This ERISA case, decided in 2015, is a case dealing with the plan administrator abusing his discretion in denying long term disability benefits.
The Plaintiff/Insured was a former military pilot who was injured in a helicopter crash. As result of this injury, the Plaintiff had a leg amputated below the knee. The Plaintiff retired from military service and became a helicopter pilot for PHI, which was insured by the Defendant. The Plaintiff flew for PHI for more than 20 years, but began to experience severe pain at the site of his amputation, which prevented him from safely wearing a prosthetic limb. As a result, he could no longer operate the foot controls of the helicopter and could no longer fly. He filed a claim for his long term disability benefits with the Defendant. The Defendant denied his long term disability benefits, determining that the Plaintiff was not totally disabled because there was no rational connection between his disability and the fact that he could do sedentary work, including alternative occupations within the company, and that he could earn a substantially similar salary in the alternative positions. However, the Plaintiff had medical proof that his mental disability, the pain sensations at the amputation site, impaired his ability to hold down a sedentary job. The Defendant continued to deny the Plaintiff’s long term disability benefits claim because it determined that there was no rational connection between the Plaintiff’s mental condition and his ability to hold a sedentary job. The Court found that this was an abuse of discretion by the Defendant’s administrator. The Court found that the proof showed that the Plaintiff’s mental condition contributed to his total disability, and therefore was disabled under the terms of the plan, and to continue to deny long term disability benefits was an abuse of the Defendant’s discretion. The Court therefore reverse the lower court and remanded the case back to the lower court for a determination of the amount of benefits.
Here, the shoe is on the other foot from our previous blogs. The Defendant came up a with a theory that the Plaintiff’s mental condition was not connected with his disability and ran with it, using it to deny his benefits. However, the Defendant didn’t have any medical proof of that in the record, and so it lost. Making the record is of top importance in these cases. Of course, it didn’t hurt that the Plaintiff’s disability was the result of his military service, and the case was in Texas.
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.