This ERISA case, decided in 2022, is a case where the Defendants, AT&T and the Plan, were both granted summary judgment. In the case, the Plaintiff/Employee claimed wrongful termination of benefits under ERISA.
In this short term disability claim under ERISA, the Plaintiff was an employee of AT&T whose job duties included installing wires, lifting heavy loads and climbing tall ladders. The Plaintiff began to experience severe migraines, lightheadedness and dizziness and concluded he could not longer perform the duties of his job. The Plaintiff applied for short-term disability benefits. Those short term benefits were initially granted but then terminated short of the 52 week benefit period when an independent medical reviewer concluded that the Plaintiff’s tests were normal and that the Plaintiff’s condition had improved. The Plaintiff appealed this decision unsuccessfully with AT&T and then sued them and the plan. The District Court dismissed the claim on summary judgment. The case is then reviewed by the U.S. Court of Appeals.
Basically, the case turned into a battle of the expert doctors, with each side having a battery of doctors who examined the Plaintiff. The Defendants’ doctors said that the Plaintiff was not disabled. The Court noted that the ERISA benefit plan that the Plaintiff was subject to gave a plan administrator discretion to determine eligibility for short term and long term disability benefits, and so the law said that the Court had to consider whether that administrator’s decision was arbitrary and capricious. The Court notes that a administrator’s decision will be found to be arbitrary “when there is an absence of reasoning in the record.” The Court then reviewed the record and determined that the Defendants’ determination was grounded in sufficient evidence and was adequately explained.
The Plaintiff also argues that the decision of the District Court to reject two items of evidence as being outside the administrative record compiled by the parties prior to case coming to Court was incorrect. The Court examines this exclusion amounted to an abuse of discretion by the District Court. The Court notes that under general ERISA principles, the Court is limited to a review of the administrative record absent certain narrow exceptions, none of which applies in this case. Therefore, the Court upheld the District Court and affirmed the dismissal.
This case demonstrates how difficult it is for the Plaintiff to win a case under the arbitrary and capricious review standard under ERISA. By merely having three peer review doctors on board, without a true independent medical evaluation, the Plaintiff’s short term disability claim was terminated. The case also demonstrates that, almost every time, any facts not included in the administrative record put in front of the carrier before the final denial letter is issued with not be recognized by the Court later. Therefore, it is essential that an employee get all medical proof and any other facts into the administrative record before then. Finally, the case points out that the Defendants took the position that any follow-on long term disability benefit claim had no chance of success because the short term disability claim had not been approved and paid for the full 52 weeks. A disabled employee must always pursue the antecedent short term disability benefits to full exhaustion to make a successful later claim for long term disability benefits.
If you need assistance navigating your claim for short term or long term disability benefits 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.