physical demands and denied his claim even though 20% of the time required travel. So he appealed and during this appeal process he was hospitalized for opioid withdrawal. Nonetheless, his treating physician continued to prescribe oxycodone with a recommendation that he also see a psychiatrist. Now he was seen by medical providers, multiple medical providers to discuss his treatment. He was seen by a pain management specialist who recommended surgery or the implantation of a spinal cord stimulator in view of his conservative failure of treatment for physical therapy, medication and even injection treatment.

Nancy Cavey [00:18:25 - 00:19:55]

Now, in the wonderful world of erisa, the courts are not allowed to give more weight to the opinion of a treating physician over that of a non treating physician. However, a disability carrier plan can't arbitrarily refuse to give credit to reliable evidence, including the opinions of treating physicians. The 7th Circuit has case law that basically says that a claimant's documented limitations can't simply be dismissed because they're subjective exaggerations, particularly where in this case they have individuals who are purporting to make credibility determinations and never meet the claimant. So courts will criticize a peer review provider who is making subjective determinations of a person's credibility just based on medical records without having the opportunity to meet the claimant. Now, in this particular case, the court noted that Bruton's debilitating back pain and the side effects of the opiate medication were observed by his treating physicians and objectively documented by his treating physicians. And he had undergone a host of pain treatments, as I've said, epidural spinal ablations, transcutaneous electrical nerve stimulation. He had taken multiple different types of medications. And in the court's opinion, it was really highly unlikely that he did all of that just to strengthen the credibility of his pain complaints or increase the chances of getting his disability benefits and in doing so fooled all of his physicians.

Nancy Cavey [00:19:56 - 00:21:00]

This is a common argument, by the way, that we see that unum also makes. But how did DRMs improperly ignore the intellectual requirements of Bruton's occupation in addition to the physical requirements? Well, the court said, look, even if he could do the sedentary aspects of his occupation, the RMS was wrong because they ignored the intellectual aspects of his occupation. They noted that his occupation was highly skilled. It involved directing, controlling, planning the activities of others, dealing with people and making judgments. Their own ve said that. Now, Burton's primary treating provider concluded that the opioid medications that he took were both required around the clock to stabilize and assist in the management of his pain. The doctors noted that it had the unfortunate effect of impacting his memory and processing speed and therefore his ability to be productive at work. It was partially on that basis that his doctor concluded that returning to work, even on a sedentary basis really wasn't feasible.

Nancy Cavey [00:21:00 - 00:21:55]

Now of course, on the other hand, DRMS doctors reasoned that the cognitive effects of opiates are short lived, generally less than two weeks as patients adjust to them, and that only long term side effects of the opiates were constipation. And I'm not going to say anything about that which would not preclude full time sedentary work. So the court said, nah, we don't really buy that. The records document the cognitive effects of his medication. And look, their own ve acknowledged the nature of his occupational duties which required extreme cognitive skills that were exercised in very stressful situations. As a result, the court said, look, you didn't even bother to have an IME and you relied on your paper reviewer. Too bad, so sad. And as a result, he was awarded his benefits.

Nancy Cavey [00:21:55 - 00:23:26]

So what are the lessons learned in a case like this? Number one, don't let a carrier or plan forget or minimize the cognitive requirements of an occupation. Number two, make sure that your medical records are discussing not only the physical restrictions and limitations and cognitive restrictions, limitations that you have that would prevent you or impair you from doing your own occupation, but that your medical records are also documenting the nature of your medical treatment, your response to that treatment, the side effects of medication, and how that unsuccessful medical treatment, how those side effects would impact your ability to do the material and substantial duties of your occupation. You just can't let it rely on chance that that is in your medical records. Your records should be addressing those. And of course, you should have a vocational evaluator's opinion that ties this all up, that addresses your inability to do the physical aspects of your duties that also impact your ability to do the material and substantial cognitive aspects of your duty, but that we're also dealing with a combination of the physical aspects of your problems with the side effects of medication. It takes a teamwork, as you can see, to make sure that you get your disability benefits and to successfully overcome a wrongful denial or termination. Now that wraps up today's episode of Winning Isn't Easy. If you found this episode helpful, please take a moment to like our page, leave a review, share share it with your family or friends.

Nancy Cavey [00:23:26 - 00:23:36]

And of course, please subscribe to this podcast. Please join us next week for another insightful discussion at Winning Isn't Easy. Thanks for listening.