This ERISA case, decided in 2009 , is a case examining what the Plaintiff’s duties are in making a claim for long term disability and in bringing a case before the Court.
In this case, the Plaintiff/Insured worked as an accountant-tax analyst, which required her to sit for most of the day and manipulate her hands, fingers and wrists in using a computer. The Plaintiff began to experience symptoms that she believed related to her rheumatoid arthritis, and she stopped working. She described these symptoms as “pain in her hands.” The ERISA plan administrator granted the Plaintiff’s short term disability benefits for a little over a year, but found that the Plaintiff’s symptoms were not supported beyond that date and denied continuing long term disability benefits under ERISA. Upon review of this decision, the appellate court determined that the Plaintiff received a full and fair review of her claim because: (1) the administrator consistently and accurately notified the Plaintiff that benefits had been denied based on a lack of evidence supporting disability and (2) the Plaintiff did not take the opportunity to request a copy of the independent medical examiner’s report or otherwise attempt to address the reliability and accuracy of that examiner’s medical findings. Substantial evidence supported the the administrator’s benefits determination because there were strong indications in the administrative record that the employee’s symptoms were related to stress rather than to rheumatoid arthritis. Therefore, the Appellate Court affirmed the lower court’s decision.
This case is demonstrative of the fact that the burden of proving these cases is on the Plaintiff. It is up to the Plaintiff to question the processes of the administrator and to develop a record and proof that will demonstrate to the Court that the assertions the Plaintiff is making about her condition are true and backed up by medical proof. The Plaintiff can’t simply disagree with a determination because she has an idea in her mind about what is causing her problems and take that before the Court and expect the Court to agree with her with no proof to back it up.
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.