McQuillin v. Hartford Life and Accident Insurance Company
This ERISA case has not been decided yet but makes an interesting argument. This is an “Amicus Curiae” (friend of the court) brief submitted by the U.S. Secretary of Labor.
The Plaintiff/Insure had received unsuccessful treatment for prostate cancer, which had left him him with a long list of medical problems. He filed a claim for long term disability with the Defendant. This claim was denied, stating that the Plaintiff had not provided enough information to show that he was unable to work. Plaintiff had 180 days to appeal this decision and sought two extensions within which to appeal. The Defendant denied the first extension and did not respond to the second, so the Plaintiff timely appealed. The Defendant then notified the Plaintiff that it had reversed its original denial but stated that this reversal did not guarantee payment of benefits. The Defendant stated that the claim department would review the submitted information and determine if the Plaintiff met the definition of disability and then render a new decision. The Defendant did not state when this would be done. The Plaintiff waited 46 days, and then filed suit under ERISA. Finally, months later, the Defendant notified the Plaintiff that it had denied his long term disability claim again. The district court dismissed the Plaintiff’s claim because it determined that the Plaintiff had not exhausted all his remedies administratively with the Defendant before resorting to the courts.
The Plaintiff argues that the Claims Procedure Regulation sets for the minimum requirements for the employee benefit plan procedures pertaining to claims for benefits. This procedure requires ERISA plans to decide benefit appeals within specified time frames. If the Defendant fails to meet these time frames, the Plaintiff is deemed to have exhausted administrative remedies and is entitled to pursue any available remedies under ERISA. The district court in this case held that the Defendant timely issued a benefit determination on review by sending the claim to its claim department. The Plaintiff argues that this is contrary to the plain language, structure and purpose of the claims-procedure regulation. The Plaintiff argues that a “benefit determination on review” requires a straight up or down decision either granting or denying benefits. The Defendant’s sending the claim to its claim department ending nothing. Further, the Plaintiff argues that the idea that plans can simply “remand” benefit appeals back to themselves without deciding whether benefits are due undermines ERISA’s goal of ensuring speedy decisions. If a “remand” qualifies as a “benefit determination on review” under ERISA, a defendant plan could repeatedly issue vacate-and-remand decisions, endlessly, without contradicting the regulations.
The U.S. Secretary of Labor issued an Amicus Curiae brief supporting the Plaintiff’s argument. It reviewed the applicable statues under ERISA for plain language and agreed with the Plaintiff’s assertions. The Secretary ends its brief by requesting that the Court reverse the lower court’s dismissal of the Plaintiff’s claims. Stay tuned for the result.
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.
Fibromyalgia and Long-Term Disability
The link below carries you to a NOLO article regarding the intersection of fibromyalgia and LTD claims. The article makes the very important point that many insurance companies almost automatically deny claims related to this debilitating disease and that it may be necessary to bring in an experienced attorney to handle a long-term disability claim based on fibromyalgia. Here at Cody Allison and Associates, we have experience with these kinds of claims and we stand ready to help you recover the benefits that are due to you. Contact us today!
http://www.nolo.com/legal-encyclopedia/long-term-disability-benefits-fibromyalgia.html
Kennedy v. Lilly Extended Disability Plan, ERISA and Long Term Disability
This ERISA case, decided in 2017, is a case dealing with the Defendant failing to make a record for the case.
The Plaintiff/Insured was hired by the Defendant and rose rapidly, eventually becoming an executive director in the human resources division. However, after working at the company for over three decades, she was forced to quit because of disabling symptoms of fibromyalgia. She made an initial claim for long term disability benefits which was granted. Three and a half years later, these benefits were terminated. She brought suit. At trial, the Defendant based it’s denial on evidence presented by a number of doctors. However, the Court found that this evidence was a hodge-podge and was not consistent. However, the Court also found that even if this evidence was not deficient, the Defendant failed to indicate what job or kind of job, and on what level, the Plaintiff would be capable of performing if it was permitted to cancel her benefit. Further, the Court found that the evidence submitted by the Plaintiff’s treating rheumatologist demonstrated that the Plaintiff had flare-ups of her condition periodically and that the Plaintiff would not be able to work any sort of regular schedule because of this. The Court found that the Defendant did not demonstrate that this doctor’s opinion was incorrect. Therefore, the judgment of the lower court, granting the Plaintiff back due and ongoing long term disability benefits was affirmed.
If the employer wants to deny the benefits under ERISA, it better have its ducks in a row. Here, the employer did not. It is clear from the opinion that the employer presented a sloppy case, and the denial of benefits was arbitrary and capricious. The Court didn’t let it stand and the employee was justly compensated.
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.
Cheney v. Std. Ins. Co., ERISA and Long Term Disability
This ERISA case, decided in 2018, is a case dealing with the limits on the ability of the court to “do what is right” rather than what the long term disability policy requires.
The Plaintiff/Insured was an attorney who had been with her firm for about 20 years and eventually became a partner. She began to suffer from a spinal disease that eventually lead to her having a three-level anterior cervical discectomy and fusion and removal of her C5 vertebra. She eventually was unable to work and submitted a long term disability claim, which was denied based on the fact that her coverage ended in December of the year before she stopped working. She brought an action before the district court. The district ruled in her favor and the Defendant appealed. The Court found that the district court, in reaching its decision, ignored certain policy provisions and made conclusions of fact without supporting evidence. A new trial was necessary because the district court failed to find when the Plaintiff had become disabled, to use as a basis of comparison all work that some licensed to practice law in Illinois may have performed, and to analyze the medical evidence in the proper light. The district court’s calculation of predisability earnings based on the last full year that the Plaintiff worked was not tenable because the Plaintiff made the consistent claim of December 20, 2011 as the date of the date of the beginning of her disability and then worked beyond that date. The Court found that the district court erred in interpreting the long term disability policy and made factual findings unsupported by the record evidence. Therefore, the district court’s judgment was vacated and the case was remanded for a new trial.
In previous blogs, we have examined the duties and responsibilities of both the Plaintiff and the Defendant in ERISA long term disability cases. Here, we have an example of the duty of the court in these cases. The district court overreached in what it did in its decision here, and it was quickly and decisively put back in line by the appellate court in a decision that was probably somewhat embarrassing for the lower court. Even the Courts are bound by the terms of the long term disability plans in these cases.
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.
Leger 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.
Newsom 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.
Dix 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.
Faciane 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.
George 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.
Judge 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.