Anesthetist with Potential for Drug Abuse Relapse on Job not Due Benefits

January 24, 2008 ( - The 4th U.S. Circuit Court of Appeals has affirmed a long-term disability plan administrator's denial of benefits for a drug addicted participant whose job duties potentially put him at risk of drug abuse relapse.

Robert R. Stanford, employed as a nurse anesthetist at Beaufort Memorial Hospital in Beaufort, South Carolina, argued in his administrative appeal that his addiction rendered him unable to perform his duties because of the high risk that he would relapse into drug use if exposed to Fentanyl in the workplace. The appellate court affirmed Continental Casualty Company’s denial of benefits. Continental rejected Stanford’s argument, concluding that “[t]he policy does not cover potential risk” of relapse.

Stanford cited a number of cases in support of his argument that risk of relapse is a form of disability under an Employee Retirement Income Security Act (ERISA)-governed benefit plan, such as cases involving the risk of recurrence of a physical condition such as a heart attack. However, the court said the risk of a heart attack is different from the risk of relapse into drug use.

“A doctor with a heart condition who enters a high-stress environment like an operating room “risks relapse” in the sense that the performance of his job duties may cause a heart attack. But an anesthetist with a drug addiction who enters an environment where drugs are readily available “risks relapse” only in the sense that the ready availability of drugs increases his temptation to resume his drug use. Whether he succumbs to that temptation remains his choice; the heart-attack prone doctor has no such choice,” the opinion said.

The court concluded that Stanford was not physically disabled or mentally impaired. According to its opinion, though limitations of his license and employer prudence would dictate that he cannot return to his old job administering Fentanyl, “Stanford is physically and mentally capable of performing that job – and countless other jobs.”

Stanford also argued that Continental’s denial of benefits was unreasonable because Continental violated ERISA’s procedural requirements, specifically by failing to consult a health care professional in determining that his risk of relapse did not constitute a disability.

However, the court pointed out that Continental did not dispute the medical judgment of Stanford’s treating physician that Stanford suffered no physical impediment to the performance of his work but remained at risk of relapse if he returned to an environment where he was required to administer Fentanyl. Continental’s denial of benefits was based solely on its determination that such a risk of relapse did not fall within the benefit plan’s definition of “disability,” the court said, noting that its determination was contractual, not medical.

Stanford first received disability benefits when he entered a drug rehabilitation program for the second time in November 2003. In December, 2004, a registered nurse consultant with Continental spoke to Stanford’s treating physician, who indicated that Stanford no longer suffered any impairment that would prevent him from performing the duties of his occupation as a nurse anesthetist. Continental terminated Stanford’s long term disability benefits in January, 2005.

In a dissenting opinion, Circuit Judge James Harvie Wilkinson III stated: “The majority has in effect used its equitable power to authorize an unwritten exception to Continental’s textual promise of coverage.” Excluding “potential risk of relapse” from coverage has no support whatsoever in the language of the plan, he said.

Wilkinson also pointed out the court’s conclusion that Stanford can work “countless other jobs.” totally disregards plan language defining disability as the inability “to perform the material and substantial duties of your regular occupation.”

The opinion in Stanford v. Continental Casualty Co., 4th Cir., No. 06-2006, 1/23/08 is here .