Avenoso v. Reliance Standard Life Insurance Company

Background

Reliance Standard Life Insurance Company issued a long-term disability-benefits plan to Michael Avenoso through Equinix, Inc. Avenoso had undergone spinal fusions and back surgery in 2014 and 2016 but continued to experience back pain. He applied for long-term disability benefits on January 4, 2017, and Reliance approved his claim on March 6, 2017.

The plan initially required Avenoso to show that he could not perform the material duties of his regular occupation. After 24 months of benefits, however, the plan required him to show that he could not perform the material duties of any occupation. Reliance concluded that Avenoso could perform sedentary work and denied further benefits. Reliance upheld that decision after Avenoso appealed.

Avenoso sued under the Employee Retirement Income Security Act of 1974 (ERISA), seeking a declaration that he was disabled under the plan and entitled to available benefits. The parties filed cross-motions for summary judgment. Summary judgment is a decision based on the record when there is no genuine dispute over a material fact and the moving party is entitled to judgment as a matter of law.

Standard of Review and Burden

Because the plan did not require deference to Reliance’s decision, the court reviewed the administrative record de novo, meaning independently rather than deferring to the insurer. The court acted as the fact finder, evaluated credibility, and weighed the evidence under the plan. Avenoso had to prove by a preponderance of the evidence—that it was more likely than not—that he was disabled under the plan’s any-occupation standard.

Evidence Considered

The court concluded that Avenoso’s medical diagnoses supported his claim, although diagnoses alone did not automatically establish disability. The court also considered the subjective nature of pain and found the diagnoses helpful in evaluating the nature and extent of his injuries.

The Social Security Administration had awarded Avenoso disability benefits based on a finding that he became disabled in July 2016. The court stated that the Social Security decision was not binding on Reliance but could be considered as evidence. The court also noted that Reliance had encouraged Avenoso to apply for Social Security benefits and required him to appeal an adverse decision, while Reliance saved approximately $2,465 per month for about two years because of the favorable award. The court found Reliance’s positions seemingly inconsistent and concluded that the Social Security determination supported Avenoso’s claim.

A functional capacity evaluation stated that Avenoso could sit only occasionally, had not shown an ability to tolerate an eight-hour workday, and had an ability level of two to three hours of work at the time of the examination. It also stated that lifting, carrying, and pulling were unsafe for him. The court found that the evaluation objectively supported a conclusion that Avenoso could not work a full day or safely perform the duties of sedentary work.

Two independent medical examinations supported Avenoso’s reports of debilitating back pain. A third physician, Dr. Jeffrey S. Liva, concluded that Avenoso had sedentary work capacity and could work eight hours per day, five days per week. The court considered that contrary opinion but found the overall evidence favored Avenoso.

Reliance’s residual employability analysis identified only sedentary occupations. The court found that the analysis was minimally useful because the suggested jobs required sitting most of the time, while no person involved in preparing the analysis appeared to have personally evaluated whether Avenoso could sit that long or perform the other material duties of sedentary work.

The court also found Avenoso’s descriptions of his daily pain and limitations credible. The court noted evidence that he moved into a one-story home with family assistance, used handrails, gave up his hobbies, could not hold his baby granddaughter, sometimes could not sleep for days, and sometimes had to lie down for minutes or hours after showering. The court found these accounts consistent with significant daily pain.

Holding and Order

The court concluded that Avenoso had shown he could not perform the material duties of any occupation on a full-time basis. It therefore ruled that he was totally disabled under the plan’s any-occupation standard and that Reliance erred by denying his long-term disability benefits.

Judge Wilhelmina M. Wright granted Plaintiff Michael Avenoso’s motion for summary judgment and denied Defendant Reliance Standard Life Insurance Company’s motion for summary judgment. The order directed that judgment be entered accordingly.

The court did not address the parties’ arguments about whether Reliance conducted a full and fair review because its ruling on disability resolved the benefits dispute. The court also did not decide Avenoso’s request for attorney’s fees and costs. It stated that Avenoso could pursue that request by filing a formal motion supported by legal and factual analysis.