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.
by Cody AllisonEvans v. UNUMProvident Corp.
This ERISA case, decided in 2005 , is another case examining the “arbitrary and capricious” standard that the Court must use in reviewing most of these cases from the lower Court.
In this case, the Plaintiff/Insured worked as a nursing home administrator. She began to suffer from complex intractable seizures. Plaintiff applied for long term disability benefits under ERISA, which were initially granted and then terminated by the Defendant. The Plaintiff filed suit seeking damages resulting from this termination and for reinstatement of her long term disability benefits. The district court granted judgement in favor of the Plaintiff, and the Defendant appealed.
The lower court held that the Defendant had acted arbitrarily and capriciously in terminating the Plaintiff’s long term disability benefits because the Defendant failed to provide a reasoned explanation, based on both the record in the case and express language of the long term disability policy, for terminating the long term disability benefits. The Court found that the Defendant’s decision to rely solely on file reviews by its in-house physicians was questionable in light of the critical credibility determinations made in those file reviews, the factual inaccuracies contained therein regarding the Plaintiff’s treatment history, and the fact that the file reviews categorically dismissed the reliable opinion of the Plaintiff’s treating physician that the stress factor militated against the Plaintiff’s return to work at her administrative position. The lower court was affirmed.
As in the previous cases we have blogged about, the “arbitrary and capricious” standard is difficult to overcome but not impossible. An insurer must act in a measured and reasoned way, and set forth independent reasons for the long term disability benefit termination, or it may not withstand scrutiny by the courts.
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 AllisonRochow v. Life Ins. Co. of N. Am.
This ERISA case, decided in 2014 , is an interesting case regarding the insurance company’s duties as a fiduciary and what damages a Plaintiff may recover when the insurance company wrongfully withholds long term disability payments it should be paying the Plaintiff.
The case had previously been before the Appeals Court which had affirmed the lower court’s finding that the defendant insurance company had acted arbitrarily and capriciously in denying the Plaintiff’s long term disability benefits under ERISA. Upon remand, the lower court ordered the Defendant to disgorge profits flowing from that wrongful denial of benefits, in the form of interest on the benefits that should have been paid to the Plaintiff. This Court examines the lower court’s ruling and determines that it erred in ordering the Defendant to disgorge the money it made from interest while holding the Plaintiff’s long term disability benefits. The Court examines the relevant statutes under ERISA and determines that those statutes are designed to make the Plaintiff whole, not to punish the Defendant for wrongfully denying something to the Plaintiff, or wrongfully gaining something from that denial. The Court finds that the previous finding that the Defendant acted arbitrarily and capriciously and forcing the Defendant to pay all long term disability benefits due and owing to the Plaintiff made the Plaintiff whole. In addition, the Court found that the Plaintiff had also already been awarded his attorneys’ fees for having to bring this suit, and that prejudgment interest may be awarded on remand. There was no showing by the Plaintiff that these awards were not sufficient to make him whole. Therefore, the Court reverses the lower court’s order that the Defendant has to disgorge these monies from interest.
Even though this case seems a trifle unfair to the Plaintiff, it is easy to see how the Court arrived at its decision. By examining the statutes from the perspective of making the Plaintiff whole, and not from the perspective of punishing the Defendant, the Court’s decision is well reasoned and accurate.
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 AllisonHelfman v. GE Group Life Assur. Co.
This ERISA case, decided in 2009, is another in the line of cases dealing with the “arbitrary and capricious” standard that the Court has to use when ERISA cases where short term and long term disability cases are appealed in most circumstances, and the case also deals with the “safe harbor” exception from ERISA.
