This ERISA case, decided in 2006 , is another examining the “arbitrary and capricious” standard of review by the Courts, in this case, applying it to the Plaintiff’s claim that she is unable to work even a sedentary job.
The Plaintiff/Insured worked as a nurse when she suffered a lower back injury. She had a disk herniation and had unsuccessful surgeries to fuse her disks and relieve her pain. She was eventually receiving lumbar epidural steroid injections and was diagnosed with degenerative arthritis and degenerative disk disease in her spinal region. Later, an intrathecal morphine pump was surgically implanted in her vertebrae. Her doctors then diagnosed her as being unable to work any job. However, the long term disability plan administrator’s doctors stated that the Plaintiff could do sedentary work, but never actually physically examined the Plaintiff. The Court found that it was uncontradicted that the Plaintiff was unable to sit for more than four hours a day and that sitting was the most significant pain-provoking activity. The Court found that therefore, sedentary work was not possible. Based on this limitation, the ERISA plan administrator failed to offer a reasoned explanation for its decision to terminate her long term disability benefits and it was arbitrary and capricious for the administrator to terminate long term disability benefits without specifying the kind of work that the Plaintiff could perform. The record contained objective evidence of the Plaintiff’s pain. The Court therefore reversed the judgment of the lower court and remanded the case.
As stated in previous cases we have blogged about, it is so important for a plan administrator to give objective reasons why something is being done, and these reasons must be based on medical evidence. It is not enough for an administrator to say that a Plaintiff can perform sedentary work in the face of evidence to the contrary, and then not explain what sort of work the administrator’s physicians believe the Plaintiff can do.
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.