Eight Circuit Court of Appeals Finds Merck Sales Representative Disabled from Occupation

The Eight Circuit Court of Appeals finds Merck sales representative disabled from his occupation, reversing and remanding the lower court’s decision in favor of Metropolitan Life Insurance Company’s (“MetLife”) denial of benefits.

Background

James Seitz was working as a Senior Professional Sales Representative for Merck & Co., Inc. (“Merck”) when he was diagnosed with spondylosis, degenerative disc disease, and depression. Seitz filed for long-term disability benefits through Merck’s disability plan, which was administered by MetLife. MetLife refused to approve the claim, alleging Sietz was not disabled for the entirety of the 26-week elimination period to render him eligible for long-term disability benefits.

Seitz suffered from back pain since 1983, but continued to work. In 2001, his treating physician wrote a letter stating that Seitz was unable to sit or stand for long periods of time due to upper back and neck pain resulting from spinal surgeries. Later that year, Seitz’s doctor again documented his patient’s restrictions and limitations, including being unable to sit, stand, walk, bend, and climb among other tasks for more than two hours per day. Seitz continued working until January 2002, as a result of exacerbation of his conditions after driving from Iowa to Illinois to attend a job training program. In May 2002, MetLife asked Seitz’s manager to complete a job description of his occupation. She noted a normal workday required him to stand for one to two hours, sit for five to six hours, and engage in extensive walking, bending, and other activities.

The Plan Language

The definition of totally disabled under Merck’s disability plan included:

Totally disabled means you are unable to perform all material aspects of your occupation during the Eligibility Period and during the first 24 consecutive months that benefits are paid under the Long–Term Disability Plan. After the first 24 consecutive months of disability, you must be unable to engage in any Gainful Employment for which you are or may become reasonably qualified by education, training or experience.

You must be under the regular care of a licensed doctor to be considered totally disabled. The doctor must also have appropriate expertise for your disability and you must follow the prescribed course of treatment.

Seitz’s Disability Claim

MetLife denied Seitz’s claim stating he was not disabled from his own occupation. Seitz submitted to additional diagnostic testing and appealed MetLife’s decision. Another doctor evaluated Seitz and determined that he could not perform the activities of his job. Seitz provided MetLife this doctor’s opinion as well as his Social Security Administration's approval of his disability benefits. MetLife then had Seitz submit to an independent medical examination (“IME”). The IME doctor agreed with Seitz’s physicians, and found he was unable to perform the duties of his occupation.

The Court’s Decision

Without a timely appeal decision, Seitz filed suit and MetLife denied the appeal the next day claiming that the medical records did not show he remained continuously disabled during the elimination period.The lower court found in MetLife’s favor and Seitz appealed. The appeals court reversed.

The Eight Circuit Court of Appeals rejected the district court’s statement that:

  • Seitz was not disabled because he could do some of the material aspects of his job; and
  • Seitz was not disabled because he could do all of the material aspects of his job, but to a limited degree.

The Court noted that it had previously held that when an individual’s own occupation to determine whether he or she is totally disabled, being able to perform some job duties -- like in Seitz’s case -- is not enough to deny disability benefits. The appeals court reversed and remanded the lower court’s decision, awarding disability benefits and prejudgment interest.

Help from an Attorney with Expertise in Disability Insurance

Disability insurance law is complicated. If your claim for disability benefits was denied or being delayed by an insurance company, it is important to get help from a lawyer with expertise in disability law.

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