Legal Precedents That May Impact Your Case
BRIEF SUMMARY OF US SUPREME COURT CASE – GLEN – To be added . . . .
UNUM's DECISION to terminate pediatric NURSE’s Long-Term Disability Benefits is REVERSED and found to be ARBITRARY. Attorney’s fees awarded.
Nancy Mikrut worked as a pediatric nurse and was insured under her company’s group disability plan. The plan is an ERISA plan funded and administered by UNUM Life Insurance Company. It provided total disability benefits under the “own occupation” definition for 24 months and “any occupation” coverage beyond that period.
Ms. Mikrut filed a claim for long-term disability benefits based on injuries sustained in an automobile accident. UNUM initially approved the claim and paid benefits. After 24 months, UNUM re-evaluated her claim. Ms. Mikrut’s treating physician advised UNUM that she suffers from low back pain that is disabling and that due to her restrictions and limitations she is disabled from any occupation. Her doctor referred to information contained in his medical records, his personal examination of her and her ongoing complaints of pain. UNUM, based on a medical records review by a UNUM medical consultant, found Ms. Mikrut capable of full-time sedentary work. Additionally, a vocational analysis conducted by UNUM found that there were several occupations that were appropriate for her skills and education level. Thus, Ms. Mikrut’s benefits were terminated and UNUM upheld its decision on Appeal.
The Judge in this case noted the UNUM did not address Ms. Mikrut’s subjective complaints of pain, did not adequately consider her grant of social security disability benefits and rejected the opinions of her treating physicians in favor of the opinions of reviewing consultants who had never met or examined Ms. Mikrut. On December 20, 2007, the judge held that Ms. Mikrut is eligible for continued long-term disability benefits and granted an award of attorney fees to her as well. See Nancy P. Mikrut v. Unum Life Insurance Co. of America, (2006 U.S. Dist. LEXIS 92265).
Judge finds HARTFORD’s decision to terminate PHARMACIST’S disability benefits was not supported by SURVEILLANCE and she is ENTITLED to disability benefits under ERISA Plan.
Robin Plummer, a pharmacist, was found disabled under her ERISA governed group disability plan. In 2003, Hartford Life Insurance Co. took over administration of the plan form Continental Insurance Company. In 2004 Hartford conducted surveillance on Ms. Plummer and obtained footage showing her driving, going to the cleaners and a department store and carrying her grandchild. They also had an independent medical examination performed by a Dr. Klein, who initially concluded that she was only capable of full time sedentary work. However, following his review of the surveillance video, Dr. Klein issued an addendum to his report stating that she could perform light-duty work and lift up to 25 pounds. Based on Dr. Klein’s report, Hartford terminated Ms. Plummer’s benefits.
De novo review was applied in this case. The Judge held that the evidence on the surveillance tapes was hardly evidence that she could return to work full time as a pharmacist. Further, the judge found that the IME was flawed, that Dr. Klein was the only doctor that thought Plummer was able to return to work and he noted that she continued to have problems with her back. His ruled in favor of Ms. Plummer, finding that she is entitled to disability benefits under the plan. See Robin Plummer v. The Hartford Life Insurance Co., 2007, U.S. Dist. LEXIS 488)
A Met Life ERISA Plan’s 24 month LIMITATION PERIOD found NOT APPLICABLE to LUMBAR DISC DISEASE. DENIAL of benefits OVERTURNED and Attorney’s Fees were Awarded.
