by Cody AllisonTranbarger v. Lincoln Live & Annuity Co.
In this 2023 ERISA case, the Court held that the trial court properly concluded that the plaintiff failed to demonstrate complete and continuous disability during the six months following her resignation under ERISA because ample evidence suggested that she could perform some work in some instances based on the report from her physical therapy sessions, which described her to moving well and suffering no pain, at the time. Also, her supervisor suggested that she could still perform some of her main duties as an accounts receivable manager. The lower court was affirmed.
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 AllisonD.K. v. United Behavioral Health
In this 2023 ERISA case, the Court held that when reviewing a claim for benefits, an administrator is not required to defer to the opinions of a treating physician. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 831, 123 S. Ct. 1965, 155 L. Ed. 2d 1034 (2003). However, a reviewer may not arbitrarily refuse to credit such opinions if they constitute reliable evidence from the claimant. Id. at 834. Medical opinions are regularly proffered as proof of a claim, and we have held reviewers “cannot shut their eyes to readily available information . . . [that may] confirm the beneficiary’s theory of entitlement.” Gaither v. Aetna Life Ins. Co., 394 F.3d 792, 807 (10th Cir. 2004). Therefore, if United arbitrarily refused to credit and effectively “shut their eyes” to the medical opinions of A.K.’s treating physicians, it acted arbitrarily and capriciously.
United also argues the district court abused its discretion when it awarded A.K. benefits outright. HN20 A court may remand for further administrative review if it determines the administrator’s flawed handling could be cured by a renewed evaluation to address, for example, [*39] a “fail[ure] to make adequate findings or to explain adequately the grounds for a decision.” Caldwell v. Life Ins. Co. of N. Am., 287 F.3d 1276, 1288 (10th Cir. 2002). See also Rekstad v. U.S. Bancorp, 451 F.3d 1114, 1121-22 (10th Cir. 20026) (remanding for plan administrator to examine relevant evidence). By contrast, a court may award benefits when the record shows that benefits should clearly have been awarded by the administrator. See Weber v. GE Grp. Life. Assurance Co., 541 F.3d 1002, 1015 (10th Cir. 2008). That is not the only instance in which a court may award benefits. If a plan administrator’s actions were clearly arbitrary and capricious, then remand is unnecessary, and a reviewing court may award benefits. DeGrado v. Jefferson Pilot Fin. Ins. Co., 451 F.3d 1161, 1175-76 (10th Cir. 2006). Other circuits have similarly found remand unnecessary for procedural flaws. HN21 As the Second Circuit explained, remand to an insurer is not appropriate if it “serve[s] primarily to give the defendants an opportunity to retool a defective [appeals] system.” Zervos v. Verizon New York, Inc., 277 F.3d 635, 648 (2d Cir. 2002). The Ninth Circuit has expressed concern with giving an additional “bite at the apple” to ERISA administrators acting unjustly. See Grosz-Salomon v. Paul Revere Life Ins. Co., 237 F.3d 1154, 1163 (9th Cir. 2001).
In considering if such a rule is appropriate here, we consider the function of judicial review for ERISA administrators. HN22 The Supreme Court has reiterated that judicial deference to ERISA plan administrators is premised on their fiduciary roles. See, e.g., Varity Corp. v. Howe, 516 U.S. 489, 506, 116 S. Ct. 1065, 134 L. Ed. 2d 130 (1996). ERISA requires fiduciaries to “discharge [*40] [their] duties with respect to a plan solely in the interest of the participants and beneficiaries.” 29 U.S.C. § 1104. When the administrator’s actions or structure threaten their ability to act as a proper fiduciary, the Court has given administrators’ decisions less deference. See Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 107-09, 109 S. Ct. 948, 103 L. Ed. 2d 80 (1989) (disallowing the arbitrary and capricious standard of review when there is a possible conflict of interest for the administrator); Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 118, 128 S. Ct. 2343, 171 L. Ed. 2d 299 (2008) (disallowing deferential review when considering the specific facts of the case). When Congress “careful[ly] balance[ed] the need for prompt and fair claims settlement procedures against the public interest in encouraging the formation of employee benefit plans,” Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 54, 107 S. Ct. 1549, 95 L. Ed. 2d 39 (1987), it did not give administrators unlimited freedom to act improperly towards claimants.
