District Court Finds ERISA Plaintiff Did Not Satisfy Burden of Demonstrating Total Disability from Sedentary Occupation

In Kris B. v. Life Insurance Company of North America, No. 3:22-cv-03717-RFL (N.D. Cal. Sept. 12, 2024), on cross-motions for judgment pursuant to FRCP Rule 52, California Northern District Rita F. Lin entered judgment in favor of LINA finding that Plaintiff failed to demonstrate by a preponderance of the evidence that she was totally disabled due to her medical conditions.

Plaintiff has a lengthy history of back and knee problems, with spine surgery dating back to when she was 16 years old. However, she had previously been able to work with her diagnosed conditions of chronic low back pain, lumbar radiculopathy, right knee pain and osteoarthritis. On December 14, 2020, Plaintiff was employed as a junior staff accountant at Blue Mountain Construction Services, a sedentary occupation, when she stopped working and submitted a claim for long-term disability benefits due to a flare up in her back pain. Plaintiff provided medical records documenting conservative care, including diagnostics, medications, physical therapy, various injections, and participation in a chronic pain management program. Plaintiff also provided a physician work status report with restrictions and limitations of standing and sitting no more than 30 cumulative minutes per hour each; lifting, carrying, pushing, and pulling no more than five pounds; and no driving.

LINA denied Plaintiff’s LTD claim after an independent medical review by PM&R physician, Dr. Raisa Bakshiyev, found that Plaintiff was able to work full time with limitations including sitting and standing for 30 minutes at a time and no heavy lifting beyond five pounds. Plaintiff appealed, citing the limitations outlined in the work status report and submitting additional medical records documenting ongoing treatment. Plaintiff also submitted an earlier work status report from a second treating provider placing Plaintiff on modified activity at work and at home and stating the following restrictions and limitations: standing, walking, and bending at the waist up occasionally (up to 25% of shift); no limitations on torso/spine twist, climbing ladders, or using scaffolds/work at height; lifting, carrying, pushing, and pulling no more than 10 pounds; and avoiding travel/commute. Plaintiff was “[o]k to work from home if able.” LINA arranged for another independent medical review by Occupational Medicine Dr. Frank Polanco, who found the medical evidence supported that Plaintiff was limited in her ability to perform frequent, prolonged, and strenuous physical/work activities, but concluded that the findings did not support that she was incapable of full-time, modified, work activities with appropriate limitations, given that she retained a functional gait, mobility, strength, and had no focal neurological deficits. He offered the following limitations: (1) occasional walking and standing up to 20 minutes at a time, for a total of 2.7 hours combined; (2) occasional crawling, kneeling, stooping, bending, and climbing; (3) occasional lifting and carrying up to 20 pounds, and pushing and pulling up to 35 pounds; (4) constant sitting with the ability to alter position as necessary; and (5) frequent reaching at all planes, gripping, grasping, and fingering. Dr. Polanco did not impose a driving limitation.

In response to Dr. Polanco’s review, Plaintiff submitted a report by Irene Mendelsohn, a rehabilitation counselor, who opined that Plaintiff could not perform her duties as an accountant based on the limitations of lifting no more than five pounds, sitting no more than four hours a day/30 cumulative minutes an hour, as well as issues with fatigue, concentration, memory recall, and absenteeism. LINA upheld its decision on appeal after Dr. Polanco reviewed Ms. Mendelsohn’s report and concluded that it did not alter his opinion. The instant lawsuit ensued.

On de novo review, the Court addressed each contested functional limitation. First, it noted that Plaintiff’s treating physician did not explain why he imposed the cumulative 30 minutes per hour sitting limitation, particularly given that he told Plaintiff that he was “not a disability doctor” and did “not have the expertise to make disability determinations.” And Plaintiff’s other treating physician who placed her on modified activity at work and at home, did not impose a sitting limitation. The Court reasoned that a sitting limitation does not necessarily preclude full-time sedentary work as an accountant, and the evidence in the record supported the conclusion that Plaintiff could perform her job by alternating between sitting and standing, as outlined by LINA’s reviewing physicians and vocational analysis. The Court pointed out that even one of Plaintiff’s treating providers recommended that Plaintiff use a sit-stand desk. The Court further acknowledged that use of a sit-stand desk or the ability to alternate between sitting and standing did not require a workplace accommodation citing other courts who have recognized such permissible methods for performing an identified job.

Second, the Court found that the restriction of “no driving” was not supported by any rationale, and in light of Plaintiff’s conservative medical care, a restriction allowing stretching and changing of positions every 30 minutes would be sufficient. Third, Plaintiff’s own treating providers disagreed on whether Plaintiff could lift 10 lbs. as required for her occupation, with some restricting her to 5 lbs. The Court reasoned as a matter of common sense, it was unclear why Plaintiff could not break up stacks or bankers’ boxes of paper files to accommodate this restriction. Ultimately, the Court concluded that although Plaintiff appeared sincere in her belief that she cannot work as an accountant due to her conditions, she had not submitted the medical evidence necessary to support her position.

If LINA or your insurer has denied or otherwise limited your disability insurance claim, contact us for assistance.