by Cody AllisonLeger v. Tribune Co. Long Term Disability Benefit Plan, ERISA and Long Term Disability
This ERISA case, decided in 2008, is a case dealing with the arbitrary and capricious standard for reviewing the decisions of the plan administrator.
The Plaintiff/Insured began receiving long term disability benefits in 1990 due to debilitating osteoarthritis in both knees. In 2005, the plan terminated her benefits and the claimant filed this action. The district court concluded that the plan’s decision was not arbitrary and capricious and granted summary judgment in its favor. On review, the Plaintiff argued that a different standard of review was required after a decision in the Glenn case by the Supreme Court. However, the Court rejected that argument, finding that the arbitrary and capricious standard was still applicable with any conflict of interest taken into account as a factor. While the Court rejected the Plaintiff’s argument that previous payment of benefits and a decision at odds with an opinion of a treating physician created a presumption that the termination decision was arbitrary and capricious, it did agree with the Plaintiff that the long term disability plan failed to consider the Plaintiff’s complete medical history and then rejected, without explanation, important aspects of the Functional Capacity Evaluation. As a result, the plan acted in an arbitrary and capricious manner in terminating benefits and a remand was necessary.
Here, the Court found no merit in the Plaintiff’s main argument, but did find that the lower court erred in the arbitrary and capricious determination. This case is a good example of the importance of exhausting all appeals before giving up on a case.
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.
by Cody AllisonNewsom v. Reliance Std. Life Ins. Co., ERISA and Long Term Disability
This ERISA case, decided in 2022, is a case dealing with the definitions of terms contained within the long term disability policy.
The Plaintiff/Insured had been employed as a software architect for 23 years. He had health problems dating back several years, including chronic fatigue syndrome, fibromyalgia, depression and attention deficit hyperactivity disorder. His health eventually deteriorated to the point that the could no longer work a 40 hour week. The employer reduced his scheduled work week to 32 hours, which it still considered to be full time. However, eventually the Plaintiff went to part time, working less that 30 hours per week. Finally, the Plaintiff became unable to work at all, and made an initial claim for short term disability benefits. In that claim, it was the Plaintiff’s doctor’s opinion that he would eventually be able to return to work in a few months. The Employer indicated that the Plaintiff had only been working part time before he stopped working, and the Defendant initially denied the claim based on the fact that the Plaintiff was not a full time active employee and did not qualify for coverage under the terms of the plan. The Plaintiff appealed this denial contending that the Defendant had incorrectly determined his date of disability under the terms of the plan. The Defendant agreed with this and paid the short term disability benefits at the 26 week maximum period. The Plaintiff also applied for long term disability benefits but the Defendant denied this for the same reasons the short term disability benefits were initially denied. Plaintiff appealed this denial, but the Defendant refused to reverse this decision. The Plaintiff then filed the court action. The district court agreed with the Plaintiff that he should be entitled to the long term disability benefits under the plan. The district court then determined the Plaintiff’s date of disability to be what the Plaintiff alleged that it was under the terms of the plan. The Defendant appealed. The Court found that the district court did not err in determining that the Plaintiff was qualified to receive long term disability benefits because he was a full time employee under the terms of the plan. The Court determined that some of the language of the plan was ambiguous and construed the ambiguity in favor of the Plaintiff. The Court also found that the district court did not err in its determination of the Plaintiff’s disability date based on the terms of the plan. However, the Court did find that the case should be remanded back to the Defendant for determination of the merits claim of the disability award, as opposed to the determination of the plan terms, which had been the subject of this suit. The Court agreed that, under the terms of the plan, this is required. Therefore, the Court remanded the case back to the Defendant to determine if the Plaintiff is entitled to long term disability payments according to the medical opinions of the doctors.
This case is example of the Court clearing the road of the “technical” issues of whether or not long term disability can be awarded, in this case an interpretation of what a full time employee is under the policy, and then allowing the Defendant to determine if the medical proof supports the long term disability award. Presumably, if the Plaintiff disagrees with the Defendant’s determination after consideration of the doctors’ opinions of his disability, he can once again bring the matter to court for a review of the Defendant’s determination.
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.
by Cody AllisonDix v. Blue Cross & Blue Shield Ass’n Long Term Disability Program , ERISA and Long Term Disability
This ERISA case, decided in 2015, is another case dealing with the “arbitrary and capricious”
standard. However, the case also has some interesting information about conflicts of interest in these types of cases.
