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A group insurer must provide long-term disability benefits for a hospital staff anesthesiologist addicted to an opioid pain medication commonly used in her anesthesia practice, a federal court ruled on Thursday.
In the case of Julie Colby v. Union Security Insurance Co., the 1st U.S. Circuit Court of Appeals in Boston considered whether the risk of a relapse into drug use can be so significant as to be considered a current disability.
In 2004, a colleague found Dr. Colby sleeping or unconscious on a hospital table, and she tested positive for fentanyl. “As matters turned out, she had for some time been self-administering opioids and had become addicted,” the court's opinion states
She later entered an inpatient substance abuse treatment program and was diagnosed as having an opioid dependence, a dysthymic disorder, and obsessive-compulsive personality traits. The exam also revealed severe back pain associated with degenerative disc disease and a history of major depression.
Her employer's group disability insurer, USIC provided benefits until the end of Dr. Colby's inpatient stay. But USIC refused to pay benefits beyond that point. It argued that Dr. Colby had been discharged and, even though she remained under a doctor's care and feared a relapse, the risk of relapse is not the same as a current disability.
After Dr. Colby exhausted her access to administrative appeals, she sued in federal district court, and the district court deemed USIC's categorical exclusion of the risk of drug abuse relapse an unreasonable interpretation of the insurance plan's coverage.
On further appeal, the 1st U.S. Circuit Court of Appeals considered a number of factors, including Dr. Colby's medical conditions and medical expert testimony that “to a reasonable degree of medical certainty,” she was at high risk of relapse if she returned to a job where she could easily access opioids.
USIC then asserted that “a doctor's opinion that there is a high probability of relapse is not objective or even reliable evidence of a current disability,” and therefore not grounds for an LTD benefits claim under its policy.
But the appeals court said the insurance plan's language “admits of no such categorical bar. It does not mention risk of relapse, let alone exclude risk of relapse as a potential basis for a finding of disability.”
USIC could have written an exclusion for risk of relapse into the plan, but did not do so, the appeals court found.
“Without such a written exclusion in place, we believe that USIC acted arbitrarily and capriciously in refusing to consider whether the plaintiff's risk of relapse swelled to the level of a disability,” the court said in its ruling.
The court also said that “a risk of relapse into substance dependence — like a risk of relapse into cardiac distress or a risk of relapse into orthopedic complications — can swell to so significant a level as to constitute a current disability.”
It upheld the district court's finding.