This ERISA case, decided in 2022 , is a very recent case examining the “arbitrary and capricious” standard of review by the Courts.
The Plaintiff/Insured had back surgery to address her back pain and antalgic gait, but was medically cleared to return to work a few weeks after the surgery. She continued to experience pain but her medical exams did not reveal any acute injuries. However, her providers repeatedly noted that she was having back problems and problems with her lower extremities. They also noted that these problems were limiting her ability to sit, stand, walk and lift much weight.
The Defendant temporarily approved the Plaintiff’s claim for short term disability benefits under ERISA, because the Plaintiff was unable to perform her “own occupation” under the plan terms. However, the Defendant denied her long term disability benefits when the Plaintiff reached the point where the plan required that she be unable to perform “any occupation” to continue to receive the long term disability benefits. The Defendant based this on a vocational expert’s opinion to concluded that there were jobs within the company that the Plaintiff could perform. The Plaintiff appealed this decision and cited an opinion by her by her doctor that she was totally unable to work. The Defendant once again denied the Plaintiff’s long term disability benefits based on the vocational expert’s conclusions that there were jobs within the company that the Plaintiff could perform. The Plaintiff again appealed, but did not produce any additional information on that appeal. The Defendant had another doctor review the Plaintiff’s file, and that doctor concluded that she was partially disabled but could work full time. The vocational expert again concluded that there were jobs within the company that the Plaintiff could work. The Plaintiff filed suit, alleging that the denial of her long-term disability benefits was arbitrary and capricious in violation of ERISA. The District Court ruled against her, so the Plaintiff appealed.
The Court examines the record and finds that the plan requires that the Plaintiff produce “objective medical information” establishing that she is unable to perform “the duties of any occupation.” The Court notes that the history that the Plaintiff has provided is mostly about her subjective pain complaints and based on the opinions of her providers, which also did not cite objective medical evidence. The Court finds that the Defendant’s experts did base their opinions on objective medical evidence that was found in the record. Therefore, the lower court’s decision is upheld.
In a sort of reverse of the cases we have previously blogged about, here, the Plaintiff did not back up her claims with objective medical evidence. Here, the Court states, “[Plaintiff} also argues that the [medical file] reviewers [engaged by the plan administrators] made improper credibility determinations by discounting her complaints of pain. But the reviewers did not make credibility determinations; they focused on the objective evidence, which is what the plan required. And the plan required [Plaintiff} . . . to support her long term disability claim with objective evidence. Given this, credibility determinations have limited probative value here.” Lastly, Plaintiff’s case was made even harder here because, after being paid own occupation benefits, she had reached the point when the plan required her to be unable to perform “any occupation.”
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.