We conclude that the district court did not abuse its discretion in declining to remand. Considering the administrator’s clear and repeated procedural errors in denying this claim, it would be contrary to ERISA fiduciary principles to mandate a remand and provide an additional “bite at the apple.” ….
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 AllisonMosely v. Unum Life Ins. Co. of Am.
In this 2023 ERISA case, the Defendant ceased providing disability benefits to the Plaintiff pursuant to a mental illness limitation of her long-term disability policy. The Plaintiff challenged this decision, arguing that the Defendant abused its discretion by finding that the basis for her disability is psychological rather than physical. The Defendant moved for summary judgment. The Court examined the record and immediately notes that the Defendant failed to provide the Plaintiff with an independent medical examination (IME) when she requested it, and that constituted a procedural error and rendered the Defendant’s benefits determination inherently arbitrary and capricious. For this reason, the Court denied the Defendant’s motion for summary judgment and remanded the case for an IME to be conducted.
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 AllisonSnapper v. Unum Life Ins. Co. of Am.
In this 2023 ERISA case, the Plaintiff, an attorney, began working for a law firm which had a long term disability policy through the Defendant insurance company. The Plaintiff had a history of back and lower leg pain problems beginning in 2008 resulting from a herniated disc. At the time he suffered this injury, the Plaintiff was a second year law student. He had several surgeries to try to correct the problem, but in September, 2016, he was involved in an automobile collision which aggravated his condition. In April, 2018, Plaintiff took a leave of absence from his job because of his condition. During this time, he sought medical treatment and physical therapy. He returned to work on July 9, 2018. After this return, he continued to get steroid injections and was eventually referred for a neurological consultation by his treating physician. The steroid injections stopped working and the Plaintiff had continual pain and nausea from his medications. He took a second leave of absence on February 19, 2019 and did not return to work. He continued to get treatment, including a spinal stimulator. He met with several surgeons about the possibility of a second surgery and finally had an extra-pedicular decompression surgery. After little success, he had another lumbar spine surgery and more physical therapy, which did not help. He continued to seek medical treatment.
Meanwhile, the Defendant had one of its Designated Medical Officers review the Plaintiff’s records to see if he was capable of performing Sedentary Work duties. The Defendant determined that the Plaintiff was capable of performing this work. The Defendant terminated the Plaintiff’s long-term disability benefits. The Plaintiff appealed this termination. The Plaintiff submitted additional proof of his inability to work and the Defendant reviewed this proof, but continued to deny benefits.
The Court in this case examined the proof on both sides, and found the Defendant’s arguments to be unpersuasive. In a lengthy opinion, the Court went through every one of the arguments and found that the Plaintiff had established that he was disabled under the plan. The Court concluded that the Plaintiff is entitled to reinstatement and an award of past-due benefits from the date of his termination until present. However, the Court makes it clear that the Defendant can continue to re-evaluate the Plaintiff for improvement.
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 AllisonMacnaughton v. Paul Revere Ins. Co.
In this 2023 ERISA case, the Plaintiff, a doctor, commenced this action against the Defendant insurer to recover unpaid benefits after an adverse benefits determination on her employer-sponsored long-term disability claim. In a previous Order, this Court remanded the claim to ensure a “full and fair review” of the Plaintiff’s appeal of the adverse decision. After remand, the defendants denied the Plaintiff’s claim a second time and both parties moved for summary judgment.
The Plaintiff is a radiologist. Part of her job is to read and examine radiographic images. The Plaintiff gave birth to twins and soon began having difficulty seeing out of her left eye. She was eventually diagnosed with nerve damage in that eye. The Defendants initially paid for the Plaintiff’s long-term disability and the Plaintiff continued to work part-time as a supervisor but not in diagnosis. Eventually, the Defendants had an IME conducted on the Plaintiff and that physician’s opinion was that the Plaintiff’s vision problems were correctable. Therefore, the Defendants terminated the Plaintiff’s benefits. Plaintiff had another physician submit a report saying that the Plaintiff’s vision problem was uncorrectable. The Defendants had another IME physician review all the records, who concluded that the Plaintiff was able to work because the condition had largely corrected itself and that her job did not require her to have two healthy eyes and depth perception. Therefore, the Defendants continued to deny benefits.
The Court notes on the summary judgment that the Defendants’ physician went through the Plaintiff’s physician’s reports point by point and rebutted each point, but the Plaintiff’s physician did not do that to the Defendants’ physician’s report. The Court concluded that the Defendant was then allowed to rely upon their physician’s report and that such reliance was not arbitrary and capricious and did not violate the standard. Therefore, the Court granted the Defendant’s Motion for Summary Judgment and denied the Plaintiff’s claim.