In this case, the Plaintiff appealed the finding that his long term disability benefits plan was governed by ERISA and the finding that one insurer’s termination of benefits was not arbitrary or capricious. The Plaintiff alleged that the “safe harbor” provision applied in his case, which exempts from ERISA coverage certain group-type insurance programs. In cases where the safe harbor provision applies, state law governs the case. In order for this provision to apply, the Court states that there are four criteria that must be met: (1) No contributions are made by an employer or employee organization; (2) Participation in the program is completely voluntary for employees or members; (3) The sole functions of the employer or employee organization with respect to the program are, without endorsing the program, to permit the insurer to publicize the program to employees or members to collect premiums through payroll deduction or dues checkoffs and to remit them to the insurer; and (4) The employer or employee organization receives no consideration in the form or cash or otherwise in connection with the program, other than reasonable compensation, excluding any profit, for administrative services actually rendered in connection with payroll deductions or dues checkoffs. In this case, the Court determined that the Plaintiff’s employer had contributed to premiums on behalf of the majority of the employees and therefore the first criterion of the safe harbor exception could not be met, so the Court affirmed the lower court’s decision. The Plaintiff then alleged that the insurer’s decision to conduct only a file review and to not interview his treating physician supported the allegation that the insurer’s determination to terminate long term disability benefits was arbitrary and capricious. The Court notes that some of the Plaintiff’s claim is based on job stress that is having health effects. The Court determined that the insurer’s thoroughness with regard to the Plaintiff’s stress was to be questioned, based on the disregard of the treating physician’s admonition that the Plaintiff not work, and that the dismissal of the Plaintiff’s claims by the insurer was purely subjective and not relevant. Therefore, the Court affirmed the lower court finding that ERISA governed the Plaintiff’s long term disability benefit plan, but reversed the lower court finding that the insurer’s termination of the Plaintiff’s long term disability benefits under ERISA was not arbitrary and capricious and remanded the case back to the lower court for further proceedings.
Once again, in ERISA cases, if there is a clause in the plan, in some states, that gives the administrator discretionary authority to determine the eligibility for short term or long term disability benefits under ERISA or to construe the terms of the plan, rather than the Court reviewing the decisions of the administrator under the de novo standard, the Court reviews under the “arbitrary and capricious” standard which means that the administrator’s decisions in denying the long term disability benefits must be arbitrary and capricious for the Court to overturn the administrator’s decisions.
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 AllisonElliott v. Metro. Life Ins. Co.
In this ERISA case, decided in 2006, the question before the Court is whether a long term disability plan administrator acted arbitrarily and capriciously in denying the claimant/Plaintiff’s long term disability benefits under ERISA.
This case is another examining the employer’s duty to not be “arbitrary and capricious” in it’s determination of whether or not a Plaintiff is entitled to long term disability benefits under ERISA. In this case, the Plaintiff had been severely injured in car accident and she began experiencing renewed pain. Her doctors could not explain why her pain had reemerged. She applied for long term disability benefits, which was denied by the administrator of her plan. The Plaintiff appealed the denial and the administrator hired a physician to review the file. This physician, after only a file review, concluded that the Plaintiff’s condition had improved and that she was capable of performing sedentary work. Based on this, the administrator continued to deny benefits. The Plaintiff took the matter to the district court in Kentucky, who found in favor of the administrator. However, the Court of Appeals found that the administrator had not relied upon an application of the relevant evidence to the occupational standard. The Court found that the administrator’s physician had not given reasons for his conclusions, never discussed the employee’s job duties, and had evaluated the Plaintiff’s ability to do sedentary work even though the term “sedentary work” did not appear in the plan’s terms. In the addition, the Court found that the administrator had given greater weight to its physician than to the employee’s treating doctor, even though the physician only performed a file review and never saw the Plaintiff. Therefore, the Court of Appeals reversed the lower court and remanded the case back to them with instructions or remand back to the administrator for a determination of whether or not, under these findings, the Plaintiff was entitled to benefits under the plan.
Once again, in ERISA cases, if there is a clause in the plan, in some states, that gives the administrator discretionary authority to determine the eligibility for short term or long term disability benefits under ERISA or to construe the terms of the plan, rather than the Court reviewing the decisions of the administrator under the de novo standard, the Court reviews under the “arbitrary and capricious” standard which means that the administrator’s decisions in denying the long term disability benefits must be arbitrary and capricious for the Court to overturn the administrator’s decisions. This case demonstrates that the arbitrary and capricious standard can be overcome if the administrator does not ground its decisions in facts and evidence.
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 AllisonShaw v. AT&T Umbrella Benefit Plan No. 1
In this ERISA case, decided in 2015, the question before the Court is whether a long term disability plan administrator acted arbitrarily and capriciously in denying the claimant/Plaintiff’s long term disability benefits under ERISA.
