Opinion ID: 2966248
Heading Depth: 2
Heading Rank: 1

Heading: Cook's Illness and Her Eligibility for Benefits

Text: Kathleen Cook had been employed with Lockheed Sanders, Inc. (Sanders) since 1983. Sanders provides its employees with short- and long-term disability benefits under policies provided and administered by Liberty. Cook filed a claim for short-term disability benefits in February 1995, having been out of work since November 1994 with symptoms of Chronic Fatigue Syndrome (CFS), as diagnosed by her treating physician, Dr. W. Stewart Blackwood. (1) Dr. Blackwood's notes from that period report that Cook was complaining of fatigue, loss of appetite, a constant cough, and depression. Diagnostic tests revealed an elevated level of the Epstein Barr virus. As recorded in the Physician's Statement of Disability accompanying Cook's claim, Dr. Blackwood stated that he was seeing Cook on a monthly basis, that she was totally disabled from both her regular occupation and any other occupation, and that he did not know when she would be able to return to work. After her short-term benefits expired in April 1995, Cook filed another claim with Liberty for benefits under the long-term disability policy. At this point, she was still unable to return to work. Attached to her claim form was a note from Dr. Blackwood. He stated that her diagnosis continued to be CFS; her symptoms were severe fatigue, cough, nasal congestion, malaise, a[s]thma, sleep disturbance and depression; and her treatment plan included homeopathic medications, vitamin supplements, acupuncture, continued counseling and Zoloft. He classified her physical capacity as severe[ly] limited: incapable of minimum activity. Liberty approved Cook's claim on May 8, 1995. Under the terms of Liberty's long-term disability benefits policy, a claimant must be disabled and require the regular attendance of a physician in order to be eligible for benefits. Disabled is defined by the policy: 1. Disability or Disabled means during the Elimination Period and the next 24 months of Disability the Covered Person is unable to perform all of the material and substantial duties of his occupation on an Active Employment basis because of an Injury or Sickness; and 2. After 24 months of benefits have been paid, the Covered Person is unable to perform, with reasonable continuity, all of the material and substantial duties of his own or any other occupation for which he is or becomes reasonably fitted by training, education, experience, age and physical and mental capacity. These definitions of disability are referred to throughout this litigation as the own occupation (first 24 months) and any occupation (after 24 months has expired) definitions of disability. Liberty paid Cook long-term disability benefits from April 1995 to April 1997 because it found she met the own occupation definition of disabled. In March 1997, as her first 24 months of benefits came to an end, Liberty informed Cook that it would be reviewing the status of her disability to determine whether she met the any occupation definition of disabled. In April of that year, Dr. Blackwood returned a Physical Capacities Form to Liberty in which he reported that Cook was still suffering from CFS, but that her only limitations were to avoid getting over-tired or working in excess of 40 hours a week. Around the same time, Dr. Blackwood issued Cook a medical certificate (2) saying she could return to work on April 14, 1997, on a trial basis, so long as she was working no more than 40 hours per week and could take regular breaks. (3) The administrative record indicates that Cook presented this certificate to Sanders, which forwarded it to Liberty. Cook returned to work on that day and Liberty temporarily suspended her benefits. Her return to work was brief. On May 5, 1997, Dr. Blackwood pulled Cook out of work again after she had a severe reaction to an infected tooth. Her medical records indicate that she complained about muscle aches and difficulty with sleeping. Also, she told Dr. Blackwood that she was feeling stress because she could not complete the work Sanders had assigned her without working more than 40 hours per week. The combination of her infection and the stress she experienced during her return to work led Dr. Blackwood to conclude that she had suffered a recurrence of CFS. His chart notes from that day also reflect his decision to put her back out of work on an indefinite basis, noting that the note we gave her previously was for a trial return to work. On May 9, 1997, Liberty renewed Cook's disability benefits and updated her status to approved under the any occupation definition of disabled. Between May 1997 and July 1998, Cook remained out of work and regularly saw Dr. Blackwood. In December 1997 and August 1998, she and Dr. Blackwood responded to Liberty's requests for updated medical information, and Liberty continued to pay her disability benefits. The most recent set of Cook's medical records included in the administrative record reveals that in June 1998, Cook reported that her fatigue had recently worsened and she was suffering generalized aches and pains, but that she was not experiencing any stress. Dr. Blackwood renewed his diagnoses of asthma, CFS, and fibromyalgia. (4) During this time, Liberty learned that Cook had been working part-time with a real estate agency. When asked about it, Cook told the analyst handling her claim that she had worked two Sundays showing houses for the agency. Liberty wrote to the agency asking for Cook's work and earnings history. They responded that her duties included occasional open houses, showings, [and] customer phone calls, and that she had earned $175.02 between April and July of 1997. Liberty informed Cook that her long-term disability benefits would be offset by the amount of money she was earning from her part-time job, but if she earned less than 20 percent of her pre-disability salary, there would be no offset.