The Plaintiff/Insured filed was an employee of the Defendant and filed for disability because of back problems. The Plaintiff’s long term disability benefits under ERISA, However, she was later notified that she would no longer be receiving these long term disability benefits because the Administrator had determined that the medical evidence no longer supported a finding of disability. The Plaintiff appealed the decision, and the denial affirmed. The Plaintiff claimed that the doctor who’s opinion the Administrator based the decision upon lied about speaking to her treating physicians, and submitted affidavits from her doctors saying that they had not spoken with the Defendant’s doctor. The Administrator declined to add these documents to the record on the basis that they were cumulative or not available at the time the Plaintiff exhausted her administrative remedies. The Plaintiff then filed suit in the district court, which granted summary judgment in favor of the Defendant. On appeal, the Plaintiff argues that the Defendant Administrator had a conflict of interest because the Defendant both funded the disability program and made benefits eligibility decisions. The Court held that the conflict did not exist because the structure of the Defendant meant that the benefits were paid into a trust which was administered by a separate board of directors. The Defendant next argues that she should have been allowed to supplement the record with the affidavits of her doctors. The Court finds that the Administrator did give the Plaintiff time to supplement the record before the decision was made, but the Plaintiff did not supplement with the affidavits until over a year after the decision was made, so the administrator did not have ample opportunity to examine and consider these records in rendering its decision, so this argument failed. Finally, the Plaintiff argues that the Administrator’s decision in denying her long term disability benefits was arbitrary and capricious, but the Court disagreed. The Court points out that the Administrator did consider the records available at the time it made its decision, and based the decision on these records, so the decision was not arbitrary and capricious.
This case is another example of the necessity of making the record in order to prevail in your case. Here, for some reason, when the Plaintiff saw what she believed to be lie from the Defendant’s physician, she waited a whole year to obtain the affidavits which may have demonstrated this. The Court found that this was too late. If the Plaintiff had timely submitted these affidavits, she might have prevailed in this case.
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.
by Cody AllisonFaciane v. Sun Life Assur. Co., ERISA and Long Term Disability
This ERISA case, decided in 2019, is a case dealing with a contractual limitations period under a policy for long term disabiliity.
The Plaintiff/Insured filed an action under ERISA claiming that the plan administrator had miscalculated his long term disability benefits payment. The lower court granted summary judgment in the case because the contractual limitations period had lapsed and the Plaintiff failed to demonstrate that the plan’s limitations provision left him an unreasonably short period to file suit from the time his claim accrued in 2008 when the administrator sent him a letter explaining his monthly benefit calculation. The Court found that the 2008 letter contained enough information for the miscalculation claim to accrue because the disputed figure was displayed prominently on the first page, and the alleged discrepancy was so large and concerned a matter so fundamental to any working person that the letter clearly repudiated the beneficiary’s entitled to greater benefits. Therefore, the Court affirmed the lower court.
This case is a great example of the fact that if you see a problem with the amount being paid to you for your long term disability benefits, or any problem under your policy, you need to do something about that problem immediately. Here, the Plaintiff got shut out because of a provision in the policy that limited the time he has to do something. You cannot sit around after you see a problem thinking that you will get it taken care of eventually. You have to get proactive with any problem you see and, if necessary, bring in an attorney to advocate for you and get these problems resolved, or you could forever lose the right to do so, like the Plaintiff did here.
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.
by Cody AllisonGeorge v. Reliance Std. Life Ins. Co., ERISA and Long Term Disability
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.
by Cody AllisonJudge v. Metro. Life Ins. Co., ERISA and Long Term Disability
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.
by Cody AllisonDel Rio v. Toledo Edison Co.
This ERISA case, decided in 2005 , is a case dealing with the fiduciary duty that the employer owes the employee.
The Plaintiff/Insured was a former employee of the Defendant. She had worked for the Defendant for eight years before her employment was terminated in 1992. In 1994, she was awarded Social Security Disability benefits. She sued her former employer alleging that between 1994 and 2000 she periodically called the employer inquiring about her rights under the long term disability plan. Each time, the Defendant Employer informed her that she had not been an employee for ten full years, and so was not eligible for long term disability benefits under the employer’s plan. The court of appeals found that the employee failed to support her claim for breach of fiduciary duty because she presented nothing more than bare assertions and the employer made no material misrepresentations regarding the employee’s ineligibility for benefits. Nothing in ERISA’s civil enforcement provision suggested that a plan beneficiary should receive a benefit award based on a plan administrator’s failure to disclose required information. Furthermore, there was no evidence that the employer failed to honor a written request for information from the employee. The employee failed to show that her emotional problems, which were basis for her Social Security Disability claim, were the result of an on-the-job injury. The Court therefore affirmed the lower court.
Once again, we see that the importance of making the record in these cases is controlling. Here, the Plaintiff employee did not make the record to back up her claims and so she was unsuccessful. At the very least, and employee is going to have to demonstrate to the Court that the condition that is the basis for her claim was caused by an injury she suffered at work for the employer.
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.
by Cody AllisonEberle v. Plan
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.
by Cody AllisonBrooking v. Hartford Life & Accident Ins. Co.
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.
by Cody AllisonBalmert v. Reliance Std. Life ins. Co.
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.