Opinion ID: 2994487
Heading Depth: 2
Heading Rank: 2

Heading: The Disability Claim

Text: The question remains whether Paul Revere correctly denied Ms. Postma’s application for disability benefits. The district court, employing the more deferential arbitrary and capricious standard of review, refused to uphold Paul Revere’s decision to deny Ms. Postma disability benefits. Although we disagree with the district court’s determination on the appropriate standard of review, we uphold the grant of summary judgment for Ms. Postma because it is clear that, when the appropriate de novo standard is employed, she has presented sufficient proof of her disability and, therefore, that she is entitled to disability benefits from Paul Revere.
Paul Revere’s LTD policy states that, to be totally disabled, the claimant must show: 1. because of injury or sickness, you cannot perform the important duties of your own occupation;
this requirement if we receive written proof acceptable to us that further Doctor’s Care would be of no benefit to you; and
R.6, Ex.A at 13. Ms. Postma clearly met the requirements for total disability after she injured her back: She was unable to work at all and therefore unable to perform the important duties of her occupation. Once Dr. Gutierrez released her to return to work, however, the provision for total disability no longer applied. The existence of the work release indicated that, as of September 9, 1992, Ms. Postma could perform at least some, although not all, of the duties of her occupation. The applicable provision for Ms. Postma then became the clause for residual disability. The policy explains the requirements for residual disability as follows: Residually disabled or residual disability means, after a continuous period of disability which lasts at least as long as your elimination period[/2]: 1. (A) you are prevented, by the same injury or sickness which caused your disability, from performing one or more of the important duties of your own occupation; or (B) you work at your own or some other occupation on less than a full-time basis; and 2. you are receiving Doctor’s Care. We will waive this requirement if we receive written proof acceptable to us that further Doctor’s Care would be of no benefit to you; and 3. you do not earn more than 80% of your prior earnings. R.6, Ex.A at 14. Although Paul Revere admits that Ms. Postma was totally disabled until she received her work release, it claims that her work release demonstrates that she was no longer disabled./3 Ms. Postma did not meet the requirements for total disability after her work release, but the question remains whether she met the requirements for residual disability. As long as Ms. Postma was continuously disabled--either totally or residually--between her work release (September 9, 1992) and the date she reinjured her back (June 11, 1993), when she again could not work at all, she is entitled to disability benefits for the entire time following her initial back injury. Ms. Postma may satisfy the first element for residual disability by showing that she cannot perform one or more of the important duties of her occupation at CPG. As a consultant for CPG, Ms. Postma had traveled by car, train, and airplane to her clients’ businesses carrying boxes of supplies. She frequently had to lift materials weighing between 10 and 20 pounds and often had to lift materials weighing between 25 and 50 pounds. Her job duties also had required her to walk and to stand for significant periods of time. Some days, she reported, she needed to stand between 8 and 9 hours. The staffing manager at CPG, John Kinstler, also explained that, as part of her job responsibilities, Ms. Postma regularly had to lift objects that weighed more than 10 pounds, to drive for over 30 minutes, to kneel, to squat, and to bend. Dr. Gutierrez’s work release for Ms. Postma listed the activities that she could not perform, including: not lifting more than 10 pounds, not driving for more than 30 minutes, not twisting, not squatting, not bending, not kneeling, and not doing any other physical activity that could injure her back. Kinstler explained that these medical restrictions prevented Ms. Postma from performing her job responsibilities./4 Thus, due to her medical restrictions, we must conclude that Ms. Postma was unable to perform one or more of the important duties of her occupation at CPG even after her work release and even after she began working at the animal hospital. After Ms. Postma found employment at the animal hospital, she worked subject to Dr. Gutierrez’s medical restrictions. These medical restrictions again demonstrate that she was prevented by her back injury from performing one or more of the important duties of her occupation at CPG. Dr. Gutierrez’s attending physician statement further clarified that Ms. Postma was unable to perform her occupation at CPG from October 1991 (the date of her initial injury) through October 1993 (the date of his report after her reinjury). Therefore, Ms. Postma satisfies the first element of residual disability beginning on the date of her work release and continuing until she reinjured her back. The next element that Ms. Postma must satisfy is the requirement that she receive a doctor’s care. The policy defines doctor’s care as the regular and personal care of a Doctor which under prevailing medical standards, is appropriate for the condition causing the disability. R.6, Ex.A at 15. Dr. Gutierrez stated that he provided the appropriate doctor’s care for Ms. Postma’s back injury, and, because Paul Revere did not provide evidence to show that Dr. Gutierrez’s care did not meet prevailing medical standards, we hold that she was under a doctor’s care and that she satisfies this element for disability. Finally, Ms. Postma must have earned less than 80% of her original income at CPG. While she was seeking employment after she received her work release, Ms. Postma clearly made less than 80% of her prior income because she did not work at all. Also, after she began working at the animal hospital, the parties do not dispute that she received less than 80% of the income she received while employed as a consultant for CPG. Thus, she meets the final element of residual disability under the policy. Because Ms. Postma can satisfy the plan’s requirements for residual disability from the time of her work release on September 9, 1992, until her reinjury on June 11, 1993, and, because Paul Revere concedes that she can meet the elements of total disability from October 2, 1991, to September 9, 1992, and again after June 11, 1993, we hold that Ms. Postma should be awarded disability benefits.