This ERISA case, decided in 2013, is another case dealing with the necessity of the Plaintiff making sure the necessary proof is there to support the claim.
The Plaintiff/Insured went through a procedure to repair an aortic valve and dilated ascending aorta, and applied for disability benefits under his company’s plan. The Plaintiff’s claim was denied when the administrator determined that he was not totally and permanently disabled under the terms of the plan. The Plaintiff raised the issue in front of the lower court that the Defendant had applied the wrong definition for “total and permanent disability” under its policy. However, the Court notes that this misapplication was only in the initial denial letter, and had been corrected by the administrator since that initial letter, so the error did not affect the outcome of everything after the error. The Court examines the record and finds that the administrator’s denial of long term disability benefits was not arbitrary and capricious because there was no objective medical evidence that supported the claimant’s argument that he was permanently unable to sit, stand or walk so as to prevent him from doing some other job for which he was fit by education, training or experience. The administrator was not required to obtain vocational evidence to support its denial of the claim for total and permanent disability because the medical evidence contained in the record provided substantial support for a finding that the claimant was not totally and permanently disabled. the administrator’s decision to conduct a file review was not arbitrary and capricious because the nurses reviewing the file made not credibility determinations about the claimant and did not second-guess the claimant’s treating physicians. Therefore, the Court affirmed the decision of the lower court.
As stated in many of our previous blogs, a claimant cannot win these ERISA long term disability cases without a record to support his or her claims. In order to overturn an administrator’s decision, the claimant has to have concrete proof of his or her position supported by the opinions and diagnoses of medical professionals. The claimant’s own assertions and opinions of his or her ability to work is simply not enough to overcome the “arbitrary and capricious” standard.
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.