Kelly Iley was diagnosed by her treating physician with lumbar disc disease ad underwent a discectomy and fusion surgery. Due to severe back pain, despite the surgeries, Ms. Iley stopped working. MetLife approved her claim for 24 months, but then terminated benefits citing the plan’s 24-month limitation period for neuromuscular and soft-tissue disorders. Ms. Iley appealed based on her doctors’ statements that she was totally disabled due to radiculopathies. MetLife upheld its denial of benefits and Ms. Iley filed her lawsuit. On September 27, 2007, Judge Cox ruled in Ms. Iley’s favor finding that MetLife’s termination of benefits was arbitrary and capricious, as the company ignored Ms. Iley’s treating doctors’ diagnosis of radiculopathy and its own findings based on diagnostic workups. Moreover, the judge found that the plan’s limitation period excludes disabilities caused by radiculopathy. Finally the judge found that although MetLife did not act in bad faith, based upon the merits of the parties’ positions and the deterrent effect of a fee award, attorneys fees were to be awarded to the Claimant. See Kelly Iley v. Metropolitan Life Insurance Co., (2007 U.S. Dist. LEXIS 165)
UNUM's DENIAL of Benefits to Office Coordinator ARBITRARTY & CAPRICIOUS due to critical flaws in evaluation - INTERNAL INCONSISTENCIES & failure to consider objective evidence.
Claimant was a housekeeping office coordinator for Ritz Carlton Hotels. Following a diagnosis of breast cancer, she had a lumpectomy and axillary lymph node dissection as well as chemotherapy and radiation. Her treating physician restricted her from heavy lifting, climbing, stooping and pushing.
Her claim was approved by UNUM for short and long-term disability benefits. A follow up medical review by a UNUM nurse showed that the Claimant also suffered edema, a chronic swelling of her arm. Benefits continued to be paid. Several months later, UNUM again reviewed the Claimant’s file. UNUM classified her job as “sedentary” and one of its own staff nurses determined that that the Claimant’s own doctors had not observed edema and that her condition did not prevent her from returning to work. This opinion was supported by a UNUM doctor and benefits were terminated.
The Claimant appealed and provided physician records and notes restricting her lifting to five pounds and showing evidence of edema and tenderness in her arm. Additionally, the Claimant submitted a vocational assessment which found that her regular occupation was not sedentary, that she had numerous difficulties completing tests and that she needed help with the activities of daily living. UNUM upheld its decision and in its final denial letter stated for the first time that the Claimant needed to see an orthopedic surgeon and neurologist to properly evaluate her symptoms.
The Appeals court found that UNUM violated ERISA by first notifying the Claimant that she needed to see an orthopedic surgeon and neurologist in its final denial letter, as the denied her toe opportunity to properly respond with argument or action to UNUM's revised rationale for terminating benefits. Additionally, the Court found that UNUM’s reasoning had critical flaws, including the failure to give full consideration to the Claimant’s vocational evidence, inconsistencies within UNUM's own reports and opinions and the UNUM reviewers’ failure to consult with the Claimant’s doctors and examine the Claimant. Thus, she was awarded continued long-term disability benefits. See Pauletta Houston v. UNUM Life Insurance Co. of America, 2007 U.S. App. LEXIS 18353)
DENTIST/REAL ESTATE DEVELOPER found TOTALLY DISABLED under his policy with EQUITABLE due to his inability to perform most or all of the duties of his occupations.
A dentist who became disabled subsequent to selling his dental practice but prior to opening a new practice also owned a construction company and development company. He filed two claims with Equitable, one because of hip pain, and then 5 years later another claim due to fatigue and abdominal pain. His gastroenterologist confirmed that the Insured was disabled from working as both a dentist and a real estate developer due to finger numbness, hand tremors, sleep problems, fatigue, anxiety and short-term memory loss. His psychiatrist also found him to be disabled as the result of depression and cognitive problems. Equitable ultimately denied the Insured’s claim on the basis that he had not actively practiced dentistry for 4 years before his disability and that his real estate position was passive in nature. The doctor filed suit and the Court held that he is totally disabled from his real estate occupation. They also found that the evidence supported his allegation that he could not perform the substantial and material duties of a dentist.
