Foss v. Standard Insurance Company

Background

Caroline Foss worked as the Assistant Director of Annual and Leadership Giving at Boston College. Standard Insurance Company issued Boston College’s long-term-disability insurance policy and handled employees’ claims under that policy.

The policy defined disability, for Foss’s employment class, as being unable because of sickness, bodily injury, or pregnancy to perform the material duties of the claimant’s normal occupation, or working while unable to earn at least 80 percent of the claimant’s increasing monthly wage base. The policy defined “normal occupation” as employment involving material duties of the same general character as the claimant’s occupation when the disability began. It allowed Standard to consider both how the employee performed the job and how that type of occupation is generally performed. The policy also gave Standard discretionary authority to decide eligibility for benefits and interpret the policy.

Foss applied for long-term-disability benefits on December 11, 2019. She identified depression and anxiety as illnesses contributing to her inability to work and reported symptoms including muscle aches, digestive problems, memory loss, fatigue, insomnia, and emotional dysregulation. Her medical records included diagnoses or assessments involving attention-deficit/hyperactivity disorder, depression, anxiety, and related symptoms. The records also described serious difficulties, including insomnia, fatigue, poor concentration, anxiety, a breakdown that led to an emergency-room visit, difficulty caring for herself, and gastrointestinal symptoms.

Standard obtained reviews from medical professionals who did not meet with Foss. The reviewers concluded that her records did not establish a disabling physical condition and that her mental-health conditions did not produce restrictions or limitations preventing her from working. Standard denied her claim on January 14, 2020, stating that the records showed emotional distress related to her particular workplace but did not show that she was unable to perform her occupation generally in a neutral work environment.

Foss appealed and submitted additional records, including a psychological evaluation and records of psychotherapy. Standard obtained another psychiatric review and a vocational review. The vocational reviewer concluded that Foss’s job corresponded to the “Major Gifts Manager” occupation and was sedentary. The psychiatric reviewer concluded that Foss’s diagnoses and treatment did not establish an impairing psychiatric condition and that the records did not show she could not work 40 hours per week because of psychological symptoms. Standard rejected Foss’s appeal and again denied benefits on November 12, 2020.

Claims and Arguments

Foss sued under the Employee Retirement Income Security Act of 1974, a federal law governing many employee-benefit plans. She and Standard filed cross-motions for summary judgment. Summary judgment is a ruling entered when the record shows no genuine dispute over a material fact and the moving party is entitled to judgment as a matter of law.

Foss argued that Standard incorrectly determined that she was not disabled under the policy and failed to conduct a full and fair review of her medical records. Standard argued that Foss had not shown its denial was arbitrary and capricious, meaning unreasonable or unsupported by substantial evidence.

Court’s Analysis

Because the policy gave Standard discretionary authority, the court reviewed the benefits denial under the deferential arbitrary-and-capricious standard. Under that standard, the court had to uphold Standard’s decision if Standard gave a reasonable explanation supported by substantial evidence. The court explained that the question was whether a reasonable person could have reached a similar decision, not whether the court would have reached the same decision.

The court recognized that Foss’s medical records documented significant mental-health struggles and that at least two medical practitioners had diagnosed her with major depressive disorder. The court also noted evidence that Foss’s condition had deteriorated to the point that she struggled with sleep and daily activities, experienced a breakdown and emergency-room visit, and had anxiety-related gastrointestinal symptoms and memory loss. The court further observed that her condition improved at least marginally after she began treating her attention-deficit/hyperactivity disorder.

The court nevertheless concluded that Standard’s reviewers’ conclusions were sufficient under the highly deferential standard of review. A reasonable person could have decided that Foss’s diagnoses and symptoms, although significant and legitimate, did not prevent her from performing the general type of job for any employer. The court therefore held that Standard’s denial of benefits was not arbitrary and capricious.

Disposition

The court denied Foss’s motion for summary judgment and granted Standard’s motion for summary judgment. The order directed that judgment be entered accordingly.