The Plaintiff was employed as a customer service representative for Michigan Bell. He stopped working as a result of chronic neck pain. He was covered under the Defendant plan. The plan administrator initially paid short term disability benefits on the claim, but he was denied long term disability benefits because the plan administrator determined that there was not objective medical documentation of the claimant’s inability to perform any occupation. However, the Court found that the administrator ignored favorable evidence submitted by the Plaintiff’s treating physicians, selectively reviewed the evidence it did consider from the treating physicians, failed to conduct its own physical examination and heavily relied on non-treating physicians. The Court even went so far as to determine that, not only was the Plaintiff entitled to his long term disability benefits, but that a remand would be a useless formality because the medical records contained objective medical evidence that the Plaintiff was disabled.
In ERISA cases, if there is a clause in the plan, in some states, that gives the administrator discretionary authority to determine the eligibility for short term or long term disability benefits under ERISA or to construe the terms of the plan, rather than the Court reviewing the decisions of the administrator under the de novo standard, the Court reviews under the “arbitrary and capricious” standard which means that the administrator’s decisions in denying the long term disability benefits must be arbitrary and capricious for the Court to overturn the administrator’s decisions. Needless to say, this is a very high standard and very difficult to overcome. However, as this case demonstrates, it is not impossible. The administrator must base his decisions on some quantifiable facts to show the Court that the decision has some basis for the denial. This one did not, and was reversed.
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 Standard Life Insurance Company
In this ERISA case, decided in 2022, the parties agreed to a trial upon submission of documentary evidence but disagreed upon the issues properly before the district court. In the case, the Plaintiff/Employee claimed that the Defendant had wrongfully denied his short term and long term disability benefits under ERISA.
The Plaintiff was employed as a software architect for Lereta, where he had been employed for 23 years. He had been having health problems since 1999, including chronic fatigue syndrome, fibromyalgia, depression and attention deficit hyperactivity disorder. His health deteriorated to a point where he could no longer work a 40 hour week. The employer tried reducing his hours to 32 hours per week, but he was unable to consistently do that. He was then moved to part time, which he worked for a while until he unable to do even that. He submitted a claim for short term disability benefits, which was denied by the plan administrator because he no longer qualified as a full time employee and thus did not qualify for short term and long term disability benefits coverage. The Plaintiff appealed this denial of short term disability benefits stating that the beginning date of his disability was incorrectly determined and that his schedule as set by the employer did qualify him as full time. Upon review, the claims examiner agreed with the Plaintiff and he was paid his maximum short term disability benefits. However, the examiner continued to deny the Plaintiff’s long term disability benefits, based on the fact that the Plaintiff did not work full time. The Plaintiff appealed the denial of his long term disability benefits but the Defendant affirmed its decision. The Plaintiff then filed suit pursuant to ERISA.
The parties agreed to a trial upon documentary evidence and the district court found for the Plaintiff. In doing so, the district court had to interpret the term “regular work week” to decide if the Plaintiff had worked full time, and it had to decide when the Plaintiff became disabled. The Defendant also argued that, if the court found that the Plaintiff was eligible for long term disability benefits, that it should have remanded the case back to the Defendant for analysis of whether the Plaintiff was disabled.
The Court of Appeals examined the issue of the district court’s determination of what a “regular” work week is, and determined that the district court was correct in its determination.
The Court then examined the district court’s determination of when the disability began, and again determined that the district court was correct. The Court examined whether the district court had made a “clear error” which is the standard of review for these questions, and determined that it had not. The Court notes that the “clear error” standard is a high standard for the Defendant to overcome.
However, on the issue of whether or not the case should have been remanded to the Defendant so that the case administrator could determine disability, the Court found that it should have been. The language of the ERISA long term disability plan that the Plaintiff was under required a determination of whether the Plaintiff was disabled as a result of injury or sickness and this question was not before the district court in the initial hearing.
This case is a prime example of how a court is bound by the issues in front of it. Sometimes, this is very frustrating for the parties, but courts can only determine the issues that the parties, through their counsel, have asked the court to determine. If a court strays outside of those issues, that court’s decision will often be reversed and the case remanded to the proper court or agency to make those decisions.
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.