In this ERISA case, decided in 2015, the question before the Court is whether a long term disability plan administrator acted arbitrarily and capriciously in denying the claimant/Plaintiff’s long term disability benefits under ERISA.
The Plaintiff was employed as a customer service representative for Michigan Bell. He stopped working as a result of chronic neck pain. He was covered under the Defendant plan. The plan administrator initially paid short term disability benefits on the claim, but he was denied long term disability benefits because the plan administrator determined that there was not objective medical documentation of the claimant’s inability to perform any occupation. However, the Court found that the administrator ignored favorable evidence submitted by the Plaintiff’s treating physicians, selectively reviewed the evidence it did consider from the treating physicians, failed to conduct its own physical examination and heavily relied on non-treating physicians. The Court even went so far as to determine that, not only was the Plaintiff entitled to his long term disability benefits, but that a remand would be a useless formality because the medical records contained objective medical evidence that the Plaintiff was disabled.
In ERISA cases, if there is a clause in the plan, in some states, that gives the administrator discretionary authority to determine the eligibility for short term or long term disability benefits under ERISA or to construe the terms of the plan, rather than the Court reviewing the decisions of the administrator under the de novo standard, the Court reviews under the “arbitrary and capricious” standard which means that the administrator’s decisions in denying the long term disability benefits must be arbitrary and capricious for the Court to overturn the administrator’s decisions. Needless to say, this is a very high standard and very difficult to overcome. However, as this case demonstrates, it is not impossible. The administrator must base his decisions on some quantifiable facts to show the Court that the decision has some basis for the denial. This one did not, and was reversed.
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.