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 AllisonPearson v. Group Long Term Disability Plan for Employees of Tyco Int’l (US), Inc.
In this 2008 ERISA case, the Plaintiff former employee filed suit against defendant long-term disability plan pursuant to ERISA to recover long-term disability benefits allegedly due him under a plan sponsored by the parent company of his former employer.
The court found that the insurance company was clearly mistaken in its assertion that no physician opined that the employee’s mental faculties were in any way deficient or impaired. The court reasoned that every attending physician’s statement submitted by the employee’s treating physician indicated either that the employee had a major psychiatric impairment in several areas or that he had a moderate impairment in occupational functioning. Furthermore, the medical records showed that the employee was taking Xanax at least by July 2001 and that he was still taking Xanax on June 28, 2006, which was the date of what appeared to be the latest medical record in the file. The insurance company argued that the employee waived this issue because he did not assert it in his administrative appeal. The court found that the employee had not waived any argument and that the insurance company should have considered whether he had a psychiatric impairment. The court reasoned that the insurance company did not advise the employee of any deficiency in his letter or request that he specify the issues that he wanted considered.
The decision of the insurance company determining that the employee was no longer eligible for long-term disability benefits was reversed, and the claim was remanded for further proceedings. The insurance company must consider not only the employee’s chronic obstructive pulmonary disease but also other impairments noted in the employee’s claimant statements and in the medical records contained in the administrative record.
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 AllisonAvenoso v. Reliance Std. Life Ins. Co.
In this 2021 ERISA case, the district court’s entry of summary judgment in favor of claimant was affirmed because, while the court adjudicated the parties’ summary judgment motions as if it were ruling in a bench trial, whether the district court’s decision survived de novo review of its legal determinations and clear-error review of its factual findings turned on whether it clearly erred in finding the claimant lacked sedentary-work capacity, on the record before it, the appellate court could not say the district court’s finding the claimant lacked sedentary-work capacity was clearly erroneous, and it had to disregard as harmless the district court’s error in adjudicating the parties’ motions for summary judgment as if it were ruling in a bench trial. The judgment of the lower court was affirmed.
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 AllisonRoehr v. Sun Life Assur. Co.
In this 2021 ERISA case, the Court found that the district court did not err by evaluating the claimant’s claims under the well-known abuse of discretion standard. The court had consistently rejected the notion that the mere presence of a potential conflict of interest is sufficient to warrant a less deferential standard, and here, the plan administrator actively sought to reduce any potential conflict of interest or bias by consulting with two independent physicians who reviewed the claimant’s medical records.
The plan administrator relied on virtually the same medical records for a decade and pointed to no information available to it that altered in some significant way its previous decision to pay benefits. There was not substantial evidence in the joint administrative record to support the plan administrator’s termination decision.
The court reversed the district court’s grant of the plan administrator’s motion for judgment on the record. The court remanded to the district court with directions to order the reinstatement of benefits.
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 AllisonYates v. Symetra Life Ins. Co.
In this 2023 ERISA case, a participant in an employee benefit plan governed by ERISA was not required to exhaust administrative remedies before challenging a denial of benefits in court when the written plan documents made no mention of any review process or administrative remedies that could be exhausted.
The plain language of the administrator’s intentionally self-inflicted injury exclusion did not apply to unintended injuries like the participant’s husband’s heroin overdose. The administrator’s denial of the participant’s claim for accidental death benefits based on that exclusion was erroneous. Judgment of the lower court was affirmed.
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 AllisonAvenoso v. Reliance Std. Life Ins. Co.
In this 2021 ERISA case, the district court’s entry of summary judgment in favor of the claimant was affirmed because, while the court adjudicated the parties’ summary judgment motions as if it were ruling in a bench trial, whether the district court’s decision survived de novo review of its legal determinations and clear-error review of its factual findings turned on whether it clearly erred in finding the claimant lacked sedentary-work capacity, on the record before it, the appellate court could not say the district court’s finding the claimant lacked sedentary-work capacity was clearly erroneous, and it had to disregard as harmless the district court’s error adjudicating the parties’ motions for summary judgment as if it were ruling in a bench trial. The judgment of the lower court was affirmed.
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.