Nurse Appeals Denial of Disability Due to Fentanyl Relapse

Ronald Bernard, a nurse anesthetist, worked at an ortho surgical clinic administering anesthesia.  In 2017, he was terminated after he admitted he was using Fentanyl, an opiate-based narcotic, at work.  Mr. Bernard’s employer stated his performance was satisfactory and had no performance issues.  He did not show any signs of drug use when he was dismissed.  Mr. Bernard was dismissed because two nurses reported he was using syringes and suspected he was using drugs.  Mr. Bernard’s treating physician stated his addiction prevented him to perform work duties as an anesthetist and unable to function in his occupation “indefinitely.”  Motions for summary judgment were filed by both Ronald Bernard and the defendant, Kansas City Life Insurance Co.

Disability Policy

Mr. Bernard became insured under both short-term and long-term disability income insurance.  He was entitled to benefits under both policies if he became disabled while employed full time.  Under each policy, a person is considered disabled if he has an “illness, disease, or physical condition” that occurred while he was covered under the insurance policy.  The disability must also prevent him from performing all the “Material and Substantial Duties of Regular Occupation,” resulting in a loss of at least 20% of his earnings.  Mr. Bernard’s long-term policy capped payment for disabilities at 24 months due to “drug abuse.”

Application for Disability Benefits

Mr. Bernard was employed as a Certified Nurse Anesthetist (CRNA) for 26 years.  He was insured for disability between December 2016 and October 2017.  For his short-term disability, Mr. Bernard indicated his injury occurred in October 2017 when he informed his employer of his Fentanyl relapse.  For his long-term disability, Mr. Bernard indicated he retired in October 2017.  He stated his first symptoms that caused his disability were “Depression/Anxiety – Relapse alcohol/drug addiction.”  He further noted his symptoms increased the past two years and was treated for them between December 2001 and February 2002 at a “treatment center.”

Kansas City Life Insurance denied Mr. Bernard’s claims for both short-term and long-term insurance disability benefits.  He was denied because it considered his termination the result of his failed drug test and admitting to illegal drug use, not to disability.  Because he only sought treatment from a physician until after his employment ended, he was not considered disabled under the policy.

Administrative Appeal of Benefits

Mr. Bernard stated in his appeal he suffered from addiction to fentanyl for several years and relapsed in October 2017.  Kansa City Life Insurance denied his long-term benefits once again in October 2018.  The insurance company defended its position by stating he did not have any performance issues “until he was removed from the operating room due to suspected drug use from which he was tested positive.”  It also stated he was not treated for Fentanyl addition until his coverage was terminated in October 18, 2017. 

Evidence of Disability Benefits Decision

Mr. Bernard’s denial of disability benefits was based on the conclusion his employment was discontinued because of his failed drug test and not impairment due to his narcotics addiction.  The short-term and long-term disability policies defined disability as when the insurance company determines the policy holder is unable to perform all the “Material and Substantial Duties of Your Regular Occupation” and a 20% or more loss in weekly earnings.  The policies stated, “disability resulting from the Sickness must begin while You are covered under the policy.”  While the long-term policy covered drug abuse, short-term disability did not. 

U.S. District Court’s Findings

The U.S. District Court found Kansas City Life Insurance unreasonably “divorce(d) Mr. Bernard’s Fentanyl use on a single occasion from his addiction and relapse.  The court noted Mr. Bernard had a medical history of narcotics addiction, including receiving treatment for three months and regularly saw a counselor for seven years after being discharged.  The court asserted there was no reasonable person who could find a nurse anesthetist so addicted to Fentanyl that he would inject himself with the drug during the workday while his co-workers were nearby and capable of performing the duties of his job.  The court stated his employer’s lack of noticing the impairment was not equivalent to him not being impaired.  It was only evidencing the employer was unaware that he was impaired.

The Court noted there was disagreement as to whether the risk of relapse is enough to render a person disabled, but there was consensus that relapse would preclude work in the field of anesthesia.  To deny anesthesiologist benefits until a relapse of narcotics addiction occurs would be a concern of public health and safety.  The court noted the case, Stanford v. Cont'l Cas. Co., 514 F.3d 354, 359 (4th Cir. 2008), to show the denial of disability benefits for a Fentanyl-addicted nurse anesthetist would require Mr. Bernard to “work and in fact suffer a relapse in order to qualify for long term disability benefits.”  The U.S. District court found the defendant’s argument one that “no reasonable arbiter could reach.”

The court added that the insurance company’s denial of Mr. Bernard’s disability benefits is based on him not receiving treatment for his relapse before his employment terminated.  The company never indicated “an insured must receive medical treatment for disability prior to the end of coverage to be eligible for benefits.  The fact Mr. Bernard didn’t see a doctor until eleven days after his last day on the job was never established as a reason that he was not disabled prior to the end of his employment.

Conclusion

Kansas City Life Insurance motion for summary judgment was denied.  Mr. Bernard’s motion for summary judgment was granted.  The U.S. District Court concluded the insurance company’s denial of Mr. Bernard’s disability benefits were not supported by substantial evidence in the record.  If you have been denied disability benefits, contact RMDLG for help.