Is the risk of relapse a continuing disability requiring payment of long-term disability (LTD) benefits? The First Circuit considered this question and decided the answer was "yes" in its recent decision, Colby v. Union Security Insurance Company, No. 11-2270 (January 17, 2013).
Julie Colby worked long hours as an anesthesiologist, suffered from severe back pain, and, as a result of her access to pain medication through her job developed a troubling opoid dependence. After being discovered passed out by a colleague, she underwent in-patient substance abuse treatment at a facility in Atlanta, Georgia.
Through her employment Colby had long-term disability insurance with Union Security Insurance Company (USIC). Colby was paid long-term disability benefits while she was at the facility but it refused to pay any benefits following Colby's discharge. Colby claimed that the risk of relapse she faced was so substantial as to constitute a continuing disability, thus entitling her to long-term disability benefits. USIC steadfastly denied her claim, asserting that the mere risk of relapse could not constitute a continuing disability under the policy.
Colby compiled substantial medical evidence and opinion that her returning to work as a physician invited a relapse into substance abuse and addiction, as the Court noted:
Copious evidence, including statements by her therapist, Patricia Dell–Ross, linked her opioid dependence to her back pain, her turbulent personal life, and the stresses of her job. Her professed inability to return to work thus contemplated not only enhanced physical and logistical exposure to her drug of choice but also the likely exacerbation of other triggering conditions. Cognizant of this nearly perfect storm, Dell–Ross, in a letter dated January 30, 2007, predicted that, should the plaintiff return to work, her “access to opiates, combined with the usual and unusual stressors of everyday life and work would make her relapse almost inevitable.”
The First Circuit was troubled by the insurer's steadfast and categorical assertion that the risk of relapse could not be a continuing disability under the policy. The court found no such exclusion in the plan language and observed that "plucking an exclusion for risk of relapse out of thin air would undermine the integrity of an ERISA plan." Furthermore, "an ERISA plan must be read in a natural, commonsense way" and "it is a commonsense proposition that a substance-dependent individual's risk of relapse can swell to a critical mass of disability."
The court also noted two other federal court decisions on the question, one by the Fourth Circuit upholding the insurer's denial of coverage, Stanford v. Continental Casualty Company, 514 F.3d 354, 360 (4th Cir.2008) (denial of LTD benefits to Fentanyl-addicted nurse anesthetist), and one ruling in the claimant's favor, Kufner v. Jefferson Pilot Fin. Ins. Co., 595 F.Supp.2d 785, 787–88 (W.D.Mich.2009) (overturning insurer's denial of continuing LTD benefits to opioid- and alcohol-dependent anesthesiologist).
There are two important take-aways from this case. First, Colby's job increased her risk of relapse: as a doctor she had access to the controlled substances that fueled her addiction to begin with. Second, the insurance company's categorical refusal to consider Colby's situation undermined its position.