Equitable appealed and the Circuit Court of Appeal rejected Equitable’s argument that the Insured is not disabled if he can perform even one of his substantial, material duties. The Court noted that the clause does not say ‘all substantial and material duties’ or ‘most’ or ‘any percentage’. The appeals court found the clause ambiguous and stated that ‘most’ or the ‘majority’ of the substantial and material duties is also a reasonable interpretation if an insured is unable to engage in his regular occupation as a result of his inability to perform most or a majority of those duties. See Dr. Allen Giddens v. The Equitable Life Assurance Society, (11th Circuit: 2006 U.S. App. LEXIS 8970)
Subjective Evidence of symptoms related to FIBROMYALGIA and CHRONIC PAIN SYNDROME was SUFFICIENT, despite a lack of objective evidence
Mr. Oliver, a systems support specialist at Coca-Cola filed for disability benefits under his company’s group long-term disability plan. Coca Cola contracted with Broadspire Services, Inc. to conduct its claims administration. The plan provided own occupation coverage for the first 24 months and any occupation coverage beyond that period.
Mr. Oliver’s treating physician diagnosed him with fibromyalgia and cited a positive EMG for chronic radiculopathy. Another of Mr. Oliver’s physicians diagnosed him with Chronic Pain Syndrome, headaches and insomnia and stated that he was disabled due to continuous headaches, neck and right arm pain. Broadspire hired a doctor to conduct a peer review of Mr. Oliver’s medical file. That doctor found that Mr. Oliver was not disabled under the policy as there was no objective evidence of a disability. Broadspire denied the claim and Mr. Oliver appealed. In his appeal, he submitted medical records from a third treating physician, a neurologist who cited an EMG as evidence of chronic radiculopathy on the right side. Broadspire had a second medical records review performed and upheld its decision. Mr. Oliver filed a 2nd appeal, submitting additional medical records from a doctor that diagnosed him with cervical myofascial pain syndrome and pseudoradiculopathy. Broadspire again upheld its denial of benefits finding no objective evidence of disability. The denial letter did not mention the MRI, EMG and nerve conduction tests submitted by Mr. Oliver. Coca Cola upheld Broadspire's decision to deny on the second level appeal, also referring to a lack of objective evidence.
The trial court ruled in Mr. Oliver’s favor and Broadspire and Coca Cola appealed. The Appeals Court upheld the trial court’s holding finding that the insurer’s denial of benefits was arbitrary and capricious. The Court noted that Mr. Oliver submitted evidence from six treating physicians, records, laboratory test results, tow EMGs and a nerve conduction test. It also faulted the insurer’s for its failure to consider subjective evidence on the ground that “as they relate to pain, subjective complaints cannot be quantitative measured.” The Court further stated that the plan does not exclude from its coverage pain related disabilities, such as fibromyalgia or chronic pain syndrome. Finally, attorney’s fees were awarded to Mr. Oliver. See Theron Oliver v. Coca Cola Co., Broadspire Services, Inc., (11th Cir.: 2007 U.S. App. LEXIS 20628)
Insured with CARPAL TUNNEL SYNDROME granted benefits under her Disability Plan
The Insured, a graphic designer, was forced to leave her job due to severe carpal tunnel syndrome and thoracic outlet syndrome. Despite several surgeries, she remained unable to use her hands for any repetitive activity. The Insured’s benefits were initially approved under her group disability policy with Life Insurance Co. of North America (LINA). Additionally, she was awarded Social Security disability benefits. After 3 years, LINA terminated the Insured’s benefits, and despite her timely appeals and submission of extensive medical evidence that she remained disabled, LINA upheld its denial.
The Insured sued and the judge concluded that she was entitled to long-term disability benefits and ruled that pre and post judgment interest should be calculated as part of the damage award. See Sharon Gardner v. Bear Creek Corp., (N.D. California)
Subjective Complaints of DIZZINESS and FATIGUE used to support a finding of TOTAL DISABILITY under CONTINENTAL INSURANCE CO.’S Plan
Mr. Lijoi was insured on a group disability plan with Continental Casualty Co. Mr. Lijoi filed for long-term disability after experiencing episodes of dizziness and fatigue. A few months later, he lost consciousness while driving and hit a metal pillar. His primary physician certified that he was totally disabled and that no job accommodation would allow him to return to work. Two years later, he was diagnosed with Hepatitis C and Chronic Fatigue Syndrome.
