Insurer’s Own Evidence Dooms Benefit Termination: Court Finds Claimant Disabled Under “Any Occupation” Standard In ERISA Policy

In Booth v. First Reliance Standard Life Insurance Company, No. 24 CIV. 3927 (KPF), 2026 WL 861640 (S.D.N.Y. Mar. 30, 2026), the United States District Court for the Southern District of New York granted summary judgment in favor of a registered nurse whose long-term disability benefits were terminated by First Reliance Standard Life Insurance Company after more than five years of payments. Although the policy granted the insurer discretionary authority to determine benefits eligibility, the court applied de novo review after finding that First Reliance Standard committed multiple non-inadvertent violations of the Department of Labor’s claims-procedure regulation — including improperly invoking a 45-day appeal extension and misapplying the tolling provision — in processing Booth’s internal appeal. The court found that Booth was Totally Disabled under the policy’s “any occupation” standard, and that the insurer’s own vocational evidence — not just the claimant’s — established that she could not perform any occupation her education, training, or experience would reasonably allow.

Background

Booth worked as a registered nurse for Montefiore Medical Center for more than a decade before a December 2017 automobile collision left her with severe low back, bilateral hip, and bilateral lower extremity pain, along with diagnoses of intervertebral disc disorder with myelopathy and lumbar spondylosis with radiculopathy. She also developed right shoulder pain that limited her range of motion. Unable to return to nursing, she applied for long-term disability benefits under the group policy First Reliance Standard issued to Montefiore.

First Reliance Standard approved Booth’s claim in May 2018, determining she could not perform the medium-exertion duties of her regular occupation as a nurse. The insurer conducted multiple medical reviews over the following years, each of which confirmed she lacked consistent work function at any exertional level. In December 2019, a Social Security Administration administrative law judge awarded Booth disability benefits, finding she had been unable to perform any past relevant work since the date of her accident — a process the insurer itself had encouraged and financially supported.

After 60 months of payments, the policy’s definition of Total Disability shifted from inability to perform one’s regular occupation to inability to perform the material duties of any occupation. First Reliance Standard conducted a new review in October 2022, in which its nurse reviewer concluded that Booth’s symptoms had stabilized and that she was capable of at least light-level exertion. In December 2022, the insurer notified Booth that her benefits would terminate effective March 7, 2023, identifying several light and sedentary occupations — including Office Nurse, School Nurse, Cardiac Monitor Technician, Hospital Admitting Clerk, and Telephone Triage Nurse — that its vocational team determined she could perform.

Booth appealed through counsel in December 2023. The insurer obtained an independent review from Dr. Shannon Blackmer, who determined that Booth could lift only up to five pounds occasionally, reach at desk level only occasionally, and walk for no more than 30 minutes total in a day. After seeking clarification from Dr. Blackmer regarding whether Booth could use a keyboard — given her severe limitations in upper extremity use — the insurer confirmed she could type frequently and issued its final denial of Booth’s appeal on March 26, 2024, 111 days after she filed it.

Standard of Review

The policy granted First Reliance Standard discretionary authority to determine benefits eligibility, which would ordinarily trigger deferential arbitrary-and-capricious review. Booth argued, however, that the court should apply de novo review based on two alleged violations of the Department of Labor’s claims-procedure regulation, 29 C.F.R. § 2560.503-1. The court rejected her first argument — that the insurer had failed to provide materials it relied upon — but agreed with her second: that the insurer’s appeal decision was untimely.

Booth submitted her internal appeal on December 6, 2023, giving First Reliance Standard 45 days to render a decision, with a deadline of January 20, 2024. The insurer sent a letter on January 18, 2024, invoking a 45-day extension on the grounds that it was awaiting the independent medical review. The court rejected that justification. Citing Salisbury v. Prudential Insurance Co. of America, 238 F. Supp. 3d 444 (S.D.N.Y. 2017), Bianchini v. Hartford Life and Accident Insurance Co., No. 24 Civ. 6535 (JGLC), 2026 WL 810303 (S.D.N.Y. Mar. 24, 2026), and other decisions within the circuit, the court explained that waiting for physician or vocational review is a routine feature of virtually every disability appeal and therefore cannot constitute a “special circumstance” warranting an extension.

The insurer also argued that the tolling provision of 29 C.F.R. § 2560.503-1(i)(4) further extended its deadline by 11 days, based on a January 26, 2024 letter inviting Booth to submit additional information if she wished to do so. The court rejected this argument as well, finding that the letter’s permissive, open-ended language — telling Booth she could submit more information if she wanted before the insurer “proceeded with its review” regardless — made clear the information was not necessary to decide her claim, and therefore could not trigger the tolling provision. The court noted that the insurer had the provision “completely backwards”: tolling applies when a claimant fails to submit information necessary to decide the claim, not when a claimant requests information from the insurer.

Even setting aside those errors, the court observed, the insurer still issued its final decision ten days after its own self-calculated revised deadline and offered no justification for that additional delay beyond calling it harmless. Because the violations were purposeful rather than inadvertent, the court applied de novo review under Halo v. Yale Health Plan, 819 F.3d 42 (2d Cir. 2016). The court noted, however, that it would have reached the same conclusion under arbitrary-and-capricious review.

Merits: The Insurer’s Own Evidence Proved Total Disability

Under de novo review, the court evaluated whether Booth met the policy’s post-60-month definition of Total Disability: the inability to perform the material duties of any occupation her education, training, or experience would reasonably allow. The parties agreed on the central fact — Booth could lift no more than five pounds, per Dr. Blackmer’s findings that the insurer itself had obtained and relied upon.

First Reliance Standard argued that a five-pound lifting capacity was sufficient to allow Booth to perform certain sedentary occupations. It defined sedentary work, drawing from the Department of Labor’s Dictionary of Occupational Titles, as requiring the ability to exert up to ten pounds of force occasionally or a negligible amount of force frequently, and contended that because Booth could lift one pound frequently, she satisfied the second half of that disjunctive definition. The insurer’s vocational expert identified three sedentary occupations she could purportedly perform: Cardiac Monitor Technician, Hospital Admitting Clerk, and Telephone Triage Nurse.

The court found that argument self-defeating. Each of the three occupations the insurer identified in the administrative record defined its sedentary physical demands to require lifting, carrying, pushing, or pulling ten pounds occasionally — with no reference to the negligible-force alternative. Because both parties agreed Booth could not lift ten pounds, and because these were the only occupations the insurer had pointed to in support of its position, the court concluded that Booth could not perform any occupation and was therefore Totally Disabled under the policy.

The court also rejected the insurer’s argument that its reliance on the Social Security Administration’s favorable disability determination was insufficient, observing that its own evidence ultimately confirmed what the SSA had found years earlier.

Takeaway

Booth is a significant reminder that an insurer’s own vocational evidence can be the basis for a plaintiff’s victory. When the only occupations an insurer identifies to defeat a Total Disability finding each require physical capacities the insurer’s own physicians have determined the claimant lacks, those job identifications do more harm than good to the insurer’s position. The case also reinforces the strict procedural requirements of 29 C.F.R. § 2560.503-1: routine medical and vocational review does not constitute a “special circumstance” warranting an appeal deadline extension, and open-ended invitations for a claimant to submit additional material do not trigger tolling.