Schwarz v. Hartford Life & Accident Ins. Co.

In this ERISA case, decided in 2020, the Court examines the duty that a Defendant Insurance Company has to the claimant.

In this claim the Plaintiff had cancer. She submitted a claim to the Defendant Insurance Company who initially approved the claim and began paying short term disability benefits. During her treatment, the Plaintiff had a node which tested cancer-free but her physician was unconvinced and recommended chemotherapy. The chemotherapy treatments that the Plaintiff had were beginning to affect her mental state and she had to see a mental health professional. In the interim, the Defendant Insurance Company had its own oncologist evaluate the Plaintiff’s records. Their oncologist noted the mental problems what the Plaintiff was having, but deemed her cancer-free and able to return to work. This is in spite of the Plaintiff’s surgeon’s notes that he had found cancer but was unable to reach the nodes. Based on their oncologist’s report, the Defendant Insurance Company denied the Plaintiff’s claim for short term and long term disability benefits.

The Plaintiff appealed the denial of short term and long term disability benefits and informed the Defendant Insurance Company that she had resumed chemotherapy. In response to this, Defendant Insurance Company commissioned two medical reviews, one by an oncologist and one by a psychiatrist. The Plaintiff pointed out that the psychiatrist hired by the Defendant was missing some of her records. However, the psychiatrist concluded that she had no psychiatric restrictions or limitations. The Defendant’s oncologist was also missing certain records and found no evidence of cancer. The Defendant sent copies of these reports to the Plaintiff’s doctors but did not provide copies of the reports to the Plaintiff or her counsel. Plaintiff’s counsel requested copies of these reports from the Defendant, but the Defendant refused to send the reports until after the appeal process had concluded. Defendant then wrote to Plaintiff’s counsel and said that the appeal had been denied based on the reasons set out by its experts.

The U.S. District Court was having none of that. The Court concluded that the Defendant “failed to substantially comply with ERISA’s procedural obligations” when it failed to provide the claimant with the physician file reviews and that because “she did not see Hartford’s two file reviews until after the final denial, Ms. Schwarz (and her legal counsel) never had the chance to evaluate or rebut the file reviews’ contentions.”

So, we see by this that the Defendant has a duty to treat the Plaintiff fairly and make its processes transparent and, if it does not, the Court will force the Defendant to do so.

If you need assistance navigating your short term or long term disability claim under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000, or send us an e-mail Cody@codyallison.com.  We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee.  We offer a free consultation and would love to speak with you.