Continental had Mr. Lijoi examined by its neurologist, who found no evidence of neurological dysfunction that would prevent him from returning to work. Mr. Lijoi submitted the results of a Functional Capacity Examination (performed at the request of his attorney) which found that there were no occupations he could perform. Continental conducted its own FCE and the Continental analyst who reviewed the results concluded that the “conditions diagnosed do not appear to be supported with objective information.”
Thus, Continental terminated his disability benefits. Mr. Lijoi appealed and Continental upheld its termination of benefits. Mr. Lijoi filed a lawsuit and the judge rejected Continental’s claim that there was not enough objective medical evidence to support a finding of total disability. He noted that the Insurance Co. provided no basis for why the findings of its own reviewers, who saw Mr. Lijoi only once, were considered reliable while the reports of his own treating physicians were determined unreliable. The judge also noted that Continental failed to properly address the diagnoses of Hepatitis C and CFS and that the company erred by not giving more weight to Mr. Lijoi’s subjective complaints of pain. Finally, the judge awarded Mr. Lijoi attorney fees. See Francis E. Lijoi v. Continental Casualty Co., (E.D. N.Y.: 2006 U.S. Dist. LEXIS 5344)
PRUDENTIAL’S DENIAL of permanent and total disability benefits to Claimant with MEMORY LOSS and COGNITIVE PROBLEMS was ARBITRARY
The Insured suffered a closed head injury after being a large tree fell on her tent while she was camping with her family. She had multiple surgeries and an extensive recovery period. She applied for disability benefits and was approved. Under Prudential’s plan, if the disability is total and permanent the Insured is entitled to a one-time benefit in the amount of $20,000.00.
The Insured’s doctors opined that she could not perform her job duties now or in the future. The Court found for the Insured and sated that it did not understand how. Prudential found that she was ‘totally disabled’ but not ‘totally and permanently disabled’. The Court also noted the lack of evidence in the record that would contradict either of the opinions from her treating doctors. As such, the Appeals Court held ruled in favor of the Insured, finding that the benefit denial was arbitrary.
LIBERTY LIFE’S Denial of Benefits to SALES MANAGER with FIBROMYALGIA, ARTHRITIS, CHRONIC FATIGUE SYNDROME is deemed ARBITRARY
Anne Crist, a regional sales manager, was diagnosed with fibromyalgia, seronegative rheumatoid arthritis, hyperlipidemia, chronic fatigue syndrome and diplopia. Liberty Mutual paid disability benefits to her for 24 months under the own occupation coverage provision of her group disability plan. Liberty then reviewed the claim under the any occupation coverage definition. An insurance company doctor reviewed surveillance videos and concluded that, even with her ailments, Ms. Crist was not totally and permanently disabled, as she could perform full-time sedentary work. Liberty had a functional capacity evaluation (FCE) conducted and the report claimed that Ms. Crist could work at a sedentary job for eight hours a day. Liberty also had an independent medical examination performed and the doctor also found Crist capable of sedentary work. Liberty terminated benefits.
In response, Ms. Crist’s treating physician notified Liberty that she was in continuous, severe pain most of the time and the key issues in her ability to return to work is her ability to “sustain” activity. Liberty upheld its decision on appeal and Ms. Crist sued.
Judge Rose held that “Liberty’s denial of benefits was arbitrary and capricious”, finding that “Liberty did not engage in a deliberate principled reasoning process”. He also rejected Liberty’s argument that Ms. Crist was required to submit objective medical information in support of her disability. He ruled that she is disabled under the policy and is entitled to retroactive benefits plus interest.